3. Pediatric Mass Casualty Incident A Quick Prep for Clinicians

4. Pediatric Mass Casualty Incidents (MCI) School disasters (national/international) School disasters (national/international) Newtown school shooting 2012 Newtown school shooting 2012 Earthquake in China 2008 with school collapses Earthquake in China 2008 with school collapses Beslan, Russia school terrorist event in 2004 Beslan, Russia school terrorist event in 2004 Columbine school shooting 1999 Columbine school shooting 1999

5. Potential Pediatric MCI Collapse of a venue used primarily youth ex. “Disney on Ice” Collapse of a venue used primarily youth ex. “Disney on Ice” Natural disaster Natural disaster Tuscaloosa tornado had >50 pediatric victims Tuscaloosa tornado had >50 pediatric victims School bus crash School bus crash

7. Potential Pediatric MCI Infectious disease outbreaks preferentially targeting children Infectious disease outbreaks preferentially targeting children Pertussis out breaks Pertussis out breaks Influenza with high impact on young patients Influenza with high impact on young patients

8. Objectives: How to Prepare For a Pediatric MCI Know the differences and similarities between children and adults Know the differences and similarities between children and adults Be aware of the special considerations for children Be aware of the special considerations for children Physical, emotional, environmental, communication, family, equipment Physical, emotional, environmental, communication, family, equipment

9. Objectives: How to Prepare For a Pediatric MCI Children with “Special Needs” Children with “Special Needs” Medications and treatments specific to children Medications and treatments specific to children Decontamination Decontamination Indications for transfer to a higher level of care Indications for transfer to a higher level of care Pearls Pearls

10. Similarities Kids are not “little adults” but the same priorities apply: Kids are not “little adults” but the same priorities apply: ABCDE’s ABCDE’s Almost all the medications are the same, they just need weight based adjustment Almost all the medications are the same, they just need weight based adjustment If a child hurts, they tell you and usually will not move If a child hurts, they tell you and usually will not move Don’t avoid a necessary procedure for a child just because they are a child! Do what needs to be done according to usual trauma care Don’t avoid a necessary procedure for a child just because they are a child! Do what needs to be done according to usual trauma care

11. Differences Children are very quick to respond to a treatment or lack of treatment so constant evaluation and re- evaluation is needed Children are very quick to respond to a treatment or lack of treatment so constant evaluation and re- evaluation is needed Family contact is a high priority Family contact is a high priority Diverting the attention of the child often lets you examine them Diverting the attention of the child often lets you examine them Distraction ideas - videos, toys, iPhone, iPad, books with pictures to point to etc. Distraction ideas - videos, toys, iPhone, iPad, books with pictures to point to etc.

12. Differences Over-triage can happen Over-triage can happen Children often prioritized higher than necessary if significant soft tissue injuries and/or crying Children often prioritized higher than necessary if significant soft tissue injuries and/or crying Carefully assess chest, abdomen, and mental status Carefully assess chest, abdomen, and mental status

13. Pediatric Assessment Triangle

14. Differences Airway Airway Head is big – in infants and small children, pad the shoulders up to achieve alignment Head is big – in infants and small children, pad the shoulders up to achieve alignment Larynx is anterior and shallow vs. adult Larynx is anterior and shallow vs. adult Narrowest part of airway is BELOW cords at cricoid ring Narrowest part of airway is BELOW cords at cricoid ring Airways are narrower and do not tolerate swelling well Airways are narrower and do not tolerate swelling well Adjusting head and neck position can improve airflow immensely Adjusting head and neck position can improve airflow immensely Constant evaluation and re-evaluation is necessary Constant evaluation and re-evaluation is necessary

15. Differences Breathing Breathing Children are generally easy to bag-valve-mask if the airway is open Children are generally easy to bag-valve-mask if the airway is open Avoid hyperventilation and over-ventilation with adult sized masks Avoid hyperventilation and over-ventilation with adult sized masks Chest wall is elastic – thus fractures are more rare, but pulmonary contusions can occur without fractures Chest wall is elastic – thus fractures are more rare, but pulmonary contusions can occur without fractures

16. Differences Circulation and Disability Circulation and Disability IV access may be difficult, consider IO access early – can always give blood or fluids via IO and most medications IV access may be difficult, consider IO access early – can always give blood or fluids via IO and most medications Falling blood pressure and compromised circulation are LATE findings of shock Falling blood pressure and compromised circulation are LATE findings of shock Children compensate well – UNTIL THEY DON’T! Children compensate well – UNTIL THEY DON’T! Look for tachycardia and other signs of early shock Look for tachycardia and other signs of early shock Look for areas of blood loss; femur fractures, scalp hematomas, abdomen/pelvis Look for areas of blood loss; femur fractures, scalp hematomas, abdomen/pelvis 20ml/kg fluid boluses initial, blood 10ml/kg 20ml/kg fluid boluses initial, blood 10ml/kg If trauma related, when giving the 2 nd fluid bolus - get the PRBC's ready to give If trauma related, when giving the 2 nd fluid bolus - get the PRBC's ready to give

