pediatric disaster life support core content lecture 2 practical issues in pediatric disaster...

Pediatric Disaster Life Support

Pediatric Disaster Life Support

Core Content Lecture 2

Practical Issues in Pediatric Disaster Medicine and Preparedness

Andrew L. Garrett, MD

Core Content Lecture 2

Practical Issues in Pediatric Disaster Medicine and Preparedness

Andrew L. Garrett, MD

Goals of this SectionGoals 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

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

Goals of this SectionGoals of this Section

To further develop the bio-psycho-social model’s applicability to pediatric disaster medicine and preparedness

To further develop the bio-psycho-social model’s applicability to pediatric disaster medicine and preparedness

Care of theChild During

Disaster

Biological

PsychologicalSoc

ial

Social

Pediatric TriagePediatric 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

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


In other words:

To do the most good for the most patients

In other words:

To do the most good for the most patients


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

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


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

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


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

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


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

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

START Triage (adults)

Confused?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

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

ExamplesExamples

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

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

ExamplesExamples

Unconscious 4 year old hit in head by debris moments ago

In a room full of injured children

Not breathing Obvious head injury

Unconscious 4 year old hit in head by debris moments ago

In a room full of injured children

Not breathing Obvious head injury

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?

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?

ExamplesExamples

IMMEDIATE DECEASED

You are receiving multiple casualties on a hospital ship

Young child found breathing but sleepy

Brought in by military helicopter with IV running

You are receiving multiple casualties on a hospital ship

Young child found breathing but sleepy

Brought in by military helicopter with IV running

ExamplesExamples

What do you want to assess?

Respiratory Rate 30 Has a palpable pulse Arouses to touch and

loud voice

What do you want to assess?

Respiratory Rate 30 Has a palpable pulse Arouses to touch and

loud voice

ExamplesExamples

DELAYED


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

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

Children with Special Health Care Needs

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 medical or physical needs Wheelchair or crutches Learning disability Vision, hearing, or language impaired Technology dependent

Ventilator Dialysis

Prevalence of CSHCNPrevalence 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

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 CSHCNSpecial 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?

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 CSHCNSpecial 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

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 ChildrenSheltering for Children

Hurricane Katrina taught us many harsh lessons about how important shelter planning is

Hurricane Katrina taught us many harsh lessons about how important shelter planning is

Sheltering IssuesSheltering 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

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


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

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


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

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

DecontaminationDecontamination

Decontamination of ChildrenDecontamination 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

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


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

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


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

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


Special Equipment Have a plan for special equipment on children

or adults Wheelchairs Electronic equipment Firearms

Special Equipment Have a plan for special equipment on children

or adults Wheelchairs Electronic equipment Firearms


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?

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?

Chemical and Biologic AgentsChemical and Biologic Agents

Chem/Bio ResponseChem/Bio Response

Frequently lumped together

Each will present to a different group and on a different timeline

Frequently lumped together

Each will present to a different group and on a different timeline

Timeline Chemical AttackTimeline Chemical Attack

PresentationOf

Symptoms

Seconds toMinutes

First respondersarrive

DECON

FewSecondary

Cases

Timeline Biological AttackTimeline Biological Attack

PresentationOf

Symptoms

Delay ofhours to

days

People may not knowabout exposure

SecondaryExposures?

Sick people presentto hospitals/clinics/EMS

Incubation time

Biological AgentsBiological Agents

Category A Category B Category C

Smallpox Anthrax Plague Botulism Tularemia Ebola Marburg

Q Fever Brucellosis Glanders Melioidosis VEE Ricin SEB Cholera

Nipah Hantavirus Yellow Fever MDRTB TBE

Category A Category B Category C


Q Fever Brucellosis Glanders Melioidosis VEE Ricin SEB Cholera

Nipah Hantavirus Yellow Fever MDRTB TBE

Biological AgentsBiological Agents

Category A


Category A


• Most Cat. A agents are detectable in their full-blown form

• Characteristic symptoms, X-rays, or progression

• Lab evaluation not typically rapid

Widened Mediastinum of Anthrax

Skin Lesion in Anthrax

Infant patient

Pneumonia of Plague

+ hemoptysis & fever

Exanthem of Smallpox

Synchronous development of lesions

Cetrifugal pattern

Paralysis ofBotulism

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



Increased surface area/volume more absorptive surface more susceptible to volume losses

Increased minute ventilation Thinner epidermis Under-keratinized epidermis Increased absorption Immature blood-brain barrier

Increased surface area/volume more absorptive surface more susceptible to volume losses

Increased minute ventilation Thinner epidermis Under-keratinized epidermis Increased absorption Immature blood-brain barrier

Vulnerabilities of Children to Bio/Chem Agents

Vulnerabilities of Children to Bio/Chem Agents

VEE-- increased morbidity in children Smallpox-- lack of immunity Trichothecenes-- more susceptible ? Melioidosis-- unique parotitis Anthrax-- ?? Less susceptible

VEE-- increased morbidity in children Smallpox-- lack of immunity Trichothecenes-- more susceptible ? Melioidosis-- unique parotitis Anthrax-- ?? Less susceptible

Specific Vulnerabilities to Specific Diseases

Children Do Not Fit the Treatment Mold

Children Do Not Fit the Treatment Mold

The two main antibiotics used to treat biowarfare agents are not typically used in children Ciprofloxacin and Doxycycline

