1. Pediatric Disaster Life Support (PDLS©): Scene Assessment, Triage, Resuscitation and Stabilization at the Scene of a Disaster
- Briefly cover pedi. rescue in general
- Pedi rescue in disaster – how does it change
Triage in prehospital setting
Criteria and techniques
James Courtney, DO

2. 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 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

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

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

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

9. 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

10. 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

13. Initial Brief Assessment
Open airway
Control major hemorrhage
Categorize

14. 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)

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

17. 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

19. 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

21. 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)

22. 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

23. 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)

24. 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).

25. Pediatric Triage

26. 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

27. 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

28. 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

29. 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

30. 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

32. 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

34. 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

35. 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

37. 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

40. 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

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

42. 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

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

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

45. 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 30/40, RR 30
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

46. 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

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

49. Decontamination

50. 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

51. 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

52. 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

53. Decontamination of Children
Special Equipment
Have a plan for special equipment on children or adults
Wheelchairs
Electronic equipment
Firearms

54. 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?

55. Child Likely To Need Specialized Care
Shock SBP <80, HR>130<50
Resp distress RR>30<10, stridor
GCS<9
Mechanism
MVA
Pedestrian/bicyclist thrown >15 feet
Penetrating injury to head, neck, trunk

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

57. Progression of Pediatric Shock
Optional
Slide 3: Progression of Respiratory Failure and Shock to
Cardiopulmonary Failure and Arrest
In infants and children a variety of conditions (such as airway obstruction, trauma, toxic ingestion, or sepsis) may ultimately cause cardiopulmonary failure and cardiopulmonary arrest.
These conditions typically produce either respiratory failure, shock, or a combination of the two and can lead to cardiopulmonary failure if not promptly and adequately treated.

58. Response to Shock 140 100 60 Percent of control 20 Compensated
Vascular resistance
Percent of control
Slide 11: Hemodynamic Response to Shock in Infants and Children
This figure illustrates typical changes in heart rate, blood pressure, and cardiac output as the child moves from compensated to decompensated (ie, hypovolemic to hypotensive) shock.
Note that tachycardia without hypotension is present in compensated shock. Blood pressure is initially maintained through an increase in systemic vascular resistance.
As cardiac output falls further, blood pressure begins to fall, and shock is characterized as decompensated shock.
Cardiac output
Blood pressure
Compensated
shock
Decompensated
shock

59. Pediatric Assessment Triangle

60. Slide 9: Rapid Cardiopulmonary Assessment: Classification of
Physiologic Status
Rapid cardiopulmonary assessment allows classification of the patient’s respiratory status.
Respiratory distress is characterized by increased effort/increased work of breathing.
Respiratory failure indicates the presence of inadequate pulmonary gas exchange, resulting in inadequate oxygenation or ventilation. Note that respiratory failure may be present with or without respiratory distress.

62. Pediatric Resuscitation
Russian Field Hospital
Nias, Indonesia
4/05

63. Treatment
Patients frequently may outnumber transport, leading to time in field where treatment can be started
Sort patients by category (GREEN, YELLOW, RED and BLACK) and treat within areas.
If GREEN patients self triaged, they need evaluation.
Limited initial treatment – don’t delay evacuation if vehicle available

64. Treatment
Kids will be mixed in – do you have enough supplies in kid size (oxygen, IVs, splints)?
Does your locality stock a “disaster truck”?
Does it have kid size equipment and kid sized doses of Hazmat antidotes?
Do you have Broselow tapes to guide dosing?

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

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

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

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

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

71. Treatment:
Dressings – rinse gross dirt with sterile fluids or tap water if available, sterile cover to prevent further contamination
Pressure dressing for active bleeding
Recruit neighbor to help hold pressure during triage while awaiting transport/evacuation
Splint – extremity injuries

72. Treatment
Medications: pain control, specific antidotes with Hazmat event/team
Monitoring: repeat assessment after triage, re-categorize if necessary (to worse, never better – they still have the same underlying injury)

73. Further field care Depends on local plans
Send personnel and supplies to site, or bring patients to hospital (personnel and supplies)
EMS –patient to hospital
NDMS – personnel and supplies to site

74. Transport
Decides which patients leave scene first and where they’re going
Helpful bystanders and self transporters will fill the nearest hospitals first.
Includes decisions about longer transport times for specialty care
Use helicopters for long distance transports

76. Children with Special Health Care Needs

77. 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

78. Children with Special Health Care Needs (CSHCN)

79. Children with Special Health Care Needs (CSHCN)

80. 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

81. 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?

82. 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

83. Sheltering for Children
Hurricane Katrina taught us many harsh lessons about how important shelter planning is

84. 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

85. Sheltering Issues Safety and Supervision
Shelters are dangerous environments
Rarely childproofed
Children move quickly throughout environment
Easy to get lost
Possible criminal element

86. 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

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

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

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

90. 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.

91. 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- 1999
Richard V. Aghababian MD, FACEP

92. 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