Transcript - Region 2 North Healthcare Coalition

Pediatric Mass Casualty : Prehospital
considerations
Faisal Patel, MD, FAAP
PEM Fellow
Beaumont Children’s / Pediatric Emergency Center
Oakland University / William Beaumont School of Medicine
Disclosures
• I have no financial disclosures to make.
Disclosure: I am not him…
What are our priorities?
Objectives
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How children are different?
Pediatric triage on the disaster scene
Pediatric considerations for decon
Providing psychological first aid during disasters
Pediatric considerations during explosives/blasts
Caring for children with special healthcare needs
How children are different?
• “Pound for pound, children breathe, drink, and eat more than
adults.”
Children are different
“Children are not small adults”
• They have unique anatomic, physiologic, immunologic,
developmental and psychological considerations
• Efforts needed in disaster preparedness, triage, diagnosis and
management of children
• Errors often stem from the lack of knowledge and experience
• Children thus are put at risk of serious harm and even death
during disasters.
Anatomic differences
• Small size, closer to the ground : Sarin gas, chlorine (heavier
than air)tend to accumulate closer to ground, more toxicity
• Smaller mass : more force per unit body surface area
• Less fat, less elastic connective tissue, closer proximity
between abdominal and respiratory organs.
Anatomic differences
• Smaller circulatory volume (80 ml/kg) and hence less fluid
reserve
• Hemorrhagic shock may result from volumes of blood lost that
could be easily handled by an adult
• Skeleton is very pliable with growth centers that injure easily
• Internal organs get injured easier without overlying bony
fracture
• Pediatric cervical spine is more amenable to ligamentous
injuries with distracting forces
Anatomic differences
• Interpretation of radiographs of cervical spine harder with
myriads of anatomical variations
• Mediastinum is very mobile : tension pneumothorax can
significantly shift the mediastinum compromising cardiac
output quickly
• Thoracic cage is smaller, and may not prevent injuries to
liver/spleen which may go unrecognized
Anatomic differences
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Head is proportionately larger with thinner calvarium
Supported by short and more fragile neck
Tongue is relatively larger
Larynx is higher and more anterior
Narrowest point is cricoid and not vocal cords
Anatomic differences
• Trachea is much shorter, higher chance or right main stem
intubation
• Lungs are smaller, higher chance of barotraumas
• Body Surface area is proportionately higher, must account for
in evaluating burns
Vitals are vital!
• They can compensate with heart rate better, and may give a
false reassurance during earlier phase of shock
• Body temperature is very important in children, may lack in
mechanisms to maintain warmth compared to adults
• Higher minute ventilation (they breathe faster), greater
exposure to toxic fumes compared to adults
• Fluid resuscitation is weight based, estimating weights in
children can be harder
Developmental differences
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Muscle tone and body composition
Mental status and social interaction
Verbal abilities
Cognitive abilities
Infant vs toddler vs pre-school vs school-aged
Infant
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Moro reflex (1-3 months)
Reaches for objects (4-6 months)
Begins to crawl (6-10 months)
Sits upright (6-10 months)
Stands (1 year)
Imitating word sounds at 6-8 months (dadadada.. Mamama)
Cannot understand words, but may find calm, continuous
speech soothing
Toddler (1-3 years)
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Walks by 15 – 18 months
Climbs stairs 1 step at 18 months
Falls more often due to increased mobility
Social interaction is unpredictable (may be fearful of strangers)
May run away
Toddler (1-3 years)
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Has basic language skills
Younger toddlers may understand single words or phrases
Does not make up false symptoms
May believe injury/pain is punishment
Views clothing/possession as a part of self
Cannot reliably point to pain
Practical considerations during disaster
• Should consider using JumpSTART to aid in pediatric triage
• Consideration for pediatric equipment, supplies, inventory for
medicines
• Dosing guides : braselow / MI MEDIC cards
• Reunification with the families can be a bottleneck in some
cases
• Post disaster stress management assumes more importance
for kids
Pediatric equipment
• Appropriate sized oxygen delivery equipment (masks, bags, et
tubes, blades)
• Appropriately sized iv cannulas
• Blood pressure cuffs
• Vital sign parameters
• Chest pads
• Medications
• Ventilators, g tubes, trachs for children with special needs
• Splinting material
Triage
Pediatric disaster triage
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Disaster : Needs outstrip immediately available resources
Disaster is relative to the resources available locally
Children usually die out of primary respiratory causes
Adults usually die out of circulatory shock following arrest
Apnea in an adult is an endpoint
Child with apnea has a good chance of having circulation
restored if respiration bolstered immediately
Pediatric disaster triage
• Some triage tools ability to ambulate / follow commands as
the only means to assess neurological status
• By this definition, most children in the infant / toddler /
preschool category will be falsely triaged to be critical
• May unnecessarily take away the resources from patients who
would benefit the most
Principles of disaster triage (physical events)
• In disasters, resources are insufficient to meet the needs
• Doing best for all may not be the best approach
• Focus on using resources where they will provide greatest
benefit
• This may mean that some of the most critical patients receive
little or no medical care
Different PDT tools
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Jump START
SACCO
Smart Tape
SALT
Jumpstart!!