In the opinion of experts, however, their use is warranted if there is a realistic risk of exposure to a biowarfare agent

The two main antibiotics used to treat biowarfare agents are not typically used in children Ciprofloxacin and Doxycycline

In the opinion of experts, however, their use is warranted if there is a realistic risk of exposure to a biowarfare agent

CiprofloxacinCiprofloxacin

First line treatment for: Anthrax Plague

First line treatment for: Anthrax Plague

DoxycyclineDoxycycline

First line treatment for: Anthrax Plague Tularemia Brucellosis Q Fever

First line treatment for: Anthrax Plague Tularemia Brucellosis Q Fever

Vaccination IssuesVaccination Issues

Anthrax vaccine not approved in children under 18

Plague vaccine (not currently in production) not approved in children

Smallpox and Yellow Fever vaccine produces more complications in kids

Anthrax vaccine not approved in children under 18

Plague vaccine (not currently in production) not approved in children

Smallpox and Yellow Fever vaccine produces more complications in kids

Other ConsiderationsOther Considerations

Underavailability of chemical and biological antidotes for children

Poor access to nerve agent autoinjector (Mark 1 kit) or pediatric Atropen™ Recently approved by FDA

National Disaster Medical System does not account for pediatric bedspace

Underavailability of chemical and biological antidotes for children

Poor access to nerve agent autoinjector (Mark 1 kit) or pediatric Atropen™ Recently approved by FDA

National Disaster Medical System does not account for pediatric bedspace

Atropen™ and Mark-1 kitAtropen™ and Mark-1 kit

Kit with Atropine AND

PralidoximePediatric Atropine autoinjectorsPediatric Atropine autoinjectors

Nerve Agent ExposureNerve Agent Exposure

RepeatATROPINE

3-5 minutesSymptoms?

ATROPINEMark-1 Kit orAtropen or

Atropine 0.1 mg/kg IV/IM

PRALIDOXIMEMark-1 Kit or

25-50 mg/kg IV/IM

BENZODIAZEPENEDiazepam 0.3 mg/kg

for seizures orsevere exposure

ExperiencingSymptoms?

RepeatATROPINE

3-5 minutesSymptoms?

ATROPINEMark-1 Kit orAtropen or

Atropine 0.1 mg/kg IV/IM

PRALIDOXIMEMark-1 Kit or

25-50 mg/kg IV/IM

BENZODIAZEPENEDiazepam 0.3 mg/kg

for seizures orsevere exposure

ExperiencingSymptoms?

Nerve Agent Exposure:

Tearing, Drooling, Urination, Diarrhea, Respiratory Distress, Convulsions

Nerve Agent ExposureNerve Agent Exposure

Atropen™ does not contain Pralidoxime Important in the treatment to reverse action of nerve

agent

Any symptomatic child should receive a Mark-1 kit unless alternatives are immediately available The risk of side effects is greatly outweighed by the

benefits Do not delay treatment

Atropen™ does not contain Pralidoxime Important in the treatment to reverse action of nerve

agent

Any symptomatic child should receive a Mark-1 kit unless alternatives are immediately available The risk of side effects is greatly outweighed by the

benefits Do not delay treatment

Summary of Bio/ChemSummary of Bio/Chem Good Biological & Chemical medical

defense requires a high index-of-suspicion on the part of clinicians

Children have unique vulnerabilities Primary Care Providers are likely to be first

responders to a Biological attack Pediatric Treatment Guidelines are now

available to assist the clinician

Good Biological & Chemical medical defense requires a high index-of-suspicion on the part of clinicians

Children have unique vulnerabilities Primary Care Providers are likely to be first

responders to a Biological attack Pediatric Treatment Guidelines are now

available to assist the clinician

ResourcesResources

PDLS is a start Much information exists to guide the

preparation and care for children in disasters

PDLS is a start Much information exists to guide the

preparation and care for children in disasters

ResourcesResources

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

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

ResourcesResources

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

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

DisclaimerDisclaimer

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.

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 DirectorsCourse 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

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 ContributorsOriginal Contributors

Gregory Ciottone, MD Lucille Gans, MD Patricia Hughes, RN Frank Jehle, MD Taryn Kennedy, MD Gretchen Lipke, MD Mariann Manno, MD Gina Smith, RN Fred Henretig, MD Theodore Cieslak, MD

Gregory Ciottone, MD Lucille Gans, MD Patricia Hughes, RN Frank Jehle, MD Taryn Kennedy, MD Gretchen Lipke, MD Mariann Manno, MD Gina Smith, RN Fred Henretig, MD Theodore Cieslak, MD

Robert McGrath, M.Ed. W. Peter Metz, MD John A. Paraskos, MD Carol Shustak, RN Elizabeth Shilale, RN A. Richard Starzyk Michael Weinstock, MD Sharon Welsh, RN Lou Romig, MD

Robert McGrath, M.Ed. W. Peter Metz, MD John A. Paraskos, MD Carol Shustak, RN Elizabeth Shilale, RN A. Richard Starzyk Michael Weinstock, MD Sharon Welsh, RN Lou Romig, MD

pediatric disaster life support core content lecture 2 practical issues in pediatric disaster...

Documents

pediatric triage slide

concepts of triage

pediatric disaster medicine

specific pediatric triage

information slide

md slide

airway obstruction slide

standard adult triage