Pediatric Disaster Life Support

1. Pediatric Disaster Life Support Core Content Lecture 2 Practical Issues in Pediatric Disaster Medicine and Preparedness Andrew L. Garrett, MD

2. Goals of this Section • Apply the concepts learned in the first section with a focus on the vulnerabilities of children in disaster • To teach specific information which will enhance the practical application of this information

3. Goals of this Section • To further develop the bio-psycho-social model’s applicability to pediatric disaster medicine and preparedness Social Biological Care of the Child During Disaster Psychological

4. Pediatric Triage

5. Pediatric Triage • Triage is the sorting of patients • During a disaster, the number of patients may exceed the amount of medical resources • It is important to allocate the limited resources to those who will most benefit from them

6. Pediatric Triage • In other words: To do the most good for the most patients

7. Pediatric Triage • Triage may occur at several points during a disaster • The scene of destruction • Mass casualty incident • At a casualty collection point or field hospital • At a receiving hospital • Mass casualty receiving

8. 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

9. 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

10. 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

11. START Triage (adults)

13. 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

15. Examples • Awake 8 yr old child brought in 3 days after earthquake with 20 others • Can not walk • Responds to voice • Respiratory Rate 50 • No obvious injuries IMMEDIATE

16. Examples • Unconscious 4 year old hit in head by debris moments ago • In a room full of injured children • Not breathing • Obvious head injury

17. Examples • What do you do? • How do you classify this child if he breathes? • How do you classify this child if he does not breathe immediately? IMMEDIATE DECEASED

18. Examples • You are receiving multiple casualties on a hospital ship • Young child found breathing but sleepy • Brought in by military helicopter with IV running

19. Examples • What do you want to assess? • Respiratory Rate 30 • Has a palpable pulse • Arouses to touch and loud voice DELAYED

20. 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

21. Children with Special Health Care Needs

22. 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

23. Children with Special Health Care Needs (CSHCN)

24. Children with Special Health Care Needs (CSHCN)

25. 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

26. 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?

27. 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

28. Sheltering for Children • Hurricane Katrina taught us many harsh lessons about how important shelter planning is

29. 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

30. Sheltering Issues • Safety and Supervision • Shelters are dangerous environments • Rarely childproofed • Children move quickly throughout environment • Easy to get lost • Possible criminal element

31. 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

32. Decontamination

33. 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

34. 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

35. 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

36. Decontamination of Children • Special Equipment • Have a plan for special equipment on children or adults • Wheelchairs • Electronic equipment • Firearms

37. 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?

38. Chemical and Biologic Agents

39. Chem/Bio Response • Frequently lumped together • Each will present to a different group and on a different timeline

40. Timeline Chemical Attack First responders arrive DECON Presentation Of Symptoms Few Secondary Cases Seconds to Minutes

41. Timeline Biological Attack Sick people present to hospitals/clinics/EMS People may not know about exposure Presentation Of Symptoms Incubation time Delay of hours to days Secondary Exposures?

42. Biological Agents

43. Biological Agents • Most Cat. A agents are detectable in their full-blown form • Characteristic symptoms, X-rays, or progression • Lab evaluation not typically rapid

44. Widened Mediastinum of Anthrax

45. Skin Lesion in Anthrax Infant patient

46. Pneumonia of Plague + hemoptysis & fever

47. Exanthem of Smallpox • Synchronous development of lesions • Cetrifugal pattern

48. Paralysis ofBotulism

49. Chemical Terrorism:Which Agents? • “Military Grade” Agents • Nerve Agents • “Blister Agents” (Vesicants) • “Blood Agents” (Cyanides) • “Choking Agents” (Phosgene, Chlorine) • Weapons of Opportunity • Toxic Industrial Chemicals

50. Chemical Terrorism:Which Agents? • “Military Grade” Agents • Nerve Agents • “Blister Agents” (Vesicants) • “Blood Agents” (Cyanides) • “Choking Agents” (Phosgene, Chlorine) • Weapons of Opportunity • Toxic Industrial Chemicals