Jumpstart
• Patient appearing as young adults, should be triaged as adults
• Triage decision is based on the assessment of Respiration,
Perfusion and Mental status
• Should take no longer than 30 seconds
• Green (minor), Yellow (delayed), Red (Critical), Black
(Diseased/Expectant)
• Triage begins by asking all the victims to move to a specific area
(green)
• Remember some of the significantly injured children may be
carried off to green area and they will need to be re-triaged
Biological events and disaster triage
• The goal of triage in bioevents is not primarily to identify
victims who need most immediate care
• Primary goal is to prevent further transmission from the first
point or moment of contact with the index case
• Conventional triage in these situations may actually promote
the transmission of the agent, putting others at harm.
• So the first step is PPI and then determining whether the
victims are probably yes or probably not exposed.
Decon and pediatric considerations
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Terrorism a realistic threat
Biological, chemical or radioactive agents
Transport of hazardous substances in trains and airplanes
Children may be intentionally targeted
Beslan (Russia) hostage crisis (Sept 2004), Peshawar (Pakistan)
school massacre (Dec, 2014)
Conditions requiring decon
• Nerve agents: Sarin, soman, malathion
– Weakness, coma, respiratory distress
• Vesicants: Mustard, ammonia, chlorine
– Eye, skin and airway irritation
• Choking agents: Phosphine
– Respiratory distress, bronchospasm
• Cyanogens: Cyanide
– CNS depression, dyspnea, metabolic acidosis
• Industrial solvents: Gasoline
– CNS depression, respiratory distress
• Biologicals: Anthrax spores
Decon principles
• Decon plan must have scalability : ie flexibility to decon 2-3
children to 50 children
• Removing clothes takes care of 90% of decon
• Showers are integral to decon
– Temp of 37-38
– Pressure of 60 pounds per square inch
• Plan should be all-weather adjustable and adaptable
• PPE is essential for the providers (Class A to D)
Decon staging
• Hot zone
– All exposed patients placed here
– All providers should be in PPE
– Use audio-visual aids to communicate with victims (speaking through
PPE is difficult!)
Decon staging
• Warm zone
– Actual process of decon takes place here
– Victims need to disrobe
– Gender segregation for little children is unnecessary
– Families encouraged to stay together
– All their belongings labeled, secured and handed over to law
enforcement
Decon staging
• Clean (Cold) zone
– Post shower area, victims held prior to transportation
– Blankets and clothing should be provided
– Pts should be retriaged
Age based issues in decon
• Infants and toddlers
– Will be slippery and wet
– Cannot cooperate
– May be placed in large container so that they are not dropped (laundry basket or
bassinet) while showering
• Preschoolers
– May throw tantrums, will be scared
– Families should be encouraged to stay with them
– Parents may assist in washing, although should not be the sole decon person
• School age children and adolescents
– May refuse to disrobe in public
– Necessary to have curtains or barriers
Age based issues with decon
• Children with special health care needs
– Non ambulatory children need decon on stretcher or wheelchair
– Ventilators are not waterproof!! Manual ventilation while being
showered
– Careful attention to airways for pts with trach
– May have central iv lines, feeding pump and tubes that cannot be
detatched from the body
– Any external equipment must be considered contaminated
– If it cannot be decontaminated, should be discarded
Complications of decon
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Removal of identifiers
Hypothermia
Fear and anxiety
Personnel safety
– Personnel may get overheated with PPE
– Should not work > 20 minutes at a stretch while wearing PPE
Aftermath of a disaster: Psych first aid (PFA)
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Establish open communication with children and family
Explain to them in basic, simple terms about what happened
Avoid graphic details
Provide clarifications and reassurance as needed
Allow the children to vent their emotions; don’t try to cheer them
up or force to mask their distress
• Avoid indicating that you know exactly how they are feeling
• Avoid telling them how they ought to feel: eg. ask how are you
doing? Instead of “you must be scared”
Psychological First Aid
• Provide them with food, shelter
• Emphasize safety: Let them know that they are safe and what
are you doing to keep them safe
• “I am going to put this belt around you so that you stay safe
and secured while we move you..”
