1. CERT Pediatrics Erich Maul, DO Fayette County CERT

2. Navigation Panel ●Background InformationBackground Information ●Preparedness for ChildrenPreparedness for Children ●Developmental IssuesDevelopmental Issues ●Physiological IssuesPhysiological Issues ●Psychological IssuesPsychological Issues ●Pediatric TriagePediatric Triage CERT Pediatrics

3. BACKGROUND CERT Pediatrics

4. Why Train for Kids? ●Kids are affected in nearly every disaster situation 1  WTC 2001 0.01%  Sundry School Shootings >80%  Natural Disaster model ~20%  Based on Census data and deduction ●In disasters, mortality rates in kids are significantly higher than adults 1 CERT Pediatrics

5. Why Train for Kids? ●Failing to plan is planning to fail ‒ Benjamin Franklin ●You will encounter kids in disaster situations ●Better to prepare for the situation than be baptized by fire. CERT Pediatrics Home

6. PREPAREDNESS FOR CHILDREN CERT Pediatrics

7. Basic Preparedness 2 ●Need to account for and include kids in preparedness plan ●Age specific needs  Diapers/wipes/cream  Formula, bottles and water  Age appropriate foods  Age appropriate toys and games  Medications-OTC and Rx  Woobie ●Communications plan  Contact lists  Text-don’t talk  In state and out of state contacts ●http://www.ready.gov/kidshttp://www.ready.gov/kids CERT Pediatrics Home

8. DEVELOPMENTAL ISSUES CERT Pediatrics

9. Children are not small adults… ●Things change as children age ●Talk about 6 distinct stages  Newborn  Infant  Toddler  Preschool  School aged  Adolescent CERT Pediatrics

10. Newborn (0-28 days old) 3 ●Can’t hold up head ●Poor temperature control ●MUST breathe through their nose ●Respond to lights and sounds ●Feel and respond to pain ●Signs of stress-color changes, yawning, hiccups, spiting up  Help these with bundling, bouncing, feeding, carrying, pacifier CERT Pediatrics

11. Infant (29 days to 12 months) 3 ●Respond to visual cues ●Learn through play and imitation ●No longer nose- breather by 3 months ●By 6 months  Head control, rolling, ORAL ●By 12 months  Crawling/cruising/walkin g/standing  Still ORAL ●Thrive on routine ●Stranger anxiety  Woobie is your best friend…and theirs  Soft voice  Get to their level  Avoid sudden movements ●THIS AGE IS MOBILE…  falls and choking hazards are huge risks CERT Pediatrics

12. Toddlers (1-3 years old) 3 ●Walking, attached to woobie, routines ●NO CONCEPT OF DANGER!!! ●Common to have difficult behavior  Find distractions  Let them make some decisions  Keep things in the present ●This age probably needs the most supervision of all CERT Pediatrics

13. Preschool (3-5 years) 3 ●More coordinated and independent ●Primitive reasoning skills ●Cooperate in groups ●Vivid imaginations, separation anxiety ●May see regressions in behavior ●Family members are key to help in disaster situations; use of positive reinforcement, rewards, clear boundaries CERT Pediatrics

14. School-ages (6-11 years) 3 ●Better reasoning skills ●Easier to put in place and need less supervision ●Give them as much independence as possible and find ways to let them participate in a meaningful way ●This group begins to get the concept and finality of death (~8 years old) CERT Pediatrics

15. Adolescents (12-18 years) 3 ●Abstract thoughts, logical reasoning, able to handle hypothetical situation ●MINIMAL CONCEPT OF DANGER!!! ●Emotionally labile ●Will respond to limits and this can offer security ●Explain things, praise the good-don’t tolerate the bad CERT Pediatrics Home

16. PHYSIOLOGICAL ISSUES CERT Pediatrics

17. Biologic functions in small systems Mouse ●Heart rate  450-750 bpm ●Respiratory rate  ~160 bpm ●Surface Area  0.0081 m 2 ●Volume  0.000069 m 3 ●SA:Vol ratio  117 Elephant ●Heart rate  25-35 ●Respiratory Rate  4-12 bpm ●Surface Area  0.583 m 2 ●Volume  25.62 m 3 ●SA:Vol ratio  0.023 CERT Pediatrics

18. Humans are no different Newborn ●Heart rate  80-160 bpm ●Respiratory rate  30-60 bpm ●Surface Area  0.0703 m 2 ●Volume  0.000532 m 3 ●SA:Vol ratio  132 Adult ●Heart rate  60-100 ●Respiratory Rate  12-20 bpm ●Surface Area  1.76 m 2 ●Volume  0.066 m 3 ●SA:Vol ratio  27 CERT Pediatrics

