Minnesota Pediatric Surge Primer
and Template Plan
(4/9/2013)
Acknowledgement:
The Minnesota Department of Health would like to acknowledge the valuable pediatric resource materials developed by New
York City and King County, WA which contributed greatly to the Minnesota document.
http://www.nyc.gov/html/doh/html/bhpp/bhpp-focus-ped-toolkit.shtml
http://www.kingcountyhealthcarecoalition.org/media/PediatricToolkit.pdf
Minnesota Pediatric Surge Primer and Template Plan
Minnesota Department of Health
CONTENTS
Introduction .......................................................................................................................................................................................................................... 3
Facility Pediatric Preparedness – 10 Steps ............................................................................................................................................................. 4
Regional Pediatric Preparedness – 8 Steps ............................................................................................................................................................. 7
Command, control, communications, and coordination ................................................................................................................................... 8
Logistics – Surge Capacity ............................................................................................................................................................................................... 8
Space / Structure............................................................................................................................................................................................................ 8
Staff and Training........................................................................................................................................................................................................... 9
Stuff – Equipment Recommendations, Pharmacy Considerations........................................................................................................ 11
Special Considerations – Mental Health, Family, Pediatric Safe Area, Infectious Disease, and Decontamination .......... 15
Mental health ........................................................................................................................................................................................................... 15
Hospital Support Center ..................................................................................................................................................................................... 15
Infectious disease ................................................................................................................................................................................................... 17
Decontamination .................................................................................................................................................................................................... 18
Operations – Patient Care ............................................................................................................................................................................................ 19
Triage ............................................................................................................................................................................................................................... 19
Treatment ....................................................................................................................................................................................................................... 20
Emergency Department Care ........................................................................................................................................................................... 20
Inpatient Care .......................................................................................................................................................................................................... 22
Transportation ............................................................................................................................................................................................................. 23
Tracking .......................................................................................................................................................................................................................... 25
Appendices ......................................................................................................................................................................................................................... 26
Appendix 1: Pediatric Safe Area Checklist ....................................................................................................................................................... 26
Appendix 2: Sample menu for pediatric patients ......................................................................................................................................... 27
Appendix 3: Children and crisis – behavioral health handouts............................................................................................................. 28
Appendix 4: MDH Pediatric Priorities Poster ................................................................................................................................................. 32
Appendix 5: Pediatric Referral Resources ....................................................................................................................................................... 33
Appendix 6: Hospital Training Matrix – Pediatric Preparedness .......................................................................................................... 35
Appendix 7: Pediatric Patient Training Scenarios ....................................................................................................................................... 36
Appendix 8: Template Pediatric Mass Casualty Annex .............................................................................................................................. 39
Appendix 9: Pediatric Technical Specialist (Job Action Sheet).............................................................................................................. 44
Appendix 10: Pediatric Services Supervisor (Job Action Sheet) ............................................................................................................ 46
Appendix 11: Pediatric Safe Area (PSA) Unit Leader (Job Action Sheet) ........................................................................................... 48
Appendix 12: Pediatric Safe Area Registry ...................................................................................................................................................... 50
Appendix 13: Pediatric Safe Area Registration Sheet (for Unaccompanied Minors) ................................................................... 51
Appendix 14: Pediatric Patient Identification and Tracking Form ....................................................................................................... 52
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2
INTRODUCTION
Children comprise 24% of the U.S. population and 6.5% are under the age of 6. Regardless of the
hospital mission in the community, ill or injured children may present seeking care. All hospitals
must be prepared to stabilize pediatric patients and have pre-determined their referral patterns
for these patients. The magnitude of a mass casualty event may overwhelm either the usual
resources of the hospital, or the transport resources available, or both. Hospitals must be prepared
to receive and continue care for pediatric patients in a mass casualty event. The emphasis on
keeping families together during an event increases the chances that children will be taken to nonpediatric facilities for care along with their adult family members.
This primer is directed at small community hospitals that do not usually provide pediatric trauma
or inpatient services (pediatric specialty centers must have a more comprehensive and integrated
approach to pediatric disaster response).
Children have unique physical and behavioral characteristics that make them particularly or
uniquely vulnerable (Table 1). These characteristics also present the caregiver with significant
challenges.
Table 1.
