Pediatric
Decontamination:
More Than Just
A Bath
Lou Romig MD, FAAP, FACEP
Pediatric Emergency Medicine
West Kendall Baptist Hospital
Miami, FL
Disclosure
The speaker has declared no
conflict of interest.
Topics
Why worry about deconning kids?
What makes deconning kids different?
Behavior
Logistics
Pediatric decon in the field
Pediatric decon at the hospital
Why worry about
contaminated kids?
Why worry about
contaminated kids?
Nebraska Alliance for Drug-Endangered
Children
http://www.nebraskadec.org/protocols.html
Risk factors for exposure
Kids:
make terrifying targets
may not recognize danger
may not be able to self-rescue or defend
themselves
may not report exposure
come in bunches
put things in their mouths and noses
Risk factors once exposed
Close to the ground
More permeable skin
Larger body surface area
Higher minute ventilation
Risk factors once exposed
Susceptibility to fluid losses
Underdeveloped immune system
Rapidly dividing cells
Deconning a radioactive school yard in
Fukushima
Risk factors once exposed
Medical providers inexperienced in
pediatric care
Inadequate preparation by rescuers and
responders, including hospitals
Inadequate forms and stocks of antidotes
What makes
deconning kids
different?
Behavior: Personnel
Need for adult supervision
Must deal with caregivers
Emotional involvement of responders
Crowd management
Behavior: The kids
Difficulty communicating
Difficulty following directions
Hesitancy to disrobe
Fear!
Logistics
Personnel intensive
Increased decon time/slowed through-put
≥10-15 min/pediatric pt total time
Prevent hypothermia
Adequate pre- and post-decon garb
Water temp 98-100° F
Warmed decon facility
Logistics
Prevent injury from water spray
60 psi
Avoid using chemicals
Prevent slips and falls
Logistics
Unaccompanied children
Identification
Supervision
Prioritization
All children first?
Based on medical triage?
Maintain privacy/security
Decon of children in the field
Decon of
victims
vs
responders
Pediatric decon in the field
Usually high-volume/low pressure
Warm water?
Adequate drying and post-decon
coverings to prevent hypothermia?
Transport all deconned for medical
evaluation?
Protocols for pedi decon?
Drills for pedi decon?
Pediatric decon at the hospital
Pediatric decon at the hospital
Never assume you won’t get pediatric
patients
Include pediatric considerations in your
decon plans (and all disaster plans!)
Train and retrain
Include children and families in all
disaster drills and training
Failure to prepare may shut down your
facility and endanger staff and patients
Arrival
When notified of an event involving
potentially contaminated victims,
activate your decon plan early.
Protect your facility!
Arrival
Never assume all contaminated patients
will arrive via EMS, already grossly
decontaminated and triaged
Children are portable!
The closest hospital is at greatest risk
Don’t assume a person knows they’ve
been contaminated
Not everyone who thinks they’re
contaminated has really been exposed
Arrival
ID and separate contaminated vs possibly
contaminated vs grossly deconned vs
clean pts
Whenever possible, keep children with
family members
Potentially contaminated unaccompanied
minors must be supervised by protected
personnel
Arrival
Determine decon priorities
Rapid (re)triage by protected personnel
Life saving interventions by protected
personnel
AW opening
Control bleeding
IM antidotes (autoinjector)
Most critical deconned first?
Children deconned first?
Pre-shower
≥90% of contamination is removed with
clothing
Toys, backpacks, jewelry and comfort
items must be bagged and tagged
Provide adequate coverage for warmth
and modesty between disrobing and
showering
Record EMS triage tag number for ID
and tracking
Pre-decon garb
Courtesy UMHealth Systems
Pre-shower
Permit family members to stay together
unless critical medical issues take priority
Family processed at the level of highest
medical priority of any single member
Consider taking digital photos of
unaccompanied minors who can’t identify
themselves before disrobing. This may assist
in identification/reunification.
Wet decon: Gender issues
Gender separation preferred for children
older than 8 years of age
Same gender personnel preferred if
needed for assistance in wet decon
Wet decon: Age issues
0-2 years
Never assume a caregiver can decon
his/herself and their child/children
Highest risk for hypothermia
Monitor child’s airway during decon
Do NOT permit decon in-arms
Two personnel to decon if no caregiver
One hand on an infant at all times.
