Pediatric Disaster Life Support (PDLS©): Scene Assessment & Triage - Briefly cover pedi. rescue in general - Pedi rescue in disaster – how does it change Triage in prehospital setting Criteria and techniques Dr. Jim Courtney Assistant Professor of Emergency Medicine

Your homework got washed away with your house! A likely story young man! See me after class!

Triage Assessment, Stabilization, Resuscitation Learning Objective At the end of this lecture, the students should be able to: describe differences in triage decision making for children describe triage categories describe field triage assessment describe initial field stabilization methods for children

General Principles of Disaster Care Scene Assessment Triage Assessment Initial Stabilization Resuscitation

Scene Assessment Ensure scene safety Establish that disaster exists Estimate number of victims: adults/children

Scene Assessment Notification to medical control: regional communications, local emergency management / disaster authority type of event initial casualty estimate

January 5, 2009 – Alta Verapaz

Make initial request for additional resources Then begin triage assessment of individual patients

Triage Assessment Derived from the French “trier” meaning to sort, it describes a medical decision making process Guides decisions about allocating scarce resources and limited time “greatest good for greatest number” Protocol helps makes decisions Appropriate performance crucial

Triage ICS separates triage from treatment immediately see everybody once briefly for overview Dynamic process, re-triage / re-evaluate at several stages Triage in disaster setting may be very difficult Pediatric population unique challenge

Initial Brief Assessment Open airway Control major hemorrhage Categorize

Triage Classifications Simple Triage And Rapid Treatment S.T.A.R.T. JumpSTART Tool for Rapid Pediatric Multicasualty Field Triage (children from 1 - 8 years of age)

Triage Categories Red / Immediate / Emergent Yellow / Urgent Green / Non-Urgent / Walking Wounded Black / Deceased or soon to be

Triage Classifications and Examples Red - tension pneumothorax, rib fractures, upper airway obstruction, hemorrhage, femur fracture, asthmatic Yellow - humerus fracture, scalp lacerations, shoulder dislocation Green - ankle sprain, simple laceration, orphaned child, subluxed radial head Black/Blue - cardiopulmonary arrest, severe open head injury

START Most commonly used triage system across country Not applicable for under 8 years old Initial eval – not final Time limited (plan <1 min/patient) Categorize and move on

START “If you can hear me and are able, walk over here” GREEN triage done – still need individual evaluation, but can await more staff, allows initial rescuers to focus on more severely injured people. Gen 80% of victims will be green, self extricate (may self transport – eases burden on field but hard on hospitals)

START EVAL (and tag) those unable to walk for transport: RPM Resp: no => open airway= still no then reposition airway = still no =>BLACK if yes => RED (immediate). Spont resp >30 => RED/ under 30 => next item of assessment

START Perfusion: cap refill > 2 sec => control bleeding, label RED; <2 sec, next item Perfusion: Radial Pulse => if no label RED; if yes then next item Mental status: Cannot follow simple commands => RED; CAN follow simple commands (and has cap refill < 2 sec and spont resp < 30) => YELLOW (delayed)

START As soon as one can categorize a patient, STOP evaluating (if they are RED for breathing, they won’t be seen any faster for additional problems) and move on. Minimal treatment during triage: airway maneuver (chin tilt, jaw thrust) and dress active blood loss (not scrapes).

Pediatric Triage

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

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

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

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

JumpSTART (under 8) Kids more airway dependent – rescue breaths attempted if pulse present (unlike adults) Resp 15-45 instead of <30 Vascular system clamps down sooner, so cap refill less reliable. Use peripheral pulse instead. Mental status AVPU instead of following simple commands

JumpSTART “If you can hear me and you are able, walk over here for help.” Probably won’t work for children If they are ambulatory, then they are GREEN Use adults on scene to help corral the GREEN children

JumpSTART Respirations: NO  open airway => yes RED; no -> check peripheral pulse. NO pulse = BLACK Pulse  15 sec mask to mouth ventilation Spont resp: NO  BLACK; YES  RED

JumpSTART Breathing: RR <15, >40 or irregular =RED RR 15-40, regular – check pulse No peripheral pulse: RED Peripheral pulse: check mental status AV (appropriate) YELLOW PU (inappropriate) RED

Kids in triage Don’t follow commands. May actually hide from rescuers May be extricated by GREEN parents/ adults with delay in triage and treatment. Need distraction and dedicated supervisor able to run after wandering toddlers

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

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

Examples IMMEDIATE DECEASED What do you do? How do you classify this child if he breathes? IMMEDIATE How do you classify this child if he does not breathe after 5 rescue breaths? DECEASED

Examples DELAYED Young child found breathing but sleepy Respiratory Rate 30 Has a palpable pulse Arouses to touch and loud voice DELAYED

Categorize the Following 7 y.o. female, crying, unwilling to move right arm, 1° burn to anterior thigh 10 y.o. male, deformed thigh, pale, pulse 120, BP 60/40, RR 36 20 y.o. female, apneic, severe head injury with visible grey matter 2 y.o. male, 2-3° burns to face, neck and chest 5 day old infant, found on ground, appears unharmed GREEN RED BLACK RED YELLOW

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

Resources PDLS is a start Much information exists to guide the preparation and care for children in disasters

Resources 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

Resources JumpSTART Triage Tool American Academy of Pediatrics 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

PDLS Content Revision Richard V. Aghababian, MD, FACEP Mark X. Cicero, MD, FAAP James M. Courtney, DO, FAAEM Andrew L. Garrett MD, FAAP Eric J. Goedecke, DO, FACEP

Original 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 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