Transcript Caring for Children During Disaster

Pediatric Disaster Life Support
©)
(PDLS : Scene Assessment, Triage,
Resuscitation and Stabilization at the
Scene of a Disaster
James Courtney, DO
Triage Assessment, Stabilization,
Resuscitation
 Learning Objective
 At the end of this lecture, the students should be
able to:
- describe differences in triage decision making for
-
children
describe triage categories
describe field triage assessment
describe principles of field triage, stabilization and
resuscitation
describe initial field stabilization methods for children
describe organization of field triage, treatment, staging,
and clearing/transportation for children
General Principles of Disaster Care
 Scene Assessment
 Triage Assessment
 Initial Stabilization
 Resuscitation
Scene Assessment
 Ensure scene safety
 Establish that disaster exists
 Estimate number of victims: adults/children
Scene Assessment
 Notification to medical control: regional
communications, local emergency management /
disaster authority
- type of event
- initial casualty estimate
 Make initial request for additional resources
Then begin triage assessment of individual patients
Triage Assessment
 Derived from the French “trier” meaning to sort, it
describes a medical decision making process
 Guides decisions about allocating scarce resources
and limited time
 “greatest good for greatest number”
 Protocol helps makes decisions
 Appropriate performance crucial
Triage
 ICS separates triage from treatment immediately
- see everybody once briefly for overview
 Dynamic process, re-triage / re-evaluate at several
stages
 Triage in disaster setting may be very difficult
 Pediatric population unique challenge
Initial Brief Assessment
 Open airway
 Control major hemorrhage
 Categorize
Triage Classifications
 Simple Triage And Rapid Treatment
S.T.A.R.T.
 JumpSTART
Tool for Rapid Pediatric Multicasualty Field
Triage (children from 1 - 8 years of age)
Triage Categories
 Red / Immediate / Emergent
 Yellow / Urgent
 Green / Non-Urgent / Walking Wounded
 Black / Deceased or soon to be
Triage Classifications and Examples
 Red - tension pneumothorax, rib fractures, upper
airway obstruction, hemorrhage, femur fracture,
asthmatic
 Yellow - humerus fracture, scalp lacerations,
shoulder dislocation
 Green - ankle sprain, simple laceration, orphaned
child, subluxed radial head
 Black/Blue - cardiopulmonary arrest, severe open
head injury
START
 Most commonly used triage system
across country
 Not applicable for under 8 years old
 Initial eval – not final
 Time limited (plan <1 min/patient)
 Categorize and move on
START
 “If you can hear me and are able, walk
over here” GREEN triage done – still need
individual evaluation, but can await more
staff, allows initial rescuers to focus on
more severely injured people.
 Gen 80% of victims will be green, self
extricate (may self transport – eases
burden on field but hard on hospitals)
START
 EVAL (and tag) those unable to walk for
transport: RPM
 Resp: no => open airway= still no then
reposition airway = still no =>BLACK
if yes => RED (immediate).
 Spont resp >30 => RED/ under 30 => next
item of assessment
START
 Perfusion: cap refill > 2 sec => control
bleeding, label RED; <2 sec, next item
 Perfusion: Radial Pulse => if no label RED;
if yes then next item
 Mental status: Cannot follow simple
commands => RED; CAN follow simple
commands (and has cap refill < 2 sec and
spont resp < 30) => YELLOW (delayed)
START
 As soon as one can categorize a patient,
STOP evaluating (if they are RED for
breathing, they won’t be seen any faster
for additional problems) and move on.
 Minimal treatment during triage: airway
maneuver (chin tilt, jaw thrust) and dress
active blood loss (not scrapes).
Pediatric Triage
Pediatric Triage
 Triage of children and adults is typically
done simultaneously during a disaster
 It is important to remember that although
the injury process may be the same, a
child’s vulnerability to that injury may be
very different
- Specifically, their response to airway obstruction
Pediatric Triage
 The standard adult triage tools do not take
into account the specific vulnerability that
children have to dying from airway
obstruction
 Children may have a reversible period of
respiratory arrest from which they may
recover if treated promptly
Pediatric Triage
 Due to this, a specific pediatric triage tool
was developed and tested
- JumpSTART
 Builds from the concepts of triage taught
in START triage, which is commonly
utilized
Confused?