Safety for young children
Wet decon: Age issues
2-8 years (“guestimate” age)
This group will likely take the longest
Not critical to separate genders but
preferred
Gender-matched personnel preferred
Older children in this age group may be
able to decon themselves with supervision
and encouragement
Wet decon: Age issues
8-18 years (“guestimate” age)
Respect modesty
Gender separation preferred
Gender-matched assistance preferred
Can decon themselves with supervision
Wet decon: Nonambulatory
Assistance by caregivers when available
Caregivers must also decon
Decon on stretcher or other restraining
device
Consider roller or slide system
Wet decon: Special needs
Allow caregiver to remain with child if at
all possible
Maintain communication with child
Increased risk for hypothermia and
medical deterioration
Be aware of need to decon stomas and
possibly remove stomal appliances
Trachs and other appliances may need to
be replaced in cold zone
Wet decon: Equipment
Equipment-dependent patients:
Non-waterproof equipment remains in hot
zone if pt is symptomatic and/or equipment
is grossly contaminated
Decon water-resistant equipment,
preferably keeping it with the patient
Wet decon: Other issues
Mild soap may be used with water
Do not use bleach or other chemicals
Genitals must be deconned as well
Depending on contaminant, eye/nose/ear
and mouth lavage may be necessary
Wet decon: Other issues
Remove dressings to decon wounds
Ideally, there should be a protected
pediatric care-capable clinician in the
decon area at all times.
Post-decon
Immediately dry patient
Assure layer of clothing or other covering
closest to skin is dry. Remember to cover
head and feet to help prevent heat loss.
Use appropriate garb or coverings to
assure warmth and comfort and protect
modesty
Post-decon garb
Decon Kits
Post-decon
Assure patient is appropriately identified
and tracked
Re-triage and commence further care
Will all those deconned be considered
patients for further medical evaluation or
is screening sufficient? Is this policy for
prospective patients of all ages?
Post-decon
Provide a child-friendly environment
Further assessment should include
evaluation for psychological trauma due
to the incident and the decon process
Ideally, provide families with information
about psychological consequences and
warning signs requiring further
evaluation
Key Points
Key Points
All hospitals should be prepared to decon
patients of all ages
Decon procedures must be determined in
advance. Training and retraining is
crucial. Training should include pediatric
considerations.
The “big one” may never come but the
“small ones” may hurt you if you’re not
prepared
Key Points
If children become contaminated they
may be at increased risk of morbidity and
mortality compared to adults
Deconning kids is personnel-intensive
Utilize caregivers but be prepared to
assist them. Keep children with their
caregivers.
Key Points
Children’s natural behavior can prolong
the decon process
Keep children warm at all times using
coverings, 98-100°F water and a warm
decon facility
Identification and tracking through the
entire decon process is critical to
reunification efforts
Key Points
Ideally, genders should be separated for
patients over early school age. Same
gender personnel are also preferred.
Patient age can influence decon
procedures
Never carry a wet slippery child through
decon
Key Points
Details are important. A contaminated
pacifier or field dressing can cause
trouble.
Keep at least one pediatric-capable
clinician available in protective gear in
decon at all times to recognize and
intervene in case a child rapidly
deteriorates
References
The Decontamination of Children, DVD, AHRQ,
Children’s Hospital Boston
“Principles of Pediatric Decontamination”, Heon and Foltin,
Clinical Pediatric Emergency Medicine, Sept 2009
“Disaster Preparedness: Hospital Decontamination and the
Pediatric Patient”, Freyberg, et al, Prehospital and Disaster
Medicine, March-April 2008
Nebraska Alliance for Drug Endangered Children,
http://www.nebraskadec.org/protocols.html
References
OSHA Best Practices for Hospital First Receivers of
Victims from Mass Casualty Incidents Involving the Release
of Hazardous Substances, Jan 2005,
http://www.osha.gov/dts/osta/bestpractices/html/hospital_fir
streceivers.html#appj
Decontamination Guidance for Hospitals, Victorian
Government, Emergency Management Branch, Department
of Human Services, Melbourne, Australia, 2007,
http://www.dhs.vic.gov.au/__data/assets/pdf_file/0004/6137
77/decon_guidance_for_hospitals.pdf
Pediatric and Obstetric Emergency Preparedness Toolkit,
New York State Dept of Health, June 2010,
http://www.health.ny.gov/facilities/hospital/emergency_pre
paredness/guideline_for_hospitals/index.htm
Questions?
Thank you!
Lecture available for download at
www.jumpstarttriage.com
louromig@bellsouth.net