• Children have physiologic, developmental, and behavioral differences from adults that influence their management during a mass casualty event (MCE).
• During an MCE, emergency department (ED) staff should expect casualties to come in two waves (dual wave phenomenon): The first wave typically appears after about 15 to 30 minutes and largely consists of “the walking wounded,” and the second wave typically arrives in 30 to 60 minutes after the onset of the event and is comprised of the more critically ill or injured patients.
• Physiological differences between adults and children make adult MCE triage protocols inappropriate for infants and children.
• EDs should have guides with predetermined medication dosing based on weight, and equipment sizes based on age, ready for mass casualties, so that staff members do not have to perform calculations during events.
• Decontamination of children generally takes longer than that of adults and should be done as a family unit to facilitate children’s cooperation and minimize the psychological impact to children.
It is critical that emergency departments (EDs) adequately prepare for mass casualty events (MCEs). EDs must not only have the capability to recognize, stabilize and care for pediatric victims of MCEs involving traumatic injuries, but also pediatric victims of biological, chemical, and radiological/nuclear agents. For any MCE, there are several unique considerations regarding pediatric victims who require differences in practices from adults such as triage and decontamination.
MASS CASUALTY EVENTS
An MCE is defined as an event characterized by an imbalance between the needs and resources available within a healthcare system. There is no predetermined number of victims that constitutes an MCE; however, many programs consider an influx of ten or more patients as an MCE.1 The inciting event can be due to natural disasters, -transportation-related failures, civil disturbances, war, terrorist-related activities, or less commonly, weapons of mass destruction that involve biological, chemical and/or radiological/nuclear agents. Whether the event is trauma related or due to a biological, chemical, or radiological/nuclear attack, children have physiologic, developmental, and behavioral differences from adults that influence their management during an MCE.2
During an MCE, ED staff should expect casualties to come in two waves, otherwise known as a dual-wave phenomenon.2 The first wave typically appears after about 15 to 30 minutes and largely consists of “the walking wounded” who are able to get to the ED by car or on foot. The second wave of patients typically arrives in 30 to 60 minutes after the onset of the event and is composed of the more critically ill or injured patients who may have needed to be extricated and arrive by either ground or air transport.2,3
UNIQUE PEDIATRIC CONSIDERATIONS
AGE, SIZE, WEIGHT
While there is no consensus regarding the upper limit of age that defines a child, many consider the pediatric population to consist of patients from birth to 18 years of age.4,5 An MCE involving pediatric victims demands a wide range of skills, an understanding of child development, and the availability of equipment to accommodate a range of sizes and weights. In terms of clinical management, age is often considered a surrogate for size and weight. Medications like antibiotics, vaccines, or antidotes need to be dosed according to the age, size, and/or weight of a child. Because of the metabolic differences in children when compared to adults, response to medication treatments may vary (Table 149-1).5
Summary of Physiologic and Developmental Differences in the Pediatric Population Versus the Adult Population
DEVELOPMENTAL AND BEHAVIORAL CONSIDERATIONS
The stage of motor and cognitive development of a child will influence a responder’s ability to communicate with and care for a victim. Nonverbal children are not able to voice their complaints or injuries and may not be able to cognitively distinguish between strangers that are helping from those who are hurting. Nonambulatory children will not be able to flee a dangerous situation and may need to be carried and transported away. Depending on the age and cognitive development of a child, he or she may refuse to move or may even run toward a threat.2
Children may lack the decisional capacity to follow directions from first responders. Children may suffer anxiety owing to separation from their family or primary caretakers during a disaster.6 Every effort should be made to reunite family members with the child as soon as possible. Keeping and treating parent and child victims of an MCE together in the same facility is a logical strategy.