19. Physics of heat loss All of theses mechanisms are affected by Surface area Respiratory rate CERT Pediatrics

20. How is function different in kids? 1 ●Thinner skin  More prone to absorb chemicals  Easier to tear and lose water (dehydration) ●Higher surface area:volume  More prone to lose heat and get hypothermic  More prone to chemical effects ●Proportionately larger head  Center of gravity is displaced  More prone to fall  More prone to injure head ●Open fontanelles (soft spots)  Can predispose to traumatic brain injury CERT Pediatrics

21. How is function different in kids? 1 ●Airway challenges  Large occiput makes airway easy to compromise  Must breathe through nose until 2 months old  Smaller size so takes less inflammation to close the airway  Many cardiac issues in children have a respiratory or airway origin CERT Pediatrics

22. How is function different in kids? The Dwindles vs. the Lemmings CERT Pediatrics Initial event Point of No Return

23. How is function different in kids? 1 ●Higher vital sign activity  Generally have higher heart rates, respiratory rates, oxygen consumption, minute volumes  Can make kids more susceptible to effects of toxins and chemicals  Can make more prone to dehydration CERT Pediatrics

24. How is function different in kids? 1 ●Softer, more pliable skeletons  Incomplete fractures ●Immature immune systems  More prone to disease ●Poor hygiene  More prone to get sick and spread disease ●Relative short stature  Closer to ground and certain chemicals/vapors CERT Pediatrics

25. How is function different in kids? 1 ●Internal organs in closer proximity and less fixed in place compared to adults  More prone to injury, even if minimal signs of trauma ●Baseline mental status may not allow for following commands  Knowledge of normal behavior key to interpreting mental status ●Developmentally reliant on adults  Whack the adults out of the picture, cause significant harm to kids CERT Pediatrics Home

26. PSYCHOLOGICAL ISSUES CERT Pediatrics

27. Kids Suffer 6,7 ●Kids are dramatically affected by disasters  WTC 2001 6 -sample of >8000 4-12 graders; ‒ almost 90% had some form of adjustment disorder >6 months ‒ >10% had PTSD, anxiety, conduct disorder, depression  Avoidance, lack of focus, sleep issues, stopped fun activities  Hurricane Katrina 7 2005-increases in marital stress, domestic violence and parental mental illness ‒ Directly related to MH problems in preschool and school aged kids CERT Pediatrics

28. Kids Suffer 7 ●Kids are dramatically affected by disasters  Hurricane Andrew 7 1992-30% of children affected by Hurricane Andrew had PTSD which persisted for nearly a year after the event! ●Evidence that kids can be affected by a disaster and not directly involved in the disaster 7  Affected by media coverage ●REALITY CHECK…  few children get the necessary help they need to be mentally healthy again 7 CERT Pediatrics

29. MH Myths ●Kids can’t interpret the stress or severity of disaster situations ●Kids are rarely affected by stress from disasters ●Most healthcare providers are skilled in diagnosing and treating mental illness ●Physical health and mental health are unrelated entities ●There is nothing you can do to help the issue CERT Pediatrics

30. Psychological First Aid 7 ●“the practice of recognizing and responding to people who need help because they are feeling stress, resulting from the disaster situation within which they find themselves.”- American Red Cross ●Goals  Emotional support, information, education, link to resources CERT Pediatrics

31. How Will Kids React in a Disaster? 7 ●Fear ●Anxiety ●Sadness ●Regressive behaviors ●Social regression ●Inattention and problems focusing ●Physical signs and symptoms ●Worsening of underlying chronic diseases CERT Pediatrics Long term can lead to PTSD

32. Psychological First Aid 7 ●Be honest, but not graphic and gory ●TALK and share ●Provide safety and security  Avoid frightening images and sounds  Allow families to stay together, if possible  Minimize pain  Allow them to grieve for losses  Distraction and guided imagery  Make every effort to state the positives of a situation  Make referral for professional help CERT Pediatrics

33. PFA Resources in KY 8 ●Kentucky Community Crisis Response Board  PFA training  Crisis response  www.kccrb.ky.gov or (888) KCCRB-28 www.kccrb.ky.gov  FREE, 24/7 ●Local resources CERT Pediatrics Home

34. PEDIATRIC TRIAGE CERT Pediatrics

35. What is Triage? ●trier: v. (French) to sort ●Method to do the greatest good for the greatest number of survivors ●Equitable, but not necessarily fair ●Used when  Number of casualties is greater than the number of rescuers  Resources are limited  Time is critical CERT Pediatrics

36. Simple Reminders 4 ●Me, Us, Them; use PPE ●Continual reassessment of the situation ●Sort the salvageable from the non- salvageable ●No one right method  CERT teaches START triage  JumpSTART is pediatric derivation CERT Pediatrics

