1. 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

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

3. 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

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

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

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

10. January 5, 2009 – Alta Verapaz

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

12. 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

13. 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

16. Initial Brief Assessment
Open airway
Control major hemorrhage
Categorize

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

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

20. 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

22. 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

24. 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)

25. 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

26. 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)

27. 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).

28. Pediatric Triage

29. 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

30. 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

31. 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

32. 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

33. JumpSTART (under 8)
Kids more airway dependent – rescue breaths attempted if pulse present (unlike adults) Resp 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

35. 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

37. 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

38. 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

40. 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

44. 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

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

46. 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

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

48. 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

49. 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

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

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

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

53. 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

54. 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