PDLS © : General Principles of Disaster Care: Pediatric Triage Assessment, Stabilization, Resuscitation

Triage Assessment, Stabilization, Resuscitation Learning Objective Learning Objective At the end of this lecture, the students should be able to: 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 principles of field triage, stabilization and resuscitation - describe initial field stabilization methods for children - describe organization of field triage, treatment, staging, and clearing/transportation for children

Oklahoma City – YMCA Day Care The Scene: The Scene: - Multiple injured kids - Delay in finding them - 4 Children: 2 not breathing, unresponsive 2 not breathing, unresponsive 2 sitting, crying 2 sitting, crying

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

Triage Assessment Derived from the French “trier” meaning to sort, it describes a medical decision making process. Derived from the French “trier” meaning to sort, it describes a medical decision making process. Appropriate performance crucial. Appropriate performance crucial. Dynamic process, re-triage / re-evaluate at several stages. Dynamic process, re-triage / re-evaluate at several stages. Determination of priority may effect the extent and quality of care the patient receives. Determination of priority may effect the extent and quality of care the patient receives.

Triage in disaster setting may be very difficult Triage in disaster setting may be very difficult Pediatric population unique challenge Pediatric population unique challenge Triage

Problems of Under / Over-Triage

Triage in Prehospital Setting ICS (Incident Command System) ICS (Incident Command System) - Medical Branch Gain Control of Scene Gain Control of Scene Triage Officer: Initial Brief Assessment Triage Officer: Initial Brief Assessment

Initial Evaluation Ensure scene safety Ensure scene safety Establish that disaster exists Establish that disaster exists Estimate number of victims: adults/children Estimate number of victims: adults/children

Initial Evaluation Notification to medical control: regional communications, local emergency management / disaster authority Notification to medical control: regional communications, local emergency management / disaster authority - type of event - initial casualty estimate Make initial request for additional resources Make initial request for additional resources Then begin triage assessment of individual patients

Initial Brief Assessment Open airway Open airway Control major hemorrhage Control major hemorrhage Categorize Categorize

Triage Categories Red / Immediate / Emergency Red / Immediate / Emergency Yellow / Urgent Yellow / Urgent Green / Non-Urgent / Walking Wounded Green / Non-Urgent / Walking Wounded Black / Blue Black / Blue

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

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

Triage Classifications Consider pediatric anatomy / physiology / age / development when categorizing child Consider pediatric anatomy / physiology / age / development when categorizing child Familiarity with Familiarity with - level of expertise of personnel - numbers and type of transport available - equipment supplies - appropriate destination for definitive care

Initial Patient Assessment Primary Survey of Child A irway - patency B reathing - rate, quality C irculation: Pulse check - quality, rate D isability: Mental status E xposure

Airway First priority even more so than in an adult. Hypoxia main factor leading to organ dysfunction, ischemia, and cardiopulmonary arrest. First priority even more so than in an adult. Hypoxia main factor leading to organ dysfunction, ischemia, and cardiopulmonary arrest. Consider need for endotracheal intubation in child with GCS<8, significant maxillofacial trauma, aspiration, or respiratory distress. Consider need for endotracheal intubation in child with GCS<8, significant maxillofacial trauma, aspiration, or respiratory distress. Remember - Oropharyngeal airway - ET size/uncuffed - ET route for delivery of medication (LANE)

Breathing Children consume oxygen x 2 that of adult Children consume oxygen x 2 that of adult Assess: respiratory rate (infants 40/min, preschool 30/min, school 20/min) Assess: respiratory rate (infants 40/min, preschool 30/min, school 20/min) Effort Effort Auscultate, percuss Auscultate, percuss Thoracic cage and rib fractures Thoracic cage and rib fractures Tension pneumothorax Tension pneumothorax

Circulation Normal values: infant 160/min, preschool 140/min, school 120/min. Normal values: infant 160/min, preschool 140/min, school 120/min. Systolic BP 80+ (age in years x 2) Systolic BP 80+ (age in years x 2) Assess: Assess: - capillary refill - temperature of extremities - color of patient Circulating blood volume: neonate 90 ml/kg, infant 80 ml/kg, older child 70 ml/kg, adult mg/kg Circulating blood volume: neonate 90 ml/kg, infant 80 ml/kg, older child 70 ml/kg, adult mg/kg Bradycardia requires immediate attention, most common cause is hypoxia, but acidosis and hypovolemia are also factors. Bradycardia requires immediate attention, most common cause is hypoxia, but acidosis and hypovolemia are also factors.

