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