37. START Triage 4 ●Simple Triage And Rapid Treatment ●Divide casualties into 1 of 4 categories  Immediate/Red-the 3 killers  Delayed/Yellow-need care but can wait  Minor/Green-walking wounded  Deceased/Black-dead or actively dying CERT Pediatrics

38. Methodology 4 ●Assess scene safety ●Designate spot for Minor casualties to go to ●Announce who you are and perform voice triage ●Pick a spot to start and move in a pattern ●Assess and tag all victims  Goal of 30 seconds per casualty ●Document types of casualties ●Treat casualties starting with “I’s” CERT Pediatrics

39. Algorithm 5 CERT Pediatrics

40. Pitfalls 4 ●NO PLAN ●Indecision and lack of leadership ●Tunnel vision on single injury ●Treating and not triaging  ONLY 3 things you “treat” during triage ‒ Airway instability ‒ Major bleeding ‒ Shock CERT Pediatrics

41. Kids are Different ●They have different injury patterns than adults ●Compensate differently than adults ●Need a modified system for triage of children CERT Pediatrics

42. The Dwindles vs. Lemmings CERT Pediatrics Initial event Point of No Return

43. JumpSTART Triage 5 CERT Pediatrics

44. JumpSTART Triage 5 ●Meant for kids 1-8 years old  Use best judgment of age ●Major modifications  Respirations  Mental status  What about non- ambulatory kids? CERT Pediatrics

45. Triaging Children 5 ●Assess the scene ●Voice triage  When kids get to Minor treatment area, perform secondary triage  Kids carried into Minor area by others MUST be triaged first!!! ●Assess Breathing  This is the major diversion ●Assess Respiratory rate  15-45 (slight diversion) ●Assess Pulses ●Assess Mental status  Another diversion CERT Pediatrics

46. Triaging Children 5 Respirations present ●Move to next step and assess respiratory rate No respirations present ●Open airway  If breathing-Immediate  If not breathing, check pulse  No pulse-Deceased  Pulse present-give 5 rescue breaths  Reassess breathing after 5 rescue breaths  Breathing-Immediate  Not breathing-Deceased CERT Pediatrics

47. Skill Training ●Mouth to Mask Respiration 1.Assemble mask and valve 2.Apply to victim’s face 3.Blow into valve just enough to make chest rise 4.Allow exhalation 5.1 breath every 3-5 seconds CERT Pediatrics

48. Practice Time! ●Grab a mask and valve ●Practice rescue breathing CERT Pediatrics

49. In a Triage Situation ●Mouth to mask respiration is used as a screening tool ●Not intended for maintenance  You need to deploy yourself wisely  Sets up a difficult situation ●Why the difference between kids and adults?  Children much more prone to respiratory cause of decline  Fix respirations-fix the kid CERT Pediatrics

50. ●Assessed Scene ●Voice Triage & Secondary Triage ●Assessed Breathing ●Assess Respiratory Rate  Goal is 15-45/minute  Move to Pulse check  45-Immediate CERT Pediatrics

51. ●Check peripheral pulse  If present, move to Mental Status check  If absent-Immediate ●Check Mental Status  AVPU scale CERT Pediatrics

52. AVPU ●Alert: self-explanatory ●Verbal: alert to verbal stimuli ●Pain: alert to or reacts to painful stimuli  Appropriate response to pain  Inappropriate response to pain ●Unresponsive: self-explanatory CERT Pediatrics

53. ●Check peripheral pulse  If present, move to Mental Status check  If absent-Immediate ●Check Mental Status  AVPU scale  iP or U-Immediate  A, V, aP-Delayed CERT Pediatrics

54. Combined Algorithm 5 CERT Pediatrics

55. Putting it into practice

56. Driving down the road, texting your BFF… ●See a bus in an embankment ●Can see some victims on the ground ●Priorities? CERT Pediatrics

57. Incident scene CERT Pediatrics N Wind 10 mph 96 o F 76% RH 14:00

58. CERT Pediatrics Inside the bus… Bus Clear

59. What’s your call? 5 ●A young school aged boy is found lying on the roadway 10 ft. from the bus. ●Breathing 10/min ●Good distal pulse ●Groans to painful stimuli

60. What’s your call? 5 ●An adult kneels at the side of the road, shaking his head. He says he’s too dizzy to walk. ●RR 20 ●CR 2 sec ●Obeys commands

61. What’s your call? 5 ●A school aged girl crawls out of the wreckage. She’s able to stand and walk toward you crying. ●Jacket and shirt torn ●No obvious bleeding