 If you remember the specific vulnerability
children have to airway compromise, this
makes sense
 The “Jumpstart” term refers to the extra
chance we give a child to breathe before
we declare them a BLACK TAG
JumpSTART (under 8)
 Kids more airway dependent – rescue
breaths attempted if pulse present (unlike
adults) Resp 15-45 instead of <30
 Vascular system clamps down sooner, so
cap refill less reliable. Use peripheral
pulse instead.
 Mental status AVPU instead of following
simple commands
JumpSTART
 “If you can hear me and you are able, walk
over here for help.”
 Probably won’t work for children
 If they are ambulatory, then they are GREEN
 Use adults on scene to help corral the
GREEN children
JumpSTART
 Respirations: NO  open airway => yes
RED; no -> check peripheral pulse.
 NO pulse = BLACK
 Pulse  15 sec mask to mouth ventilation
 Spont resp: NO  BLACK; YES  RED
JumpSTART
 Breathing: RR <15, >40 or irregular =RED
 RR 15-40, regular – check pulse
 No peripheral pulse: RED
 Peripheral pulse: check mental status
 AV (appropriate) YELLOW
 PU (inappropriate) RED
Kids in triage
 Don’t follow commands.
 May actually hide from rescuers
 May be extricated by GREEN parents/
adults with delay in triage and treatment.
 Need distraction and dedicated supervisor
able to run after wandering toddlers
Examples
 Awake 8 yr old child
brought in 3 days
after earthquake with
20 others
 Can not walk
 Responds to voice
 Respiratory Rate 50
IMMEDIATE
 No obvious injuries
Examples
 Unconscious 4 year old
hit in head by debris
moments ago
 In a room full of injured
children
 Not breathing
 Obvious head injury
Examples
 What do you do?
How do you classify
this child if he
breathes?
IMMEDIATE
How do you classify
this child if he does
not breathe after 5
rescue breaths?
DECEASED
Examples
 You are receiving
multiple casualties on
a hospital ship
 Young child found
breathing but sleepy
 Brought in by military
helicopter with IV
running
Examples
 What do you want to
assess?
 Respiratory Rate 30
 Has a palpable pulse
 Arouses to touch and
loud voice
DELAYED
Categorize the Following
1. 7 y.o. female, crying, unwilling to move right arm, 1°
burn to anterior thigh GREEN
2. 10 y.o. male, deformed thigh, pale, pulse 120, BP
30/40, RR 30 RED
3. 20 y.o. female, apneic, severe head injury with visible
grey matter BLACK
4. 2 y.o. male, 2-3° burns to face, neck and chest RED
5. 5 day old infant, found on ground, appears unharmed
YELLOW
Pediatric Triage
 Focus on integration of children in to the
triage system
 Once a child is classified as a color,
quickly move them to a treatment area in
order of severity
- RED first, then YELLOW, then GREEN
Preplanning
 Needs assessment of community
 Commitment on part of institutions and key
personnel to treating injured children
 Consider children with special needs
 Consider evacuation process for NICU/PICU/SCU
for newborns
 Lack of supervision
Decontamination
Decontamination of Children
 Special issues must be accounted for
before undertaking decontamination of
children
 Advance planning will make the difference
 Goal is to integrate care of children with
that of the general population
Decontamination of Children
 Parents
- After a disaster or major emergency, most parents
will not separate from their children
- Decontamination patient flow must account for this
- Takes longer than expected to decontaminate
parent and child
Decontamination of Children
 Temperature Extremes
- Decontamination water must not be ice cold for
young children
Risk of hypothermia, especially in winter
Children must be covered immediately
- Risk of injury if too hot or chemicals used
Do not use bleach in decon water
Do not use rough scrubbing devices
Decontamination of Children
 Special Equipment
- Have a plan for special equipment on children or
adults
Wheelchairs
Electronic equipment
Firearms
Decontamination of Children
 Special Issues
- How long does it take a child to take a shower or
bath normally?
