Pediatric Mass Casualty IncidentA Quick Prep for Clinicians
Pediatric Mass Casualty Incidents (MCI)
School disasters (national/international) Newtown school shooting 2012 Earthquake in China 2008 with school
collapses Beslan, Russia school terrorist event in 2004 Columbine school shooting 1999
Potential Pediatric MCI
Collapse of a venue used primarily youth ex. “Disney on Ice”
Natural disaster Tuscaloosa tornado had >50 pediatric victims
School bus crash
Potential Pediatric MCI
Infectious disease outbreaks preferentially targeting childrenPertussis out breaksInfluenza with high impact on young
patients
Objectives: How to Prepare For a Pediatric
MCI Know the differences and similarities between
children and adults
Be aware of the special considerations for children Physical, emotional, environmental,
communication, family, equipment
Objectives: How to Prepare For a Pediatric
MCI
Children with “Special Needs”
Medications and treatments specific to children
Decontamination
Indications for transfer to a higher level of care
Pearls
Similarities
Kids are not “little adults” but the same priorities apply: ABCDE’s Almost all the medications are the same, they just need
weight based adjustment
If a child hurts, they tell you and usually will not move
Don’t avoid a necessary procedure for a child just because they are a child! Do what needs to be done according to usual trauma care
Differences
Children are very quick to respond to a treatment or lack of treatment so constant evaluation and re-evaluation is needed
Family contact is a high priority
Diverting the attention of the child often lets you examine them
Distraction ideas - videos, toys, iPhone, iPad, books with pictures to point to etc.
Differences
Over-triage can happen Children often prioritized higher than necessary
if significant soft tissue injuries and/or crying Carefully assess chest, abdomen, and mental
status
Pediatric Assessment Triangle
Differences
Airway Head is big – in infants and small children, pad the
shoulders up to achieve alignment Larynx is anterior and shallow vs. adult Narrowest part of airway is BELOW cords at cricoid ring Airways are narrower and do not tolerate swelling well Adjusting head and neck position can improve airflow
immensely Constant evaluation and re-evaluation is necessary
Differences
Breathing Children are generally easy to bag-valve-mask if
the airway is open Avoid hyperventilation and over-ventilation with
adult sized masks Chest wall is elastic – thus fractures are more
rare, but pulmonary contusions can occur without fractures
Differences Circulation and Disability
IV access may be difficult, consider IO access early – can always give blood or fluids via IO and most medications
Falling blood pressure and compromised circulation are LATE findings of shock Children compensate well – UNTIL THEY DON’T! Look for tachycardia and other signs of early
shock Look for areas of blood loss; femur fractures,
scalp hematomas, abdomen/pelvis 20ml/kg fluid boluses initial, blood 10ml/kg If trauma related, when giving the 2nd fluid bolus
- get the PRBC's ready to give
Provider Fears
Impact on the child’s life
Unable to communicate with the child
“Never did that procedure on a child”
The emotional connection to children that prevents the provider from treating the child
Fear of inflicting pain/anxiety
Unaccustomed with pediatric equipment and dosing
Special Considerations: Physical
Often they are first patients to show signs of toxicity of a poison
Thinner skin/smaller size therefore more susceptible to toxins and ionizing radiation
Increase respiratory rate, inhaling a larger dose of toxin
Larger surface area to mass ratio Closer to the ground and most toxic
gases are heavier than oxygen
Special Considerations: Physical
Vital signs are age related
Higher incidence of head and major organ injuries Major organs are closer together Larger head size Rib cage is softer and less protective
Small children have small glycogen stores – thus drop their blood sugar under stress Point of care glucose on all children with
major injury/illness
Special Considerations: Emotional
Family/familiar items are key Try to keep families together, if impossible,
keep familiar items with the child
Child appropriate books, DVD’s, music
Diversion techniques Soap bubbles, music, lights, etc.