Children need to be reassured that their reactions are not a result of something right or wrong, but a normal reaction to an abnormal event. Taking photos or noting the clothing or personal articles on the child may be useful in helping parents identify their children.7 Children rarely carry personal identification, which makes the process of identifying victims and later reuniting family with their children challenging.8
Physicians and other healthcare professionals need to be vigilant about recognizing the signs and symptoms of children who are at risk for developing posttraumatic stress disorder (PTSD) after an MCE. It is known that children suffer varying degrees of psychological disturbances after an MCE.9–11 However, long-term effects are not well understood.10
Somatization is common, and many parents may not identify symptoms as psychological in nature. While physicians may not feel qualified to treat these disorders, it is important to have mechanisms in place to help children address their reactions to disaster. Mental health workers should work with children and families immediately or soon after an event and intervene as necessary.12
There are several unique physiological differences that make children potentially more vulnerable to exposures of agents that may be involved or released in an MCE. For example, children have increased respiratory rates, which can lead to increased absorption of aerosolized chemicals, and, thus, may develop more severe illness. Also, because of their small size, children are generally closer to the ground and so are potentially more vulnerable to agents that either settle on the ground or do not become airborne and further because children are smaller, they have an increased body surface area and thinner skin relative to adults and so they are at risk for increased absorption of toxic agents.13 It is important to recognize these differences to allow for timely triage and identification of victims that may require immediate care (Table 149-1).
CONSIDERATIONS FOR THE DELIVERY OF CARE TO THE PEDIATRIC POPULATION
PROVISION OF CARE
A well-organized plan with community involvement can have positive effects on disaster response. However, many emergency medical services systems do not have pediatric-specific plans or general plans that adequately account for pediatric requirements. In one study, only 248 out of 1808 prehospital emergency medical services surveyed had any specific plans for the care of children.14 These plans can and should include recommendations for the use of a pediatric-specific mass casualty triage protocol, pediatric-sized equipment and supplies, proper decontamination guidelines, plans for reunification of children with their family, and for recognizing and addressing post-event mental health needs of children and families.
Ideally, it is best to transport pediatric MCE victims to either a regional pediatric hospital or one that has extensive pediatric expertise. Logistically, this may be impossible, depending upon the type of disaster and the resources of the affected community. An MCE may involve both adults and their children. Ideally, families should stay together. Therefore, hospitals need to consider providing care to the family as a unit. That is, general hospitals need to be able to care for pediatric patients and pediatric hospitals need to be prepared to care for adult parent victims as well.15 It is essential that all healthcare workers and prehospital responders receive proper training and equipment to deal with children, often the most vulnerable victims.
Adult mass casualty triage protocols cannot be universally used for pediatric patients. Physiological differences between adults and children make the adult MCE triage protocols inappropriate for infants and children. Many pediatric-specific triage protocols have been proposed including JumpStart, SALT, SACCO, and the Pediatric Assessment Triangle. Currently, there are limited studies to indicate which protocol works best in the pediatric population. Mass casualty pediatric victims (red: critical care, yellow: walking wounded, green: well) should be reevaluated upon arriving in the ED as their status can rapidly change.16–20
It is extremely important to have an array of infant-, child-, and adult-sized masks, airways, and endotracheal tubes available. One of the challenges in airway management is determining the proper endotracheal tube size. A pediatric emergency measuring tape, such as a Broselow® tape may be useful in estimating the proper equipment size and medication doses. Establishing intravenous access can be difficult and time consuming, especially in the smallest patients. Alternative access sites (scalp, umbilical, central venous sites) and means (ultrasound aided, intraosseous [IO] access) must be considered. Commercial IO devices function like a drill and can rapidly establish access, especially in a critical patient. MCE plans should include provisions for a minimum supply of appropriate pediatric-sized equipment and extra supplies. Some authors recommend having 72 hours supply for the average daily pediatric patient census at all times in a hospital.15 Equipment should be organized and stored in a designated area within the ED where it is easily accessible in an MCE.21
Appropriate medications and antidote administration can be difficult to determine in the pediatric population, especially during an MCE. While most antidotes are not FDA-approved in children, recommendations support the use of such medications when indicated in a disaster or an MCE because the risks outweigh the benefits. The Food and Drug Administration (FDA) recently approved the use of ciprofloxacin and doxycycline in children as prophylaxis against inhalational anthrax and hydroxocobalamin for use in cyanide toxicity.22