Unique Consequences in Children During a Disaster, Owing to Anatomic and Physiologic Characteristics
Characteristic
Cause
Consequences
Larger head for a given body weight
Greater skin surface for body weight
Small blood vessels
Higher center of gravity
Evaporative heat and water losses
Relative size with younger age
Closer proximity of solid organs with less bony
protection
Wide range of normal vital signs
Relative size with younger age
Large differences in size, weight, and normal
values
Difficult to determine normal values for a given
individual, particularly for clinicians more
accustomed to caring for adult patients
Rapid heart and respiratory rate
Normal physiologic variables based on age and
weight
Normal physiologic variables based on age and
weight
Faster intake of airborne agents
dissemination to tissues
Greater likelihood of medication errors
Shorter height
Closer to the ground
Often found in groups
Immature cognitive and coping skills
Daycare and school
Age and experience, psychological development
Greater exposure to chemical and biologic toxins
that settle near the ground due to higher
density
More likely to see multiple casualties
Less likely to flee from danger, inability to cope,
inability to care for themselves, find sustenance,
and avoid danger
Wide range of weight across pediatric age range
More likely to suffer head injuries and falls
Hypothermia and dehydration
Difficult venous access, more difficult fluid and
medication delivery
Greater chance of multi-organ injuries
and
Branson, R. (2011). Disaster planning for pediatrics. Respiratory Care, 56(9), 1457-1465. DOI: 10.4187
General goals for planning are as follows in Table 2 – these may need to be adjusted depending on
the community Hazard Vulnerability Analysis and the facility role in the community. Basic
numbers were developed according to risk of a school bus crash, day care center incident, and
similar incidents involving larger groups of children present in any community. Green patients are
listed mainly to assure that planning for supervision, safe areas, and family support centers
accounts for a reasonable expected volume of patients from a school or transport related incident.
Note that ‘Red’ or critical patient numbers reflect only those < 8 years (as older children can be
managed with adult equipment) and will be admitted/transferred. Yellow/green patients do not
require as many size-critical resources but do require supervision and general medical care.
3
Table 2 Guidelines for facility pediatric casualty planning
MN Trauma System Designation
Level 4
Level 3
Level 2
Level 1
Critically injured (Red)*
< 8 years old
< 1 year
2
1
4
2
6
3
8
4
Non-critical - Age < 18
Yellow patients
Green patients
5
10
10
15
15
20
20
30
*Assume will require airway management, IV access at minimum
Steps to facility and regional preparedness are detailed at the start of the document, and supported
by discussion organized around the CO-S-TR framework (Command, Control, Communications and
Coordination, Staff, Stuff, Space, and Special considerations, Triage, Treatment, Transport, and
Tracking)1. The appendix contains handouts and other supporting documents to the facility EOP
including a template for a Pediatric Mass Casualty Annex.
The most important step in the planning process is for each facility to identify a champion of
pediatric preparedness that can provide expertise, time, and leadership to implement these steps.
At the regional level, one or more of these individuals can provide the support needed to enhance
regional discussions, planning, and preparedness activities.
FACILITY PEDIATRIC PREPAREDNESS – 10 STEPS
All hospitals should plan for care of pediatric patients
Critically ill pediatric patients may present to ANY hospital
Transfer of patients to specialized hospitals may not be feasible
1. Survey staff to identify in-house (and possibly community) pediatric expertise:
 Hospitals and networks should survey staff and admitting physicians to develop a
database of personnel with pediatric experience, training and willingness to participate
in a disaster response
 Identify key pediatric positions that staff will occupy in a disaster (see below)
 Include notification procedures for key staff and response team members in the plan
2. Create pediatric leadership positions for key personnel and qualified staff
 Pediatric Preparedness Coordinator:
o May be a nurse, physician, or emergency manager with pediatric experience
o Has a planning role distinct from any response roles they may hold
o Will likely be the critical ‘champion’ that leads preparedness / advocacy efforts at the
institution
o It is critical that the person chosen has the time and motivation to provide
substantive assistance to the Emergency Preparedness team
1
Further information on the CO-S-TR framework see http://www.dmphp.org/cgi/content/full/2/Supplement_1/S51
4
 Pediatric Technical Specialist – usually a physician:
o Serves as regular member of the Hospital Disaster Committee
o Coordinates medical aspects of pediatric disaster planning
o During a response determines overall priorities for pediatric patients and supporting
logistical and policy needs. Also determines necessary surge capacity, and locations
for care if multiple pediatric casualties (including priority for transportation to other
facilities)
 Pediatric Services Supervisor:
o Participates in ongoing Hospital Disaster Committee work
o Plans and equips pediatric care and pediatric safe areas
o Assures that pediatric treatment and holding areas are properly assigned, equipped
and staffed during an incident
o Assigns Pediatric Safe Area Unit Leader and provides supervision and support during
an incident
o Ensures the safety of children awaiting disposition after evaluation
 Logistics Section:
o Plans for pediatric-specific supply needs in conjunction with other members of the
planning team
o During a response, ensures that children’s needs are addressed by Logistics,
including transportation, materials, and nutrition
3. Write a Pediatric Mass Casualty Annex to your Emergency Operations Plan
 See template from MDH (Appendix 8)
 Above experts should participate in plan development, along with the Emergency
Preparedness committee and other stakeholders
 Development of the plan will drive subsequent actions below
4. Pediatric training and exercise plan:
 Determine (or review) medical and nursing staff training requirements to assure that
appropriate basic and advanced emergency care and trauma life support can be offered
to children (including credentialing or pre-requisite requirements to working in the ED,
etc.)
