Pediatric Mass Casualty
Incident
A Quick Prep for
Clinicians
Pediatric Mass Casualty
Incidents (MCI)
 School disasters (national/international)
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Newtown school shooting 2012
Earthquake in China 2008 with school collapses
Beslan, Russia school terrorist event in 2004
Columbine school shooting 1999
Potential Pediatric MCI
 Collapse of a venue used primarily youth ex.
“Disney on Ice”
 Natural disaster
 Tuscaloosa tornado had >50 pediatric victims
 School bus crash
Potential Pediatric MCI
 Infectious disease outbreaks preferentially
targeting children
 Pertussis out breaks
 Influenza with high impact on young
patients
Objectives: How to Prepare
For a Pediatric MCI
 Know the differences and similarities between
children and adults
 Be aware of the special considerations for children
 Physical, emotional, environmental, communication,
family, equipment
Objectives: How to Prepare
For a Pediatric MCI
 Children with “Special Needs”
 Medications and treatments specific to children
 Decontamination
 Indications for transfer to a higher level of care
 Pearls
Similarities
 Kids are not “little adults” but the same priorities apply:
 ABCDE’s
 Almost all the medications are the same, they just need
weight based adjustment
 If a child hurts, they tell you and usually will not move
 Don’t avoid a necessary procedure for a child just
because they are a child! Do what needs to be done
according to usual trauma care
Differences
 Children are very quick to respond to a treatment or
lack of treatment so constant evaluation and reevaluation is needed
 Family contact is a high priority
 Diverting the attention of the child often lets you
examine them
 Distraction ideas - videos, toys, iPhone, iPad, books
with pictures to point to etc.
Differences
 Over-triage can happen
 Children often prioritized higher than necessary if
significant soft tissue injuries and/or crying
 Carefully assess chest, abdomen, and mental status
Pediatric Assessment
Triangle
Differences
 Airway
 Head is big – in infants and small children, pad the
shoulders up to achieve alignment
 Larynx is anterior and shallow vs. adult
 Narrowest part of airway is BELOW cords at cricoid
ring
 Airways are narrower and do not tolerate swelling well
 Adjusting head and neck position can improve airflow
immensely
 Constant evaluation and re-evaluation is necessary
Differences
 Breathing
 Children are generally easy to bag-valve-mask if the
airway is open
 Avoid hyperventilation and over-ventilation with adult
sized masks
 Chest wall is elastic – thus fractures are more rare, but
pulmonary contusions can occur without fractures
Differences
 Circulation and Disability
 IV access may be difficult, consider IO access
early – can always give blood or fluids via IO and
most medications
 Falling blood pressure and compromised
circulation are LATE findings of shock
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Children compensate well – UNTIL THEY DON’T!
Look for tachycardia and other signs of early shock
Look for areas of blood loss; femur fractures, scalp
hematomas, abdomen/pelvis
 20ml/kg fluid boluses initial, blood 10ml/kg
 If trauma related, when giving the 2nd fluid bolus
- get the PRBC's ready to give
Provider Fears
 Impact on the child’s life
 Unable to communicate with the child
 “Never did that procedure on a child”
 The emotional connection to children that prevents
the provider from treating the child
 Fear of inflicting pain/anxiety
 Unaccustomed with pediatric equipment and
dosing
Special Considerations:
Physical
 Often they are first patients to show signs of
toxicity of a poison
 Thinner skin/smaller size therefore more
susceptible to toxins and ionizing
radiation
 Increase respiratory rate, inhaling a larger
dose of toxin
 Larger surface area to mass ratio
 Closer to the ground and most toxic gases
are heavier than oxygen
Special Considerations:
Physical
 Vital signs are age related
 Higher incidence of head and major organ injuries
 Major organs are closer together
 Larger head size
 Rib cage is softer and less protective
 Small children have small glycogen stores – thus
drop their blood sugar under stress
 Point of care glucose on all children with major
injury/illness
Special Considerations:
Emotional
 Family/familiar items are key
 Try to keep families together, if impossible, keep
familiar items with the child
 Child appropriate books, DVD’s, music
 Diversion techniques
 Soap bubbles, music, lights, etc.