IV Access Attempt peripheral access if unsuccessful in < 90 sec. consider IO or cutdown. Attempt peripheral access if unsuccessful in < 90 sec. consider IO or cutdown. Estimated body weight: (age in yr.. x 2) + 10 Estimated body weight: (age in yr.. x 2) + 10 Blood volume = 80 mls/kg x body weight Blood volume = 80 mls/kg x body weight Estimate blood loss: # pelvic ring = 10% total blood volume, # femur up to 20%. Estimate blood loss: # pelvic ring = 10% total blood volume, # femur up to 20%. IO access sites IO access sites - distal femur - proximal tibia - med/lat malleolus - iliac crests High success rate, up to 80% in less than one minute High success rate, up to 80% in less than one minute

Consider IV Access in the Following: Time to definitive care minutes Time to definitive care minutes Prolonged extrication / entrapment Prolonged extrication / entrapment Dehydration > 15% Dehydration > 15% Multiple fractures Multiple fractures Scalp lacerations with significant blood loss Scalp lacerations with significant blood loss

Children After Burns Airway and ventilation a priority in management. Cover burn area in a clean sheet and wrap patient in a clean blanket. Airway and ventilation a priority in management. Cover burn area in a clean sheet and wrap patient in a clean blanket. Calculate percentage burn Calculate percentage burn Consider specialized facility for following: Consider specialized facility for following: - 2/3 degree > 10% - 2/3 degree face, hands, feet, genitalia, perineum, and major joints - 3 degree > 5% - electrical burns - inhalation injury - preexisting medical problems - associated trauma in which burn injury > risk

Disability GCS useful in children > 1yr GCS useful in children > 1yr

Exposure Examine the entire child Examine the entire child Hypothermia may occur secondary to exposure, sepsis, shock, and may lead to metabolic acidosis, decreased respiration, bradycardia and cardiac arrest. Newborns at high risk. Hypothermia may occur secondary to exposure, sepsis, shock, and may lead to metabolic acidosis, decreased respiration, bradycardia and cardiac arrest. Newborns at high risk. What are your plans for newborns, infants who have no guardians? What are your plans for newborns, infants who have no guardians?

Field Stabilization Airway - chin lift, jaw thrust, oro- or nasopharyngeal airway Airway - chin lift, jaw thrust, oro- or nasopharyngeal airway Breathing - supplemental O2 as available Breathing - supplemental O2 as available - limited resources for mechanical/manual ventilation Circulation - hemorrhage control - direct pressure, dressings (rotating tourniquets) Circulation - hemorrhage control - direct pressure, dressings (rotating tourniquets) - limited resources for IVF Fracture Stabilization - using resources available Fracture Stabilization - using resources available

Field Stabilization There is little role for initiation of CPR in disaster situations There is little role for initiation of CPR in disaster situations Consider on site organization of arriving personnel and arriving resources Consider on site organization of arriving personnel and arriving resources Consider establishment of clearing/staging unti: Consider establishment of clearing/staging unti: - triage patients for treatment on site or transport to hospital/health care facility - efficient utilization of resources, personnel, and supplies

Resuscitation/Stabilization Simple measures that do not require sophisticated equipment are most appropriate. Simple measures that do not require sophisticated equipment are most appropriate. Needs must be evaluated and balanced against available resources. Needs must be evaluated and balanced against available resources. The principle of “doing the greatest good for the greatest number”. The principle of “doing the greatest good for the greatest number”.

Pediatric Trauma Score Score Size>20 kg10-20 kg 20 kg10-20 kg<10 kg AirwayNmaintainableunmaintainable Systolic BP>90 mmHg30-90 mmHg 90 mmHg30-90 mmHg<30 mmHg CNSawakeobtunded/LOCcoma/decerebrate Skeletalnoneclosed #open/multiple # Cutaneousnoneminormajor/penetrating trauma Useful as a triage tool in the multiple injured child. Useful as a triage tool in the multiple injured child. Score <8 = need for advance level of care, high risk category Score <8 = need for advance level of care, high risk category ~ 30% mortality >8 = community hospital capable of treating children >8 = community hospital capable of treating children

Child Likely To Need Specialized Care Shock SBP <50 Resp distress RR>30 30<10, stridor GCS<9 GCS<9 Mechanism Mechanism - MVA - Pedestrian/bicyclist thrown >15 feet - Penetrating injury to head, neck, trunk

Child Likely To Need Specialized Care Specific injuries skull # skull # pneumothorax, flail chest pneumothorax, flail chest abd trauma with peritoneal signs abd trauma with peritoneal signs amputation / degloving amputation / degloving vascular injury vascular injury burn with inhalation burn with inhalation FB aspiration / ingestion FB aspiration / ingestion

Preplanning Needs assessment of community Needs assessment of community Commitment on part of institutions and key personnel to treating injured children Commitment on part of institutions and key personnel to treating injured children Consider children with special needs Consider children with special needs Consider evacuation process for NICU/PICU/SCU for newborns Consider evacuation process for NICU/PICU/SCU for newborns Lack of supervision Lack of supervision Requirement of children in shelters Requirement of children in shelters

Categorize the Following 7 y.o. female, crying, unwilling to move right arm, 1° burn to anterior thigh 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 30/40, RR y.o. male, deformed thigh, pale, pulse 120, BP 30/40, RR y.o. female, apneic, severe head injury with visible grey matter 20 y.o. female, apneic, severe head injury with visible grey matter 2 y.o. male, 2-3° burns to face, neck and chest 2 y.o. male, 2-3° burns to face, neck and chest 5 day old infant, found on ground, appears unharmed 5 day old infant, found on ground, appears unharmed