PDLS©:
General Principles of Disaster
Care: Pediatric Triage Assessment,
Stabilization, Resuscitation
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
Oklahoma City – YMCA Day Care
 The Scene:
- Multiple injured kids - Delay in finding them
- 4 Children:
2 not breathing, unresponsive
2 sitting, crying
General Principles of Disaster Care
 Triage Assessment
 Initial Stabilization
 Resuscitation
Triage Assessment
 Derived from the French “trier” meaning to sort, it
describes a medical decision making process.
 Appropriate performance crucial.
 Dynamic process, re-triage / re-evaluate at several
stages.
 Determination of priority may effect the extent and
quality of care the patient receives.
Triage
 Triage in disaster setting may be very difficult
 Pediatric population unique challenge
Problems of
Under / Over-Triage
Triage in Prehospital Setting
 ICS (Incident Command System)
- Medical Branch
 Gain Control of Scene
 Triage Officer: Initial Brief Assessment
Initial Evaluation
 Ensure scene safety
 Establish that disaster exists
 Estimate number of victims: adults/children
Initial Evaluation
 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
Initial Brief Assessment
 Open airway
 Control major hemorrhage
 Categorize
Triage Categories
 Red / Immediate / Emergency
 Yellow / Urgent
 Green / Non-Urgent / Walking Wounded
 Black / Blue
Triage Classifications
 Simple Triage And Rapid Treatment
S.T.A.R.T.
 JumpSTART
Tool for Rapid Pediatric Multicasualty Field
Triage (children from 1 - 8 years of age)
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
Triage Classifications
 Consider pediatric anatomy / physiology / age /
development when categorizing child
 Familiarity with
- level of expertise of personnel
- numbers and type of transport available
- equipment supplies
- appropriate destination for definitive care
Initial Patient Assessment
Primary Survey of Child
Airway - patency
Breathing - rate, quality
C irculation: Pulse check - quality, rate
D isability: Mental status
Exposure
Airway
 First priority even more so than in an adult. Hypoxia main
factor leading to organ dysfunction, ischemia, and
cardiopulmonary arrest.
 Consider need for endotracheal intubation in child with
GCS<8, significant maxillofacial trauma, aspiration, or
respiratory distress.
Remember
- Oropharyngeal airway
- ET size/uncuffed
- ET route for delivery of medication (LANE)
Breathing
 Children consume oxygen x 2 that of adult
 Assess: respiratory rate (infants 40/min, preschool
30/min, school 20/min)
 Effort
 Auscultate, percuss
 Thoracic cage and rib fractures
 Tension pneumothorax
Circulation
 Normal values: infant 160/min, preschool 140/min, school 120/min.
 Systolic BP 80+ (age in years x 2)
 Assess:
-
capillary refill
temperature of extremities
color of patient
 Circulating blood volume: neonate 90 ml/kg, infant 80 ml/kg, older
child 70 ml/kg, adult 65-70 mg/kg
 Bradycardia requires immediate attention, most common cause is
hypoxia, but acidosis and hypovolemia are also factors.
IV Access
 Attempt peripheral access if unsuccessful in < 90 sec. consider
IO or cutdown.
 Estimated body weight: (age in yr.. 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
Consider IV Access in the Following:
 Time to definitive care 30-60 minutes
 Prolonged extrication / entrapment
 Dehydration > 15%
 Multiple fractures
 Scalp lacerations with significant blood loss
Children After Burns
 Airway and ventilation a priority in management. Cover burn area
in a clean sheet and wrap patient in a clean blanket.
 Calculate percentage burn
 Consider specialized facility for following:
- 2/3 degree > 10%
- 2/3 degree face, hands, feet, genitalia, perineum, and major
joints
- 3 degree > 5%
- electrical burns
- inhalation injury
- preexisting medical problems
- associated trauma in which burn injury > risk
Disability
 GCS useful in children > 1yr
Exposure
 Examine the entire child
 Hypothermia may occur secondary to exposure,
sepsis, shock, and may lead to metabolic
acidosis, decreased respiration, bradycardia and
cardiac arrest. Newborns at high risk.
 What are your plans for newborns, infants who
have no guardians?
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
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 unti:
- triage patients for treatment on site or transport to
hospital/health care facility
- efficient utilization of resources, personnel, and
supplies
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”.
Pediatric Trauma Score
Score
Size
Airway
Systolic BP
CNS
Skeletal
Cutaneous
+2
>20 kg
N
>90 mmHg
awake
none
none
+1
10-20 kg
maintainable
30-90 mmHg
obtunded/LOC
closed #
minor
-1
<10 kg
unmaintainable
<30 mmHg
coma/decerebrate
open/multiple #
major/penetrating
trauma
 Useful as a triage tool in the multiple injured child.
 Score <8 = need for advance level of care, high risk category
~ 30% mortality
 >8 = community hospital capable of treating children
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
Child Likely To Need Specialized Care
Specific injuries
 skull #
 pneumothorax, flail chest
 abd trauma with peritoneal signs
 amputation / degloving
 vascular injury
 burn with inhalation
 FB aspiration / ingestion
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
 Requirement of children in shelters
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