 Assure access to courses such as Pediatric Advanced Life Support (PALS), Advanced
Pediatric Life Support (APLS), and the Emergency Nursing Pediatric Course (ENPC) for
hospital staff on an ongoing basis (these courses are examples, not a definitive list)
 Arrange updates and re-certifications as needed
 Arrange brief, scenario-driven trainings in clinical areas (simulation training – see
examples in Appendix 7)
 Determine training needs then develop and implement training on the pediatric mass
casualty plans at the facility (awareness, knowledge, and proficiency levels – see
Appendix 6)
 Conduct drills and exercises and identify and correct deficiencies
5
5. Pediatric equipment plan:
 Establish disaster pediatric equipment needs – obtain and maintain stocks (see page 13)
 Consider creating and stocking pediatric disaster carts in designated areas, including a
cart specifically for Pediatric Critical Care in the emergency department (which should
also be used for ‘routine’ critical cases, not just mass casualty events) and designated
supplies for the Pediatric Safe Area
6. Pediatric pharmaceutical plan:
 Establish procedures for pediatric dosing (resuscitation medications/kits/color-coded
bags)
 Maintain and update an inventory of essential disaster drugs (consider 96-hour supply of
key medications)
7. Pediatric nutrition plan:
 Maintain at least a 3-day food and drinking water supply for use during an emergency,
including age-appropriate nutritional supplies for both healthy children and those with
special dietary needs
 Consider Memoranda of Understanding with area stores or vendors for delivery of
additional supplies
8. Special security needs of children addressed:
 Plan a Pediatric Safe Area (PSA) to hold uninjured, displaced or released children who
are awaiting arrival of adult caregivers
 Designate who will fill the role as Pediatric Safe Area Unit Leader as part of this planning
and identify staffing ratios and supply issues (see Appendix 11)
 Develop a system to track both accompanied and unaccompanied children (see example
system with colored wristbands in Pediatric Mass Casualty Annex template, Appendix 8)
 Develop a protocol to rapidly identify and protect displaced children, including recording
key identifying information for use in later tracking and reunification with caregivers
9. Transfer / Transport issues:
 Consider signed transfer agreements (See EMS-C templates:
http://www.emscmn.org/resources)
 Understand regional transport resources for pediatric transfers
 In case transfer is delayed, plan provide extended care to children during a disaster,
including provision of equipment for age-appropriate internal transport (rolling cribs,
laundry baskets, etc.) and bedding (pack-n-plays, etc.)