17. Provider Fears Impact on the child’s life Impact on the child’s life Unable to communicate with the child Unable to communicate with the child “Never did that procedure on a child” “Never did that procedure on a child” The emotional connection to children that prevents the provider from treating the child The emotional connection to children that prevents the provider from treating the child Fear of inflicting pain/anxiety Fear of inflicting pain/anxiety Unaccustomed with pediatric equipment and dosing Unaccustomed with pediatric equipment and dosing

18. Special Considerations: Physical Often they are first patients to show signs of toxicity of a poison Often they are first patients to show signs of toxicity of a poison Thinner skin/smaller size therefore more susceptible to toxins and ionizing radiation Thinner skin/smaller size therefore more susceptible to toxins and ionizing radiation Increase respiratory rate, inhaling a larger dose of toxin Increase respiratory rate, inhaling a larger dose of toxin Larger surface area to mass ratio Larger surface area to mass ratio Closer to the ground and most toxic gases are heavier than oxyge n Closer to the ground and most toxic gases are heavier than oxyge n

19. Special Considerations: Physical Vital signs are age related Vital signs are age related Higher incidence of head and major organ injuries Higher incidence of head and major organ injuries Major organs are closer together Major organs are closer together Larger head size Larger head size Rib cage is softer and less protective Rib cage is softer and less protective Small children have small glycogen stores – thus drop their blood sugar under stress Small children have small glycogen stores – thus drop their blood sugar under stress Point of care glucose on all children with major injury/illness Point of care glucose on all children with major injury/illness

20. Special Considerations: Emotional Family/familiar items are key Family/familiar items are key Try to keep families together, if impossible, keep familiar items with the child Try to keep families together, if impossible, keep familiar items with the child Child appropriate books, DVD’s, music Child appropriate books, DVD’s, music Diversion techniques Diversion techniques Soap bubbles, music, lights, etc. Soap bubbles, music, lights, etc.

21. Special Considerations: Environmental Monitor temperature frequently Monitor temperature frequently Make sure the entire body is viewed for re- evaluation and then cover Make sure the entire body is viewed for re- evaluation and then cover “Child friendly” environment “Child friendly” environment Group children together in care areas Group children together in care areas Have areas for discharged “well” children where they can be monitored until sent home or to other care facilities Have areas for discharged “well” children where they can be monitored until sent home or to other care facilities

22. Special Considerations: Environmental Ratios for Adult to Child Monitoring AgeRatioGroup Size Infant1:48 Toddler1:714 Pre-school1:1020 School age 1:1530 Minnesota Rule 9503.0040

23. Special Considerations: Communication Speak to the child at their developmental level of understanding Speak to the child at their developmental level of understanding Be honest Be honest Keep the child informed as to “what is happening” and avoid surprises Keep the child informed as to “what is happening” and avoid surprises Supply basic needs Supply basic needs Appropriate food, liquids and bedding Appropriate food, liquids and bedding Help them go to the bathroom Help them go to the bathroom

24. Special Considerations: Family Parents will often seek care for their children and ignore their own health Parents will often seek care for their children and ignore their own health Avoid separating families Avoid separating families Empower family members in the care and monitoring of each other Empower family members in the care and monitoring of each other Have a plan for unidentified/unaccompanied minors Have a plan for unidentified/unaccompanied minors Digital photos and check off lists of identifying information Digital photos and check off lists of identifying information

25. Special Considerations: Family Appropriate food, toys and /bedding Appropriate food, toys and /bedding Ratio of the number of caregivers to the number of children is dependent on age of children Ratio of the number of caregivers to the number of children is dependent on age of children Have a plan on how you will discharge children to people other than their parents Have a plan on how you will discharge children to people other than their parents Have a plan on how you will track and record disposition of patients Have a plan on how you will track and record disposition of patients

26. Special Considerations: Equipment Remember: only 6.5% of the population is 8 years or younger Remember: only 6.5% of the population is 8 years or younger Plan equipment for < 8 years – above this can use small adult equipment Plan equipment for < 8 years – above this can use small adult equipment Key equipment issues are: Key equipment issues are: IO and IV – remember pumps, buretrols and pediatric specific fluids IO and IV – remember pumps, buretrols and pediatric specific fluids Airway equipment – intubation and ventilation Airway equipment – intubation and ventilation Back-up airway equipment Back-up airway equipment Surgical chest tube equipment Surgical chest tube equipment

27. Special Considerations: Equipment Have equipment for transportation of children Have equipment for transportation of children Booster and car seats Booster and car seats Know how to adapt transport cots to fit small children Know how to adapt transport cots to fit small children Have appropriate equipment to handle children Have appropriate equipment to handle children (AAP - http://www2.aap.org/visit/Checklist_ED_Prep-022210.pdf ) (AAP - http://www2.aap.org/visit/Checklist_ED_Prep-022210.pdf ) Antidotes and medications for pediatrics Antidotes and medications for pediatrics Especially analgesia and sedation early in event Especially analgesia and sedation early in event