• Allow parents and close family members to stay with the
children
• Shield them or relocate to prevent unnecessary traumatic
exposures
Children’s reaction to disaster and crisis
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Increased fear
Anxiety disorder
Difficulty to concentrate, confused
Irritability, immature behavior, aggressive
Regressive behavior
Stress related symptoms, eg stomachaches, headaches
Role of a pre-hospital provider
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Triage the patients that may need help
Children who are direct victims with physical injury
Children whose close relatives were severely injured/died
Directly witnessed death
Separation from parents
Loss of pet, belongings
Pre-existing mental health problems
Parents who appear to be struggling themselves mentally
Role of a prehospital provider
• A brief narrative of what happened should be recorded
– Events as known or as described
– Reconstruct the story for the events that occurred
Bomb blasts/ explosives
• Suicide bombs
– More successful as they evade detection
• Package bombs
– Crowded places
• Vehicle bombs
– Heavy explosive material
Blast physics
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Chemical gets converted to gas with LARGER volume
Rapidly expanding “blast wave” translating into “blast wind”
Project outward in all directions
Open vs confined space
Injury severity directly proportional to the distance from blast
site
Blast injuries
• Primary (external overpressurization by the blast wave)
– Air filled / fluid filled organs at highest risk
– Blast lung, auditory, cardiac and abdominal blast injuries
• Secondary
– Blast winds causing objects to strike the victim
– Blunt or penetrating trauma from flying debris, sharp metal etc
• Tertiary
– Blast wind propelling victim against a fixed object
• Quarternary
– Thermal/chemical burns, inhalational injuries, asphyxiation, radiological
exposure, psychological effects
Management during blasts
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Scene control! (Ensure safety for yourself and the bystanders)
“Scoop and run” approach may be warranted
Protect the critically ill but salvageable patients
Victims with amputated parts and no signs of life are considered
dead
• CPR should not be done on the scene
• Airway management with c-collar are of paramount importance!
• Needle decom, splinting, direct pressure/tourniquets are ok
Children with special healthcare needs
• “Those who have or are at increased risk for a chronic physical,
developmental, behavioral or emotional condition and who
also require health and related services of a type or amount
beyond that required by children generally”
Medical conditions
• Airway
– Asthma, BPD, Cystic fibrosis , Tracheomalacia
• Cardiac
– Complex congenital heart disease, cyanotic/acyanotic defects
• Down syndrome or other genetic conditions
• Traumatically disabled children
• Neurologic problems
– Epilepsy, severe cognitive impairement, cerebral palsy
• Endocrine, Oncologic or Immunologic process
Technology needed to support special care needs
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Tracheostomy and tracheostomy tubes
Home ventilators
BiPAP
Central IV catheters
Internal pacemakers and defibrillators
Feeding catheters and gastrostomy tubes
Colostomies
CSF shunts
Vagal nerve stimulators
Try to prevent caregiver separation
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Families play a critical role
They are familiar with them and can provide basic health care
Separation puts their life at risk
They may become unstable just from being separated from
caregivers
Take home points
• Children are different : Focus on pediatric airway, use the tools
(Braselow, JumpStart) to your advantage
• Triage is critical: Recognize your limitations
• Keep them with family, keep them happy, keep us happy!
• Scene control for blasts : Scoop and run..
• Children with special needs: Caregivers are your best resources
References
• Foltin G, Tunik M, Cooper A, Treiber M. Pediatric Disaster
Preparedness: A resource for planning, management and
provision of Out-of-hospital emergency care. New York, NY:
Center for Pediatric Emergency Medicine; 2008.