 Hospitals without pediatric intensivists or trauma surgeons should develop a plan with
referral hospitals to provide support for inpatient / continued care if transfer cannot be
accomplished (including telephone consultation and potentially telemedicine or other
resource linkages)
10. Pediatric considerations in the Victim Decontamination Plan:
 Develop a system to keep children with their caregiver, unless medical issues take
priority (or teen-aged children decline to shower with parents)
 Assure specifics of supplies and training are addressed (see page 13)
6
REGIONAL PEDIATRIC PREPAREDNESS – 8 STEPS
1. Assess regional pediatric and trauma expertise:
 Identify providers who are willing to act as regional advisors / experts (often facility
pediatric technical specialists are the best source)
 Coordinate with your Regional Trauma Advisory Council (RTAC)
2. Determine regional pediatric training needs:
 Identify common needs
 Develop objectives and identify content to be presented
 Establish calendar and present materials
 Encourage ongoing, site-specific simulation sessions
3. Assess available pediatric capacity in region:
 Facilities providing pediatric inpatient care / PICU care
 Facilities that could provide inpatient care in a crisis situation
 Surge capacity for pediatric patients
4. Assess equipment needs in region:
 Based on EMS and hospital input determine if any standardized equipment, caches, or group
purchases of materials are appropriate
5. Establish regional referral plan and transportation assumptions:
 Determine preferred and back-up referral facilities including contact phone numbers
 Discuss guidelines for patient transfer (priority transfer for children < 8 years of age, etc. –
see Pediatric Priorities Poster for guidance:
http://www.health.state.mn.us/oep/healthcare/pedspriorities.pdf)
 Circulate transfer agreements (available from EMS-C at: www.emscmn.org/resources) for
consideration
 Establish the role of the Regional Healthcare Resource Center, Regional Healthcare
Preparedness Coordinator, Pediatric Technical Experts, and EMS regional leadership during
a pediatric Mass Casualty Incident (MCI)
 Document these findings and expectations in a Regional Pediatric Annex that may be
referenced by the facilities in the area
6. Assess pediatric mental health capacity:
 Provide psychological first aid (PFA) training with points of emphasis on PFA for children
 Assess the professional mental health resources available for pediatric patients and how
these might be augmented (or sent to an affected facility as a strike team during an incident)
 Assess how faith-based, school counseling, social work, and other personnel may be enlisted
to broaden mental health capabilities
7. Establish / refine concept of operations for a regional Family Assistance Center:
 Assure common expectations regarding transfer of information about pediatric
victims/patients including:
o Re-unification procedures (What is threshold for releasing a child? Verbal assent of
child? Photo of child with family?)
o Tracking process (including access to MNTrac or other sources of information)
o Documentation and sharing of information on unidentified patients
o Death notifications
o Family mental health support
7
8. Exercise:
 Assure that above issues are incorporated into regional exercises
 Evaluate exercise performance and address problems or gaps
COMMAND, CONTROL, COMMUNICATIONS, AND COORDINATION
Activation of the facility emergency operations plan follows usual all-hazards processes, as does
the use of the Hospital Incident Command system and other incident management techniques.
However, the facility should assure that Hospital Command Center issues relative to pediatric
incidents are addressed:







Access controls should be implemented early in the incident, as there is likely to be
tremendous media and parental pressure on the facility, which should be directed through
appropriate venues/entrances
Traffic control may be an issue
Specific pediatric personnel may have to be notified during a pediatric incident – this may
occur through designated callback procedures or be automated – though it still will require
a request to activate the callback
Phone systems / switchboards are likely to be jammed
Media interest will be higher than in a ‘usual’ mass casualty event which may place severe
demands on the Public Information Officer
Accurate patient tracking and coordination of information with schools, family assistance
centers in the community, and other entities requires specific early attention by the Liaison
Officer
Coordination with the Regional Healthcare Preparedness Coordinator and/or receiving
hospitals and transport agencies may be required early in the event. The Liaison Officer
and/or the Pediatric Technical Specialist or Pediatric Services Supervisor may be tasked by
the Incident Commander (or designee) to address these issues – specific prompts should be
built into the Job Action sheets for these positions.
LOGISTICS – SURGE CAPACITY
SPACE / STRUCTURE
Prior to the event, spaces conducive to pediatric care should be identified:
 Triage areas
 Ambulatory care
 Emergency / Resuscitation care
 Inpatient care (including PICU if applicable)
 Pediatric Safe Area (observation for discharged pediatric patients awaiting a caregiver,
children that cannot be supervised by caregivers who are undergoing treatment, and
children of facility staff responding to provide assistance that did not have other options for
child care)
Spaces should be listed as:
 Conventional spaces – areas where such care is normally provided
8


Contingency spaces – areas where care could be provided at a level functionally equivalent
to usual care
Crisis spaces – areas where sufficient care could be provided when usual resources are
overwhelmed (this might involve non-pediatric providers supervising inpatient care,
temporary intensive care / ventilator support for patients who cannot be moved, etc.)