- Children may not be cooperative
- Children will likely be frightened with protective
suits
- How do you track a non-verbal, naked child after
decontamination?
Child Likely To Need Specialized Care
 Shock SBP <80, HR>130<50
 Resp distress RR>30<10, stridor
 GCS<9
 Mechanism
- MVA
- Pedestrian/bicyclist thrown >15 feet
- Penetrating injury to head, neck, trunk
Child Likely To Need Specialized Care
Specific injuries
 skull fracture
 pneumothorax, flail chest
 abd trauma with peritoneal signs
 amputation / degloving
 vascular injury
 burn with inhalation
 FB aspiration / ingestion
Progression of Pediatric Shock
Response to Shock
Vascular
resistance
Percent of control
140
100
60
20
Cardiac
output
Compensated
shock
Blood
pressure
Decompensated
shock
Pediatric Assessment Triangle
Pediatric Resuscitation
Russian Field Hospital
Nias, Indonesia
4/05
Treatment
 Patients frequently may outnumber transport,
leading to time in field where treatment can be
started
 Sort patients by category (GREEN, YELLOW,
RED and BLACK) and treat within areas.
 If GREEN patients self triaged, they need
evaluation.
 Limited initial treatment – don’t delay
evacuation if vehicle available
Treatment
 Kids will be mixed in – do you have enough
supplies in kid size (oxygen, IVs, splints)?
 Does your locality stock a “disaster truck”?
 Does it have kid size equipment and kid sized
doses of Hazmat antidotes?
 Do you have Broselow tapes to guide
dosing?
Field Stabilization
 Airway - chin lift, jaw thrust, oro- or nasopharyngeal
airway
 Breathing - supplemental O2 as available
- limited resources for mechanical/manual
ventilation
 Circulation - hemorrhage control - direct pressure,
dressings (rotating tourniquets)
- limited resources for IVF
 Fracture Stabilization - using resources available
Field Stabilization
 There is little role for initiation of CPR in disaster
situations
 Consider on site organization of arriving personnel and
arriving resources
 Consider establishment of clearing/staging until:
- triage patients for treatment on site or transport to
hospital/health care facility
- efficient utilization of resources, personnel, and
supplies
Resuscitation/Stabilization
 Simple measures that do not require
sophisticated equipment are most appropriate.
 Needs must be evaluated and balanced against
available resources.
 The principle of “doing the greatest good for the
greatest number”.
Consider IV Access in the Following:
 Time to definitive care 30-60 minutes
 Prolonged extrication / entrapment
 Dehydration > 15%
 Multiple fractures
 Scalp lacerations with significant blood loss
IV Access
 Attempt peripheral access if unsuccessful in <90 sec.
consider IO.
 Estimated body weight in kg: (age in yrs x 2) + 10
 Blood volume = 80 mls/kg x body weight
 Estimate blood loss: # pelvic ring = 10% total blood volume,
# femur up to 20%.
 IO access sites
- distal femur
- proximal tibia
- med/lat malleolus
- iliac crests
 High success rate, up to 80% in less than one minute
Treatment:
 Dressings – rinse gross dirt with
sterile fluids or tap water if available,
sterile cover to prevent further
contamination
 Pressure dressing for active bleeding
- Recruit neighbor to help hold pressure
during triage while awaiting
transport/evacuation
 Splint – extremity injuries
Treatment
 Medications: pain control, specific
antidotes with Hazmat event/team
 Monitoring: repeat assessment after
triage, re-categorize if necessary (to
worse, never better – they still have the
same underlying injury)
Further field care
 Depends on local plans
 Send personnel and supplies to site, or
bring patients to hospital (personnel and
supplies)
- EMS –patient to hospital
- NDMS – personnel and supplies to site
Transport
 Decides which patients leave scene first and
where they’re going
 Helpful bystanders and self transporters will
fill the nearest hospitals first.
