1. Pediatric Disaster Life Support (PDLS ©) : Scene Assessment & Triage 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 Learning Objective At the end of this lecture, the students should be able to: 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 Scene Assessment Triage Assessment Triage Assessment Initial Stabilization Initial Stabilization Resuscitation Resuscitation

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

9. Scene Assessment Notification to medical control: regional communications, local emergency management / disaster authority 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 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 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” “greatest good for greatest number” Protocol helps makes decisions Appropriate performance crucial Appropriate performance crucial

13. ICS separates triage from treatment immediately - - see everybody once briefly for overview Dynamic process, re-triage / re-evaluate at several stages Dynamic process, re-triage / re-evaluate at several stages Triage in disaster setting may be very difficult Triage in disaster setting may be very difficult Pediatric population unique challenge Pediatric population unique challenge Triage

16. Initial Brief Assessment Open airway Open airway Control major hemorrhage Control major hemorrhage Categorize Categorize

17. Triage Classifications Simple Triage And Rapid Treatment Simple Triage And Rapid TreatmentS.T.A.R.T. JumpSTART JumpSTART Tool for Rapid Pediatric Multicasualty Field Triage (children from 1 - 8 years of age)

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

20. Triage Classifications and Examples Red - tension pneumothorax, rib fractures, upper airway obstruction, hemorrhage, femur fracture, asthmatic Red - tension pneumothorax, rib fractures, upper airway obstruction, hemorrhage, femur fracture, asthmatic Yellow - humerus fracture, scalp lacerations, shoulder dislocation Yellow - humerus fracture, scalp lacerations, shoulder dislocation Green - ankle sprain, simple laceration, orphaned child, subluxed radial head Green - ankle sprain, simple laceration, orphaned child, subluxed radial head Black/Blue - cardiopulmonary arrest, severe open head injury Black/Blue - cardiopulmonary arrest, severe open head injury

22. START Most commonly used triage system across country Most commonly used triage system across country Not applicable for under 8 years old Not applicable for under 8 years old Initial eval – not final Initial eval – not final Time limited (plan <1 min/patient) Time limited (plan <1 min/patient) Categorize and move on 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. “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) 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 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). 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 Spont resp >30 => RED/ under 30 => next item of assessment

26. START Perfusion: cap refill > 2 sec => control bleeding, label RED; 2 sec => control bleeding, label RED; <2 sec, next item Perfusion: Radial Pulse => if no label RED; if yes then 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 YELLOW (delayed) Mental status: Cannot follow simple commands => RED; CAN follow simple commands (and has cap refill 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. 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). Minimal treatment during triage: airway maneuver (chin tilt, jaw thrust) and dress active blood loss (not scrapes).

28. Pediatric Triage

29. Triage of children and adults is typically done simultaneously during a disaster 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 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 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 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 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 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 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 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 15-45 instead of <30 Kids more airway dependent – rescue breaths attempted if pulse present (unlike adults) Resp 15-45 instead of <30 Vascular system clamps down sooner, so cap refill less reliable. Use peripheral pulse instead. Vascular system clamps down sooner, so cap refill less reliable. Use peripheral pulse instead. Mental status AVPU instead of following simple commands Mental status AVPU instead of following simple commands

35. JumpSTART “If you can hear me and you are able, walk over here for help.” “If you can hear me and you are able, walk over here for help.” Probably won’t work for children Probably won’t work for children If they are ambulatory, then they are GREEN If they are ambulatory, then they are GREEN Use adults on scene to help corral the GREEN children Use adults on scene to help corral the GREEN children

37. JumpSTART Respirations: NO  open airway => yes  RED; no -> check peripheral pulse. Respirations: NO  open airway => yes  RED; no -> check peripheral pulse. NO pulse = BLACK NO pulse = BLACK Pulse  15 sec mask to mouth ventilation Pulse  15 sec mask to mouth ventilation Spont resp: NO  BLACK; YES  RED Spont resp: NO  BLACK; YES  RED

38. JumpSTART Breathing: RR 40 or irregular =RED Breathing: RR 40 or irregular =RED RR 15-40, regular – check pulse RR 15-40, regular – check pulse No peripheral pulse: RED No peripheral pulse: RED Peripheral pulse: check mental status Peripheral pulse: check mental status AV (appropriate) YELLOW AV (appropriate) YELLOW PU (inappropriate) RED PU (inappropriate) RED

40. Kids in triage Don’t follow commands. Don’t follow commands. May actually hide from rescuers May actually hide from rescuers May be extricated by GREEN parents/ adults with delay in triage and treatment. May be extricated by GREEN parents/ adults with delay in triage and treatment. Need distraction and dedicated supervisor able to run after wandering toddlers 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 Awake 8 yr old child brought in 3 days after earthquake with 20 others Can not walk Can not walk Responds to voice Responds to voice Respiratory Rate 50 Respiratory Rate 50 No obvious injuries No obvious injuries IMMEDIATE

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

46. What do you do? What do you do? How do you classify this child if he breathes? Examples IMMEDIATE DECEASED How do you classify this child if he does not breathe after 5 rescue breaths?

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

48. Categorize the Following 1. 7 y.o. female, crying, unwilling to move right arm, 1° burn to anterior thigh 2. 10 y.o. male, deformed thigh, pale, pulse 120, BP 60/40, RR 36 3. 20 y.o. female, apneic, severe head injury with visible grey matter 4. 2 y.o. male, 2-3° burns to face, neck and chest 5. 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 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 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 PDLS is a start Much information exists to guide the preparation and care for children in disasters Much information exists to guide the preparation and care for children in disasters

51. Resources U.S. Center for Disease Control U.S. Center for Disease Control - www.cdc.gov www.cdc.gov National Center for Disaster Preparedness National Center for Disaster Preparedness - http://www.ncdp.mailman.columbia.edu/ http://www.ncdp.mailman.columbia.edu/ American Psychological Association American Psychological Association - www.apa.org www.apa.org

52. Resources JumpSTART Triage Tool JumpSTART Triage Tool - www.jumpstarttriage.org www.jumpstarttriage.org American Academy of Pediatrics American Academy of Pediatrics - http://www.aap.org/terrorism/topics/disaster_planning.html http://www.aap.org/terrorism/topics/disaster_planning.html Pediatric Disaster Preparedness Consensus Conference Summary Pediatric Disaster Preparedness Consensus Conference Summary - http://www.bt.cdc.gov/children/pdf/working/execsumm03.pdf http://www.bt.cdc.gov/children/pdf/working/execsumm03.pdf U.S. Department of Homeland Security U.S. Department of Homeland Security - www.dhs.gov www.dhs.gov

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 Gregory Ciottone, MD Lucille Gans, MD Lucille Gans, MD Patricia Hughes, RN Patricia Hughes, RN Frank Jehle, MD Frank Jehle, MD Taryn Kennedy, MD Taryn Kennedy, MD Gretchen Lipke, MD Gretchen Lipke, MD Mariann Manno, MD Mariann Manno, MD Gina Smith, RN Gina Smith, RN Fred Henretig, MD Fred Henretig, MD Theodore Cieslak, MD Theodore Cieslak, MD Robert McGrath, M.Ed. Robert McGrath, M.Ed. W. Peter Metz, MD W. Peter Metz, MD John A. Paraskos, MD John A. Paraskos, MD Carol Shustak, RN Carol Shustak, RN Elizabeth Shilale, RN Elizabeth Shilale, RN A. Richard Starzyk A. Richard Starzyk Michael Weinstock, MD Michael Weinstock, MD Sharon Welsh, RN Sharon Welsh, RN Lou Romig, MD Lou Romig, MD