Usually, conventional spaces will be used first and contingency and crisis spaces activated
according to incident demands. The table below provides samples of what might be included in a
facility assessment.
Space Surge Table
Triage
Emergency
Ambulatory
Inpatient (floor and ICU-level)
Pediatric Safe Area
Conventional
Emergency
Emergency
Clinic
None
Family room
Contingency
Emergency lobby
GI procedure area
Meeting room
Floor beds – list
Small meeting room
Crisis
Parking lot
Same day surgery
Cafeteria
Floor beds, ICU care in PACU
Secure large meeting / dining area
At the time of an incident, currently available beds and spaces (including operating rooms, postanesthesia care unit (PACU), ICU, ventilators, etc.) should be assessed and expedited movement or
discharging of inpatients performed as needed to accommodate the patient surge. Pediatric
patients should be placed on units that are secure, and ideally cohorted on the same units to
simplify staffing and support. Unaccompanied patients should share rooms with other
unaccompanied patients if possible. Unaccompanied children MUST have supervision at all times
regardless of location.
STAFF AND TRAINING
Staff working in the Emergency Department or usually providing pediatric care may already have
baseline training expectations for their positions, which should be documented as needed.
Additional staff with pediatric training who would not normally be involved in emergency care
should be identified. These may include pediatric or family medicine clinic providers that may
provide crucial assistance when large numbers of pediatric patients require care.
A process for contacting these staff should be identified in the facility Pediatric Mass Casualty
Annex, as well as the expectations for where they should report. Credentialing and training issues
for these staff should be addressed, if required, prior to an event.
Sources of staff with potential pediatric expertise may include:
o Emergency medicine, pediatrics, family medicine
o Anesthesia, ENT, pediatric surgery, trauma surgery, general surgery, orthopedics,
urology, neurosurgery, thoracic surgery
o Nurses, physician assistants, nurse practitioners from OR, PACU, ICUs, inpatient units
and outpatient clinics
o Pharmacy, respiratory therapy, and other support staff
9
Support staff for the pediatric safe area and escorts for patients could be drawn from a number of
sources including licensed day care centers, schools, and other facilities. These arrangements
should be documented in the facility plan and those listed facilities/staff should understand their
roles and ideally have participated in a prior exercise. Hospital personnel should always provide
supervision of the Safe Area regardless of outside assistance being provided.
Training falls into two basic categories:
 Formal classes (for example Advanced Trauma Life Support - ATLS, Advanced Pediatric Life
Support - APLS, Pediatric Advanced Life Support - PALS) that are:
o Expected as part of job description / job class – this would likely apply to physicians
and nurses working in certain areas (ATLS for physicians staffing the Emergency
Department for example) – these should be documented in the planning process
o Encouraged as supplemental education / enrichment of staff that might participate
in a mass casualty response – personnel taking these classes should be documented
 Facility education:
o Pediatric Mass Casualty Annex components – space, staff, stuff
o Equipment – location and use
o Simulation sessions
o Exercises
o Decontamination team education about pediatric-specific issues
Additionally, staff in other categories/areas may have experience with pediatric care that provides
them with a level of comfort and expertise allowing them to assist in care during a disaster – these
staff should be identified via survey or other means and their contact information tracked. They
should be encouraged to keep current with pediatric topics and enroll in available courses and
offered trainings to maintain their skills and confidence.
Finally, there is a need for pediatric-specific expertise in clinical support services such as
respiratory therapy and pharmacy. Clinical pharmacists and respiratory therapists are core
personnel in a hospital disaster response, and their abilities and need for training should be
assessed so that they are able to meet the pediatric-specific challenges (such as medication
preparation / administration and ventilator or other respiratory care management).
Call-back / notification procedures for staff with relevant pediatric skills should be documented in
the Pediatric Annex as required (for example, if all providers are trained to the same level, there is
no basis for a separate notification list – however, if specific key providers have a higher level of
expertise these providers should be notified preferentially).
Create key pediatric positions for response in a disaster event; refine Job Action Sheets and add to
your hospital’s Emergency Operations Plan Pediatric MCI annex (see Facility Pediatric
Preparedness 10 Steps section on page 3, and sample Job Action Sheets in Appendices 9-11).
o Pediatric Technical Expert
o Pediatric Safe Area Unit Leader
o Pediatric Services Supervisor
Assure that line staff have appropriate Standard Operating Procedures or job aids immediately
available to initiate response in their work areas.