28. Decontamination Make simple picture descriptions of decon procedures for young children (can be used for non-English speaking patients as well) Make simple picture descriptions of decon procedures for young children (can be used for non-English speaking patients as well) Train with the DVD “The Decontamination of Children” from AHRQ Train with the DVD “The Decontamination of Children” from AHRQ Consider using heavy-duty laundry baskets for infants and small children Consider using heavy-duty laundry baskets for infants and small children Products that work well for oily substances – baby shampoo and Dawn Products that work well for oily substances – baby shampoo and Dawn

29. Decontamination Use large volumes of water at low pressure Use large volumes of water at low pressure Consider decontamination of the entire family at the same time Consider decontamination of the entire family at the same time Respect the wishes of teens Respect the wishes of teens Close monitoring of temperature Close monitoring of temperature Active rewarming after decontamination Active rewarming after decontamination

30. Children with Special Needs Look for medic alert bracelets and care plans Look for medic alert bracelets and care plans Many are dependent on medications given at specific times during the day Many are dependent on medications given at specific times during the day Allow children to take their own medications Allow children to take their own medications If missing their medications, be prepared to give alternative medications If missing their medications, be prepared to give alternative medications Many are dependent on ventilators and other electrical equipment and may need to recharge batteries Many are dependent on ventilators and other electrical equipment and may need to recharge batteries

31. Children with Special Needs Alternate equipment may be necessary if the child’s is broken or not with them Alternate equipment may be necessary if the child’s is broken or not with them If a child is non-communicative and has no personal care attendant with them, providers will need to meet the needs of the child If a child is non-communicative and has no personal care attendant with them, providers will need to meet the needs of the child Adequate intake of nutrition and output Adequate intake of nutrition and output Medications and mode of ingestion Medications and mode of ingestion Adequate pain relief Adequate pain relief

32. Medications and Treatments Use weight based dosage for all medications and equipment Use weight based dosage for all medications and equipment Weigh the patient and dose according to weight “Gold Standard” Weigh the patient and dose according to weight “Gold Standard” Use a length-based tool (Broselow tape) for weight estimation if you cannot weigh the child Use a length-based tool (Broselow tape) for weight estimation if you cannot weigh the child Use an age-predicted weight estimation chart as a last option because it is the least accurate Use an age-predicted weight estimation chart as a last option because it is the least accurate

33. Medications and Treatments Medications not used in children Medications not used in children Limited use of Tetracycline derivatives in children under 8 years of age Limited use of Tetracycline derivatives in children under 8 years of age No Aspirin No Aspirin No OTC cold medicines No OTC cold medicines Analgesia – titrated doses of narcotics Analgesia – titrated doses of narcotics Consider intra-nasal, sq, nebulized routes Consider intra-nasal, sq, nebulized routes

34. Indications for Transfer Children given the top priority to be transferred to a higher level of care Children given the top priority to be transferred to a higher level of care Age less than 5 years Age less than 5 years Multiple injuries or high-energy mechanism Multiple injuries or high-energy mechanism Signs of hypotension/shock that is not improving Signs of hypotension/shock that is not improving Altered mental status Altered mental status Underlying complex illness/disease Underlying complex illness/disease

35. Pearls Early signs of shock can be missed Early signs of shock can be missed BP is the last and least reliable VS in pediatric shock BP is the last and least reliable VS in pediatric shock Perfusion can be influenced by temperature Perfusion can be influenced by temperature Children get tired and LOC can then be unreliable Children get tired and LOC can then be unreliable Look for medical alert bracelets Look for medical alert bracelets High fever can cause increase in respiratory and heart rates High fever can cause increase in respiratory and heart rates Pediatric Triangle of Assessment Pediatric Triangle of Assessment

36. Pearls Use intra-osseous lines as needed Use intra-osseous lines as needed Same procedure as an adult Same procedure as an adult Pre-infuse with 5mL 2% Lidocaine without preservative or epinephrine before infusing fluid in an IO to reduce pain Pre-infuse with 5mL 2% Lidocaine without preservative or epinephrine before infusing fluid in an IO to reduce pain Consider using the distal femur in children less then 6y – just medial to quadriceps tendon anterior approach Consider using the distal femur in children less then 6y – just medial to quadriceps tendon anterior approach

37. Pearls Treat pain Treat pain Anxiety often goes away if pain is treated Anxiety often goes away if pain is treated Be liberal with oxygen Be liberal with oxygen Unlike some adult patients, very few children have trouble with high oxygen concentrations Unlike some adult patients, very few children have trouble with high oxygen concentrations Respiratory danger signs Respiratory danger signs Increased work of breathing Increased work of breathing Grunting or nasal flaring Grunting or nasal flaring Stridor or wheezing Stridor or wheezing

38. Pearls High potential for 10-fold errors in dosing – make sure to “reality check” doses and double-check dosing High potential for 10-fold errors in dosing – make sure to “reality check” doses and double-check dosing Even though children can go into shock quickly, you DO have time to think before you act. Even though children can go into shock quickly, you DO have time to think before you act.

39. ReassessReassessReassess