 Includes decisions about longer transport
times for specialty care
 Use helicopters for long distance transports
Children with Special Health Care
Needs
Children with Special Health Care
Needs (CSHCN)
 Children with special medical or physical
needs
- Wheelchair or crutches
- Learning disability
- Vision, hearing, or language impaired
- Technology dependent
Ventilator
Dialysis
Children with Special Health Care
Needs (CSHCN)
Children with Special Health Care
Needs (CSHCN)
Prevalence of CSHCN
 Based on a national survey
- 1 in 5 households self identify as having a
CSHCN
- Approximately 1 in 8 children are identified by
parents as being CSHCN
 Care of these children must be integrated
in to the care of all children during a
disaster
Special Challenges for CSHCN
 Sheltering
- Controversy: Together or separately?
- Controversy: Should CSHCN be considered medical
patients if they are not injured or ill?
 Decontamination
- What is the best way to decontaminate medical hardware
such as a wheelchair?
- How do we decontaminate technology, such as a
ventilator?
Special Challenges for CSHCN
 Transportation
- Take equipment with or leave behind during evacuation?
 For all of these topics, special advance
planning is required to be successful in taking
care of all children
Sheltering for Children
 Hurricane Katrina taught us many harsh
lessons about how important shelter
planning is
Sheltering Issues
 Hygiene
- Children pose a special risk to maintaining
hygiene in a shelter operation
- Basic supplies such as wipes and diapers
frequently overlooked
- Children are at a special risk of acquiring
gastrointestinal and respiratory diseases
- Children are exceptionally good at spreading
these diseases
- Must plan for handwashing/sanitizing
Sheltering Issues
 Safety and Supervision
- Shelters are dangerous environments
- Rarely childproofed
- Children move quickly throughout environment
- Easy to get lost
- Possible criminal element
Sheltering Issues
 Health Maintenance
- Clean water and healthy food a challenge
- Children require something to do
Consider a recreational therapy group
- Children require more sleep
Shelters are frequently loud
- Pediatric Health Screening important
Prevention of disease
Maintaining primary care for extended stays
Resources
 PDLS is a start
 Much information exists to guide the
preparation and care for children in
disasters
Resources
 U.S. Center for Disease Control
- www.cdc.gov
 National Center for Disaster Preparedness
- http://www.ncdp.mailman.columbia.edu/
 American Psychological Association
- www.apa.org
Resources
 JumpSTART Triage Tool
- www.jumpstarttriage.org
 American Academy of Pediatrics
-
http://www.aap.org/terrorism/topics/disaster_planning.html
 Pediatric Disaster Preparedness
Consensus Conference Summary
-
http://www.bt.cdc.gov/children/pdf/working/execsumm03.pdf
 U.S. Department of Homeland Security
- www.dhs.gov
Disclaimer

The information herein should NOT be used as a substitute of
an appropriately certified and licensed physician or health care
provider. The information herein is provided for educational
and informational purposes only and in no way should be
considered as an offering of medical advice. The authors,
editors, and publisher of this site have used reasonable efforts
to provide up-to-date, accurate information that is within
generally accepted medical standards at the time of production.
However, as medical science is ever evolving, and human error
is always possible, PDLS does not guarantee total accuracy or
comprehensiveness of the information on this site, nor are they
responsible for omissions, errors, or the results of using this
information. The reader should confirm the accuracy of the
information in this article from other sources. In particular, all
drug doses, indications, and contraindications should be
confirmed in package inserts.
Course Directors
 PDLS 2.0 content revision- March 2006
- Andrew L. Garrett MD, FAAP
- Richard V. Aghababian, MD, FACEP
University of Massachusetts Medical School
 PDLS course- 1999
- Richard V. Aghababian MD, FACEP
Original Contributors
 Gregory Ciottone, MD
 Lucille Gans, MD
 Patricia Hughes, RN
 Frank Jehle, MD
 Taryn Kennedy, MD
 Gretchen Lipke, MD
 Mariann Manno, MD
 Robert McGrath, M.Ed.
 W. Peter Metz, MD
 John A. Paraskos, MD
 Carol Shustak, RN
 Elizabeth Shilale, RN
 A. Richard Starzyk
 Gina Smith, RN
 Michael Weinstock, MD
 Fred Henretig, MD
 Sharon Welsh, RN
 Theodore Cieslak, MD
 Lou Romig, MD