62. What’s your call? 5 ●A toddler lies with his lower body trapped under a seat inside the bus. ●Apneic ●Remains apneic with modified jaw thrust ●No pulse

63. What’s your call? 5 ●Adult female driver still in the bus, trapped by her lower legs under caved-in dash. ●RR 24 ●Cap refill 4 sec ●Moans with verbal stimulus

64. What’s your call? 5 ●A toddler lies in the aisle just inside the door. ●RR 50 ●Palpable distal pulse ●Withdraws from painful stimulus

65. What’s your call? 5 ●A woman is carrying a crying infant. She is able to walk. ●RR 20 ●CR 2 sec ●Obeys commands

66. What’s your call? 5 ●An infant is carried by the previous victim. ●He’s screaming but the woman quiets him to RR of 34 ●Good distal pulse ●Focuses on rescuer, reaches for mom. ●No obvious significant external injuries.

67. What’s your call? 5 ●A young school aged boy props himself up on the road. ●RR 28 ●Good distal pulse ●Answers question and commands. ●Has obvious deformity of both lower legs.

68. What’s your call? 5 ●Toddler found outside the bus, lying on the ground in a heap. ●Apneic ●Faint distal pulse palpable ●Breathing after 5 rescue breaths

69. What’s your call? 5 ●A school aged girl lies among the wreckage. ●RR 40 ●Absent distal pulse ●Withdraws from painful stimulus

70. What’s your call? 5 ●A screaming infant is found along the side of the road. ●RR 38 ●Good distal pulse ●Focuses and reaches for you. ●Has a partial amputation of the foot without active bleeding.

71. What’s your call? 5 ●An adult male lies inside the bus. ●Apneic ●Remains apneic with jaw thrust

72. What’s your call? 5 ●A youngster is up and walking around but is limping ●Alert, crying hysterically for his mother

73. What’s your call? 5 ●A school aged boy lies close to the bus. ●RR 36 ●Absent distal pulse ●Sluggishly looks at you when you talk to him

74. What’s your call? 5 ●A young teen girl lies among the wreckage, crying for someone to help her up. A man with her says she needs her wheelchair. ●RR 22 ●Palpable distal pulse ●Alert ●Has minor cuts and bruises

75. What’s your call? 5 ●An adult male in driver position of SUV ●RR 20 ●Good distal pulse ●Obeys commands but cries that he can’t move his legs OR

76. What’s your call? 5 ●An older school aged child is found sitting outside the SUV. ●RR 28 ●Good distal pulse ●Groggy, confused and slowly follows commands but won’t get up and walk.

77. First EMS Unit Arrives CERT Pediatrics N Wind 10 mph 98 o F 76% RH 14:15

78. Final Counts ●Immediate7 or 6 ●Delayed4 or 5 ●Minor5 ●Deceased2 ●Total 18 ●EMS assumes control, what do you do now? CERT Pediatrics

79. Summary ●Need to include kids in disaster preparedness ●Kids are not small adults ●Dramatically affected physically and mentally by disasters ●Pediatric triage is similar to adult triage ●Changes to assessments of  Breathing  Respiratory rate  Mental Status ●Don’t forget to triage children carried into the Minor treatment area CERT Pediatrics Home

80. References 1.Lyle K, Thompson T, Graham J. Pediatric Mass Casualty: Triage and Planning for the Prehospital Provider. Clinical Pediatric Emergency Medicine. 2009;10(3):173-185. 2.FEMA. Be a Hero: FEMA Youth Preparedness Program. 2014; http://www.ready.gov/kids. Accessed August 26, 2014. 3.CHLA. Disaster Training Videos: Age-specific Care Considerations. 2009; http://www.chladisastercenter.org/site/c.ntJYJ6MLIsE/b.4695823/k.6FD2/Disaster_Training_Videos.htm, August 27, 2014. 4.FEMA. Unit 3-Disaster Medical Operations Part 1. CERT Basic Training Instructor Guide: Department of Homeland Security; 2011. 5.Romig L. The JumpSTART Pediatric MCI Triage Tool. 2002; http://www.jumpstarttriage.com/JumpSTART_and_MCI_Triage.php. Accessed August 20, 2014. 6.Schonfeld D. Mental Health Concerns. Clinical Pediatric Emergency Medicine. 2009;10(3):153-155. 7.Schonfeld D, Gurwitch R. Addressing Disaster Mental Health Needs of Children: Practical Guidance for Pediatric Emergency Health Care Providers. Clinical Pediatric Emergency Medicine. 2009;10(3):208-215. 8.KCCRB. Kentucky Community Crisis Response Board. 2014; http://kccrb.ky.gov/. Accessed August 28, 2014. CERT Pediatrics

81. Contact CERT Pediatrics