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 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 Section  To further develop the bio-psycho-social model’s applicability to pediatric disaster medicine and preparedness Care of the Child During Disaster Biological Psychological Social

Pediatric 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

Pediatric Triage  In other words: To do the most good for the most patients  In other words: To do the most good for the most patients

Pediatric Triage  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

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  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  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  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?  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

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

 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? Examples IMMEDIATEDECEASED

 You are receiving multiple casualties on a hospital ship  Young child found breathing but sleepy  Brought in by military helicopter with IV running Examples

 What do you want to assess?  Respiratory Rate 30  Has a palpable pulse  Arouses to touch and loud voice Examples DELAYED

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  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 (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

Children with Special Health Care Needs (CSHCN)

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

Sheltering 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

Sheltering Issues  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

Sheltering Issues  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

Decontamination

Decontamination 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

Decontamination of Children  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

Decontamination of Children  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

Decontamination of Children  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

Decontamination of Children  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 Agents

Chem/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 Attack Presentation Of Symptoms Seconds to Minutes First responders arrive DECON Few Secondary Cases

Timeline Biological Attack Presentation Of Symptoms Delay of hours to days People may not know about exposure Secondary Exposures? Sick people present to hospitals/clinics/EMS Incubation time

Biological Agents

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 of Botulism

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  “Military Grade” Agents  Nerve Agents  “Blister Agents” (Vesicants)  “Blood Agents” (Cyanides)  “Choking Agents” (Phosgene, Chlorine)  Weapons of Opportunity  Toxic Industrial Chemicals

 “Military Grade” Agents  Nerve Agents  “Blister Agents” (Vesicants)  “Blood Agents” (Cyanides)  “Choking Agents” (Phosgene, Chlorine)  Weapons of Opportunity  Toxic Industrial Chemicals  “Military Grade” Agents  Nerve Agents  “Blister Agents” (Vesicants)  “Blood Agents” (Cyanides)  “Choking Agents” (Phosgene, Chlorine)  Weapons of Opportunity  Toxic Industrial Chemicals Chemical Terrorism: Which Agents?

 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

 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  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

Ciprofloxacin  First line treatment for:  Anthrax  Plague  First line treatment for:  Anthrax  Plague

Doxycycline  First line treatment for:  Anthrax  Plague  Tularemia  Brucellosis  Q Fever  First line treatment for:  Anthrax  Plague  Tularemia  Brucellosis  Q Fever

Vaccination 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 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 kit Kit with Atropine AND Pralidoxime Pediatric Atropine autoinjectors

Nerve Agent Exposure Nerve Agent Exposure: Tearing, Drooling, Urination, Diarrhea, Respiratory Distress, Convulsions

Nerve 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/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

Resources  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

Resources  U.S. Center for Disease Control   National Center for Disaster Preparedness   American Psychological Association   U.S. Center for Disease Control   National Center for Disaster Preparedness   American Psychological Association 

Resources  JumpSTART Triage Tool   American Academy of Pediatrics   Pediatric Disaster Preparedness Consensus Conference Summary   U.S. Department of Homeland Security   JumpSTART Triage Tool   American Academy of Pediatrics   Pediatric Disaster Preparedness Consensus Conference Summary   U.S. Department of Homeland Security 

Disclaimer  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 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  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  Richard V. Aghababian MD, 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  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