Family Considerations: Pediatric patient’s
identification, tracking and reunification
Faisal Patel, MD, FAAP
PEM fellow
RO EC / Beaumont Children’s / OUWB SOM
Aftermath of Katrina and Rita
• 411,000 got dispersed across the 48 states in the US
• 5000 children were listed as missing or separated (National
Centre for Missing and Exploited Children)
• 5050 / 5182 cases were resolved. (98% success)
• Some children were found in a separate state
• Most children with family friends and distant relatives
Challenges
• Rescuers are often overwhelmed with the sheer volume
• Many of the victims don’t actually end up being patients
• Katrina: Many families preferentially sent their kids first to
safety in buses
• Subsequently got separated
The felt need..
• Time sensitive
• Photo technology
• Centralized, real time, data collection tool
– Real time
– Documentation
– Origin, transition points, final location
• Software, hardware caveats
Reunification
• The process of assisting displaced disaster survivors, including
children, in voluntarily reestablishing contact with family and
friends after a period of separation
Unaccompanied minors
• Children who have been separated from both parents, legal
guardians, and other relatives and are not being cared for by
an adult who, by law or custom, is responsible for doing so
Reunification of families: 2 important questions
• What tasks need to be performed?
• What resources are available to assist in your locality?
Reunification: Basic steps
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Identify the patient..
Initiate the tracking process..
Contact the appropriate responsible local agency..
Provide secure shelter, care and tracking…
Identify…
• Ask for key information
– name, age, pre-disaster address
– names of parents/legal guardians
– last known whereabouts of parents/legal guardians
– relatives' contact information
– any disabilities, access and functional needs, or medical needs
Identify…
• Note physical description
– height, weight, hair color, eye color, gender
– scars, birthmarks
– description of clothing/jewelry
– School or child care setting may be a source of this information
Initiate…
• your institution or location's tracking procedure
– wristband
– web-based system
– digital photograph
Initiate…
• Tracking without barcodes/pictures/tags
– Indelible marker: Prior to the separation of the child and the adult
Contact…
• the appropriate responsible agency in your location
• Key resources
– law enforcement
– child welfare/child protective services
– the National Center for Missing and Exploited Children reunification
system [24-Hour Hotline 1-800-THE-LOST (1-800-843-5678)]
Contact…
• Other possible resources
– Community partners that may assist in a disaster with tracking and
reunification of children.
– educational, child care, recreational facilities
– juvenile justice or other medical facilities
– Family Assistance Centers
– medical examiner's offices
Contact…
• Resources to consult
– Your organizational emergency preparedness plan
– An organizational emergency preparedness officer
– Local or state emergency management office
– Local or state child welfare agency
– State or territorial missing-child clearinghouse
Provide…
• Shelter
• Care
• Continued tracking
Shelter
• Determine the designated pediatric safe area for the hospital
– Well child waiting area at the pediatric ward
• Account for all the children (count heads)
• Access to the area must be secured
Transition of responsibilities
• Can you legally leave the children at the hospital?
– Once you have delivered the children to the hospital
– provided all the identifying information you have gathered
– you can transfer responsibility for further tracking to the hospital
staff
Before releasing the child to the family..
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Identity of the family member must be verified and
Determine whether they have the legal custody of patient
Procedures for these determinations are complex
May require assistance from child welfare agencies, law
enforcement, and the judicial system
Using technology to help us
Patient connection
• A call center becomes operational if >10 victims of disaster are
admitted
• Families can now call a single hotline number
• American Red Cross exempt from HIPAA during disasters
• American Red Cross could access the information across all
hospitals where the victims may be
• Information provided by family is then matched with that
provided by the hospital
Take home points
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Identify the pts
Enter them into a tracking system
Facebook can he useful!
Your responsibility until you “hand over” to the hospital staff
References
• Post-disaster reunification of children- A nationwide approach.
2013.
• Tracking and Reunification of Children in Disasters: A Lesson
and Reference for Health Professionals; National Center for
Disaster Medicine and Public Health
• Foltin G, Tunik M, Cooper A, Treiber M. Pediatric Disaster
Preparedness: A resource for planning, management and
provision of Out-of-hospital emergency care. New York, NY:
Center for Pediatric Emergency Medicine; 2008.