Dose calculations can be cumbersome in an MCE because of the emergent need to initiate lifesaving treatment and the inability to obtain accurate weights. One strategy is to have medication names organized in an easy to read chart with pre-calculated doses that is located in a pediatric disaster kit and readily visible. Prepackaged medications, like MARK I autoinjectors containing atropine and pralidoxime, have the advantage of pre-filled medications in an easy-to-use device that does not require intravenous access. However, these are not recommended in children less than 3 years.22,23
The FDA approved pediatric-specific atropine autoinjectors in 2003, but these are not yet mass produced for sale in the United States.24 The Broselow® tape system is available as a color-coded pediatric tape that contains doses for chemical treatment agents, including adult autoinjectors, thus, decreasing the amount of time required to determine doses for victims. It is patterned after the original tape such that it can be used simultaneously.25
CONSIDERATIONS FOR WEAPONS OF MASS DESTRUCTION
The US Centers for Disease Control and Prevention (CDC) has identified 35 biological agents that can potentially cause harm and if large populations were exposed, could overwhelm current medical facilities.26 Among the 35 potential biological agents, anthrax, small pox, plague, tularemia, hemorrhagic fever virus and botulinum are thought to be able to have the most impact on public health and security. Challenges with diagnosing diseases due to biological agents include an incubation period, which can range from days to months and that the initial presentation of biological agents may mimic other common respiratory illnesses such as influenza. Dissemination of biological agents can be airborne, or through food and water supply. EDs will be among the first medical care providers treating victims due to a biological attack. Early detection can minimize further exposure and prevent spread. Given the infrequency and rareness of outbreaks, national treatment guidelines may be continuously revised during the time of an event. The CDC offers both a hotline (800-232-4636) and continuously updated website for healthcare providers (http://emergency.cdc.gov/bioterrorism/, accessed May 30, 2014).27,28
Unlike biological attacks that can be covert, an attack caused by chemical agents will cause a sudden surge of victims with similar medical complications. Initially, the chemical agent may not be known; thus, the responsibility of identifying the agent may fall into the hands of the clinicians based on the victims’ presenting symptoms. Decontamination is important to reduce ongoing exposure to the agent as well as to protect healthcare workers from secondary exposure.
Agents reviewed in this section include nerve agents, vesicants, phosgene, and cyanide.27,28
(See Table 149-2 for details on biologic and chemical agents).
Weapons of Mass Destruction: Biological and Chemical Agents
RADIOLOGICAL AND NUCLEAR AGENTS
Radiation and nuclear threats can come from nuclear detonation, dirty bombs (bombs with radiologic dispersive devices, radiologic exposure devices, and nuclear power plant disruptions.
Symptoms due to radiation exposure are dose dependent; exposure >3.5 Gy has a 50% mortality. Those exposed may exhibit signs of acute radiation syndrome. Initial signs include nausea, vomiting, and malaise. This is followed by a symptomatic free period where absolute lymphocyte count is the best predictor of further injury. Hematopoietic syndrome occurs weeks after radiation exposure to 1.5 to 2 Gy and presents with signs of bone marrow failure such as neutropenia, anemia, and thrombocytopenia. Medical treatment includes supportive care. Potassium iodine is indicated for a radiation exposure from a nuclear power plant. Other radiation antidotes can be found at the Radiation Emergency Medical Management web site (www.remm.nlm.gov, accessed May 30, 2014).29,30
Decontamination needs to be performed in any MCE that involves suspected biological, chemical, or radiation exposures. Most decontamination (85%–95%) is accomplished simply by removing clothes and securing them in sealed bags or containers.2 There are several key points to keep in mind about the decontamination of children. Most importantly, children are at higher risk for hypothermia than adults. It is important to ensure that water pressure is low (60 psi) and water temperature is 100°F (37.8°C). Skin exposure to wind and air should be limited as much as possible and extra blankets and other warming equipment (mylar blankets, heating fans, etc.) should be provided, especially after water decontamination. Ambient air should be kept warm to minimize evaporative heat loss. In general, it takes longer to decontaminate children. Families should be decontaminated as a unit as some children are hesitant to disrobe, unable to disrobe by themselves, or are frightened or anxious about being separated from parents or known caretakers. Patience and extra personnel may be required to perform decontamination and to maintain steady patient flow.2 Because personal protective equipment (PPE) limits the dexterity of healthcare personnel, handling and decontaminating small children and infants require a higher degree of caution.31
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