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STUFF – EQUIPMENT RECOMMENDATIONS , PHARMACY CONSIDERATIONS
Basic patient care:
Storage of disaster supplies is often difficult in hospitals due to space and maintenance issues.
However, there is no substitute for appropriate hospital beds and clinical monitoring equipment.
Pediatric-sized beds are not normal inventory in hospitals that do not provide dedicated pediatric
services. If adult beds have to be used for pediatric patients, side protection may have to be
augmented to prevent falls. Additionally, beds may need to be unplugged for certain age groups to
prevent them from being raised too high or otherwise being placed in positions that may cause
injury.
Hospitals should consider having at least 5 porta-cribs (pack-n-play) available for small children
who may be patients or located in the Safe Area. Larger hospitals, especially those providing
pediatric inpatient services should consider additional resources. Cots may be suitable for older
children in the Safe Area or for crisis/shelter care but should be supplemented with egg-crate or
other mattresses for use beyond a few hours.
Adequate monitoring equipment must be available including appropriately sized blood pressure
cuffs, oximetry probes, and ECG leads.
Hospitals should be familiar with the pediatric capabilities of ventilators used at their facility and
pediatric considerations (including dead space volumes, need for pediatric circuits, etc.).
Emergency care:
Some institutions use a color-based equipment scheme correlated to a measuring tape (Broselow
system – up to 36kg). Others may elect to use age-correlated weight / actual weight-based drug
and equipment guides. Regardless, each institution must have a system to assure appropriate
dosing and sizes of equipment are used for pediatric patients.
Equipment must be organized and easily accessible. Personnel must be familiar with the pediatric
equipment and have opportunities to practice with it; otherwise this will contribute to the
potential for errors in a stressful mass casualty environment. Additionally, necessary procedures
may not be performed due to a reluctance to ‘break the seal’ on emergency equipment.
This section assumes that the emergency department has usual emergency medications, basic
intravenous (IV) fluids (including normal saline, dextrose-containing ½ normal saline, ¼ normal
saline, etc.), intravenous micro-drip tubing, adult size IV cannulas, usual needles, syringes,
connecting tubing, and electronic patient monitoring equipment and diagnostic equipment
(thermometer, cardiac monitor, oximetry, etc.).
Providers and planners should assess their supplies relative to their institutional preparedness
goal. Goals should be established by looking at the table below and adjusting as needed based on
the community and institutional role. In general, the equipment list below should be used per
critical patient so that a facility planning for 4 critically injured patients should have 4x the
recommended disposable supplies below that will be needed for each patient – these may be
packaged in kits to aid response, especially the airway and vascular access equipment which may
be needed emergently. A separate infant kit is recommended – providers may wish to confine the
smallest tube, mask, and blade sizes to the infant kits only (<1 year).
11
According to the hospital’s trauma level, basic planning goals for patients less than 8 years old (as
older children can be managed using adult equipment) are:
MN Trauma System Designation
Level 4
Level 3
Level 2
Level 1
Critically injured (Red)*
< 8 years old
< 1 year
2
1
4
2
6
3
8
4
Non-critical - Age < 18
Yellow patients
Green patients
5
10
10
15
15
20
20
30
*Assume will require airway management, IV access at minimum
Reasonable supply planning may assume that:




Airway – All Red (critical) patients require airway management (back-up airway equipment
including supra-glottic and surgical airway supplies must be available, though only one set per
facility is needed)
Breathing – One of every two Red patients needs a chest tube (minimum two per facility), all
Red and Yellow patients require supplemental oxygen by mask
Circulation - All Red and Yellow patients and one third of Green patients require intravenous
(IV) access (some of these may require intra-osseous (IO) access) which includes cannulas, arm
boards, fluids, drip sets, etc.
Disability / Neuro – all Red and Yellow patients require a cervical collar. One third of all
patients require a splint (SAM, cardboard/arm board, plaster, etc.)