Special Considerations: Environmental
Monitor temperature frequently
Make sure the entire body is viewed for re-evaluation and then cover
“Child friendly” environment
Group children together in care areas
Have areas for discharged “well” children where they can be monitored until sent home or to other care facilities
Special Considerations: Environmental
Ratios for Adult to Child Monitoring
Age Ratio Group Size
Infant 1:4 8
Toddler 1:7 14
Pre-school 1:10 20
School age 1:15 30
Minnesota Rule 9503.0040
Special Considerations: Communication
Speak to the child at their developmental level of understanding
Be honest
Keep the child informed as to “what is happening” and avoid surprises
Supply basic needs Appropriate food, liquids and bedding Help them go to the bathroom
Special Considerations: Family
Parents will often seek care for their children and ignore their own health
Avoid separating families
Empower family members in the care and monitoring of each other
Have a plan for unidentified/unaccompanied minors Digital photos and check off lists of identifying
information
Special Considerations: Family
Appropriate food, toys and /bedding Ratio of the number of caregivers to the number
of children is dependent on age of children Have a plan on how you will discharge children to
people other than their parents Have a plan on how you will track and record
disposition of patients
Special Considerations: Equipment
Remember: only 6.5% of the population is 8 years or younger
Plan equipment for < 8 years – above this can use small adult equipment
Key equipment issues are: IO and IV – remember pumps, buretrols and
pediatric specific fluids Airway equipment – intubation and ventilation Back-up airway equipment Surgical chest tube equipment
Special Considerations: Equipment
Have equipment for transportation of children Booster and car seats Know how to adapt transport cots to fit small
children
Have appropriate equipment to handle children
(AAP - http://www2.aap.org/visit/Checklist_ED_Prep-022210.pdf)
Antidotes and medications for pediatrics Especially analgesia and sedation early in event
Decontamination Make simple picture descriptions of decon
procedures for young children (can be used for non-English speaking patients as well)
Train with the DVD “The Decontamination of Children” from AHRQ
Consider using heavy-duty laundry baskets for infants and small children
Products that work well for oily substances – baby shampoo and Dawn
Decontamination
Use large volumes of water at low pressure
Consider decontamination of the entire family at the same time
Respect the wishes of teens
Close monitoring of temperature
Active rewarming after decontamination
Children with Special Needs
Look for medic alert bracelets and care plans
Many are dependent on medications given at specific times during the day Allow children to take their own medications If missing their medications, be prepared to
give alternative medications
Many are dependent on ventilators and other electrical equipment and may need to recharge batteries
Children with Special Needs
Alternate equipment may be necessary if the child’s is broken or not with them
If a child is non-communicative and has no personal care attendant with them, providers will need to meet the needs of the child Adequate intake of nutrition and output Medications and mode of ingestion Adequate pain relief
Medications and Treatments
Use weight based dosage for all medications and equipment Weigh the patient and dose according to
weight “Gold Standard” Use a length-based tool (Broselow tape) for
weight estimation if you cannot weigh the child Use an age-predicted weight estimation
chart as a last option because it is the least accurate
Medications and Treatments
Medications not used in children Limited use of Tetracycline derivatives in
children under 8 years of age No Aspirin No OTC cold medicines
Analgesia – titrated doses of narcotics Consider intra-nasal, sq, nebulized routes
Indications for Transfer
Children given the top priority to be transferred to a higher level of care Age less than 5 years Multiple injuries or high-energy mechanism Signs of hypotension/shock that is not
improving Altered mental status Underlying complex illness/disease
Pearls
Early signs of shock can be missed BP is the last and least reliable VS in pediatric
shock Perfusion can be influenced by temperature Children get tired and LOC can then be unreliable
Look for medical alert bracelets
High fever can cause increase in respiratory and heart rates
Pediatric Triangle of Assessment
Pearls
Use intra-osseous lines as needed Same procedure as an adult Pre-infuse with 5mL 2% Lidocaine without
preservative or epinephrine before infusing fluid in an IO to reduce pain
Consider using the distal femur in children less then 6y – just medial to quadriceps tendon anterior approach
Pearls
Treat pain Anxiety often goes away if pain is treated
Be liberal with oxygen Unlike some adult patients, very few children
have trouble with high oxygen concentrations
Respiratory danger signs Increased work of breathing Grunting or nasal flaring Stridor or wheezing
Pearls
High potential for 10-fold errors in dosing – make sure to “reality check” doses and double-check dosing
Even though children can go into shock quickly, you DO have time to think before you act.
ReassessReassessReassess
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