Special Considerations:
Environmental
 Monitor temperature frequently
 Make sure the entire body is viewed for reevaluation and then cover
 “Child friendly” environment
 Group children together in care areas
 Have areas for discharged “well” children where
they can be monitored until sent home or to other
care facilities
Special Considerations:
Environmental
Ratios for Adult to Child Monitoring
Age
Ratio
Infant
1:4
8
Toddler
1:7
14
Pre-school
1:10
20
School age
1:15
30
Minnesota Rule 9503.0040
Group Size
Special Considerations:
Communication
 Speak to the child at their developmental level of
understanding
 Be honest
 Keep the child informed as to “what is happening”
and avoid surprises
 Supply basic needs
 Appropriate food, liquids and bedding
 Help them go to the bathroom
Special Considerations:
Family
 Parents will often seek care for their children and
ignore their own health
 Avoid separating families
 Empower family members in the care and
monitoring of each other
 Have a plan for unidentified/unaccompanied
minors
 Digital photos and check off lists of identifying
information
Special Considerations:
Family
 Appropriate food, toys and /bedding
 Ratio of the number of caregivers to the number of
children is dependent on age of children
 Have a plan on how you will discharge children to
people other than their parents
 Have a plan on how you will track and record
disposition of patients
Special Considerations:
Equipment
 Remember: only 6.5% of the population is 8 years or
younger
 Plan equipment for < 8 years – above this can use
small adult equipment
 Key equipment issues are:
 IO and IV – remember pumps, buretrols and pediatric
specific fluids
 Airway equipment – intubation and ventilation
 Back-up airway equipment
 Surgical chest tube equipment
Special Considerations:
Equipment
 Have equipment for transportation of children
 Booster and car seats
 Know how to adapt transport cots to fit small children
 Have appropriate equipment to handle children
 (AAP - http://www2.aap.org/visit/Checklist_ED_Prep-022210.pdf)
 Antidotes and medications for pediatrics
 Especially analgesia and sedation early in event
Decontamination
 Make simple picture descriptions of decon
procedures for young children (can be used
for non-English speaking patients as well)
 Train with the DVD “The Decontamination of
Children” from AHRQ
 Consider using heavy-duty laundry baskets
for infants and small children
 Products that work well for oily substances –
baby shampoo and Dawn
Decontamination
 Use large volumes of water at low
pressure
 Consider decontamination of the entire
family at the same time
 Respect the wishes of teens
 Close monitoring of temperature
 Active rewarming after decontamination
Children with Special Needs
 Look for medic alert bracelets and care plans
 Many are dependent on medications given at
specific times during the day
 Allow children to take their own medications
 If missing their medications, be prepared to give
alternative medications
 Many are dependent on ventilators and other
electrical equipment and may need to recharge
batteries
Children with Special
Needs
 Alternate equipment may be necessary if the child’s
is broken or not with them
 If a child is non-communicative and has no personal
care attendant with them, providers will need to
meet the needs of the child
 Adequate intake of nutrition and output
 Medications and mode of ingestion
 Adequate pain relief
Medications and Treatments
 Use weight based dosage for all medications and
equipment
 Weigh the patient and dose according to weight
“Gold Standard”
 Use a length-based tool (Broselow tape) for weight
estimation if you cannot weigh the child
 Use an age-predicted weight estimation chart as a
last option because it is the least accurate
Medications and Treatments
 Medications not used in children
 Limited use of Tetracycline derivatives in children
under 8 years of age
 No Aspirin
 No OTC cold medicines
 Analgesia – titrated doses of narcotics
 Consider intra-nasal, sq, nebulized routes
Indications for Transfer
 Children given the top priority to be transferred to a
higher level of care
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Age less than 5 years
Multiple injuries or high-energy mechanism
Signs of hypotension/shock that is not improving
Altered mental status
Underlying complex illness/disease
Pearls
 Early signs of shock can be missed
 BP is the last and least reliable VS in pediatric shock
 Perfusion can be influenced by temperature
 Children get tired and LOC can then be unreliable
 Look for medical alert bracelets
 High fever can cause increase in respiratory and
heart rates
 Pediatric Triangle of Assessment
Pearls
 Use intra-osseous lines as needed
 Same procedure as an adult
 Pre-infuse with 5mL 2% Lidocaine without
preservative or epinephrine before infusing fluid in an
IO to reduce pain
 Consider using the distal femur in children less then
6y – just medial to quadriceps tendon anterior
approach
Pearls
 Treat pain
 Anxiety often goes away if pain is treated
 Be liberal with oxygen
 Unlike some adult patients, very few children have
trouble with high oxygen concentrations
 Respiratory danger signs
 Increased work of breathing
 Grunting or nasal flaring
 Stridor or wheezing
Pearls
 High potential for 10-fold errors in
dosing – make sure to “reality check”
doses and double-check dosing
 Even though children can go into shock
quickly, you DO have time to think before
you act.
Reassess
Reassess
Reassess