1. Populations At Risk - Pediatrics Dr. Daniel Kollek Executive Director The Centre for Excellence in Emergency Preparedness

2. Content Who CEEP is Why focus on children? Child specific issues The CEEP process and resources

3. What is CEEP?

4. Why focus on children?

5. Child specific issues Physiology Anatomy Development Psychosocial Other

6. Physiology Children have a higher minute ventilation. Due to shorter stature, they are more likely to be exposed to heavier than air respiratory toxins. Children have a large skin to body mass – more hypothermia and transdermal absorption of toxins. Children are at much higher risk of dehydration and shock. It is harder to establish intravenous access in children. Children vary enormously in both size and weight and thus, routine protocols and standing orders are difficult to establish. Malnutrition is a more significant problem with smaller children.

7. Anatomy Children’s skeletons are far more pliable than adults and provides less protection for internal organs. The ratio of mass of head to mass of body is larger in children than adults and thus, the likelihood of a head injury in a child is higher.

8. Developmental Children’s cognitive and motor skills vary with age, development, and occasionally with other underlying illnesses. It is not always possible to know if a child has deviated from their usual functional norm. Children do not always have the psychological and cognitive maturity to be able to process events. A child may not have the language skills to provide a clinical history. In an event where a child is separated from a caregiver, the child may not have the cognitive ability to recognise the risk and evade it.

9. Psychosocial Families should, ideally, be treated as a unit. This needs to be taken into consideration for any situation where isolation is required. Even though the child may not be a primary victim, children may be truly or virtually orphaned as a result of an event that impacts on their parents. Disaster planning needs to involve school and child-care staff for: – a disaster that occurs during day-time hours – an event that involves long term closure of schools The need for child care has impact on the hospital caregivers and staff. Children are possible targets of predators, more so when separated from their usual caregivers.

10. Other Children exposed to radiation are at a higher risk of developing radiation-induced cancer such as thyroid cancers. Presently hospitals are not allowed to provide immediate and on-going care to children who are unable to provide consent and whose guardians are not available for a variety of reasons. There is implied consent for most resuscitative therapy but the consent issues are less clear when it comes to non-acute care. Children do not always identify that they are in pain or may not be examined due to pain. Caregivers are not always comfortable calculating doses for smaller children. Many vaccination protocols do not make allowances for children or in fact, the vaccine may not be approved for small children.

11. Child specific injuries Head injury Skeletal injury Thermoregulation Blood loss Emotional Trauma

12. Mechanisms of injury - 1 Head injury Head injuries account for approximately 60% of all MCE and disaster injuries in the pediatric population. In states of unconsciousness, children’s upper airways tend to get obstructed due to: – relatively large, flaccid tongue – large head flexion induced by the prominent occiput

13. Mechanisms of injury - 2 Skeletal injury Children have more pliant and flexible bones than adults and are therefore subject to fewer bone fractures. Internal organ are not uncommon. Injuries to children and adolescents also include growth plate injury.

14. Mechanisms of injury - 3 Thermoregulation Children are at a higher risk of thermal injury and its aftereffects because of: – the less mature thermoregulatory mechanism in children – The higher surface area-to-mass ratio compared to adults

15. Mechanisms of injury - 4 Blood loss Children have relatively small amounts of blood (80 ml/kg), What may seem to be minor bleeding may in effect represent a significant volume loss and severe shock. Children’s cardiovascular system is generally free of chronic disabling conditions therefore, children may tolerate hypovolemic stress better than adults.

16. Mechanisms of injury – 5 Emotional Trauma In addition to physical injuries, emotional trauma, caused for example by separation from the parents, is an important factor in pediatric care. Children may also be more easily frightened by events that they cannot understand such as a health care provider in PPE.

17. Prognosis Children tolerate multiple organ injuries better than adults Prognosis usually depends on the severity of the head injury, if present. Children have a better prognosis for most, if not all, disaster-related conditions.

18. Disaster Response and Children Prehospital Care Pediatric Guidelines Mass Casualty Triage Guidelines for Pediatrics (as opposed to Normal Triage) General Guidelines for Treatment Areas Pediatric Equipment/Resources lists Psychosocial Needs & Treatment guidelines Health Care Facility Pediatric Risk Assessment Health Care Facility Pediatric Readiness Assessment tool Guidelines for Children with Special Needs

19. Disaster Response and Children Prehospital Care Pediatric Guidelines Mass Casualty Triage Guidelines for Pediatrics (as opposed to Normal Triage) General Guidelines for Treatment Areas Pediatric Equipment/Resources lists Psychosocial Needs & Treatment guidelines Health Care Facility Pediatric Risk Assessment Health Care Facility Pediatric Readiness Assessment tool Disaster guidelines for Children with Special Needs

20. The CEEP process Defining a need Convening an expert group Literature search First document draft Iterative review Penultimate draft Group meeting for final review and approval Submission for endorsement Posting and distribution

21. How to access CEEP resources www.ceep.ca www.ceep.ca/tools.htm