12
Per-Patient Disaster Critical Care Supplies - (may have to increase stocks of items to account for
Yellow/Green patients such as IV access supplies, cervical collars)
Item
Size
Quantity
Notes
Airway / Breathing
Laryngoscope handle
1
Laryngoscope blades
Miller 0, 1, 2, Mac 1,2
1 each
ET tubes
3.0, 3.5, 4, 4.5, 5, 5.5
1 each
Pediatric gum bougie
1
Stylet for ET tubes
Supraglottic rescue airway
Note that some blades and tubes may be confined to the
infant kit(s)
Cuffed if possible
2 (small, med)
1 each size
per facility
1
1,2
Ped non-rebreather mask
Ped nebulizer mask
1
Ped nasal cannula
1
Infant simple mask
1
Infant nasal cannula
1
BVM pediatric (500mL)
1
Infant BVM mask
1
Child BVM mask
1
Oral airway
00, 01
Chest tube
16, 20
Suction catheters
5,8
1 each
1 per 2 red
patients
1 each
For example, LMA
And appropriate suction and surgical trays (at least 2 sets
per department minimum)
Circulation / Access
Arm boards
2
IV catheters
24, 22, 20
2 each
IO needles and tubing
Peds and adult
2 each
Pressure bag or IV pump
1
3-way stopcock
1
Pediatric defibrillation pads
1 set
Short and medium
Battery-operated driver system recommended
For IO
(per facility – should consider 2 sets available)
Diagnostics / Monitoring
BP cuffs
Infant and child
1 each
Infant, pediatric
1 each
Pediatric ECG electrodes
Oximetry probes
6
End-tidal CO2 monitoring
Pediatric drug and equipment
reference
1
Waveform preferred, colorimetric at minimum
1
Broselow or age/weight-based
GI / GU
Indwelling urinary catheter
8,10,12
1 each
(e.g. Foley)
NG
6,8,10,12,14,16
1 each
May stock every other size at small facility
Other supplies
Pediatric cervical collar
Department Supplies
1
NOT per patient
1 per ED
OB / delivery kit
1
Per department / area
Surgical airway tray
1
Per department / area
Scale
1
Appropriate to weigh infants / children – per area
Umbilical vein catheter kit
1
Per department / area
Pediatric central line
Needle tracheostomy /
cricothyrotomy supplies
4F 5cm, 5F 8cm
optional
1
Per department / area – ideally kept as a kit
Note: This equipment list is derived from AAP/ACEP recommendations for general emergency departments – thus, hospitals should have most of
these materials already available. Quantities of some materials may need to be increased.
13
Medications:
Pediatric mass casualty management does not usually involve unique medications. However, use of
oral or nasal analgesia (e.g. fentanyl via mucosal atomizer device (MAD) or oral oxycodone elixir)
may provide for more rapid symptom control with less provider effort and are strongly
encouraged.
Dosing errors in pediatric patients are often 10x the actual dose needed due to multiplication and
decimal point errors. This can lead to complications, and even death. Height or weight-based
references MUST be available, and drug doses must be carefully checked prior to administration
(including a ‘common sense’ check comparing the dose to an adult dose and relating that to the
patient weight – e.g. 15 kg child should get one fourth of the adult dose of most medications).
Optimally, an emergency dosing card should be generated for every patient based on weight that
outlines usual drug dose by mg AND by mL of supplied solution as this is a common source of
medication error. Clinical pharmacists that can provide support in the Emergency Department can
be invaluable in assisting with appropriate dosing if adequate staff is available.
Providers must be careful not to push fluids and medications too aggressively through small
intravenous catheters. Constant pressure from a pump or pressure bag is required to keep intraosseous lines patent, and intra-osseous lidocaine may be needed for patient comfort in the awake
patient. Certain fluids (such as hypertonic saline) are not compatible with IO administration.
Providers may wish to review usual resuscitation drugs for compatibility and error potential and
conduct education or develop procedures that reduce the chance of errors.
Consider stocking a 72-96 hour supply (given usual use and planning goals as outlined above) of
medications such as:2










Resuscitation drugs – epinephrine, atropine, amiodarone, calcium chloride, magnesium
Analgesia – narcotics, ibuprofen, ketamine
Bronchodilators – including appropriate nebulizer masks, metered dose inhalers, and spacers
Antibiotics – including intravenous (narrow and broad-spectrum – for example cefazolin,
ceftriaxone, and expanded spectrum penicillins such as piperacillin/tazobactam), palatable oral
antibiotics such as amoxicillin (consider stocking flavored syrups to enhance palatability) and
topical bacitracin (for burns)
Anti-virals – acyclovir (IV and oral), oseltamivir
Anti-emetics - ondansetron, others - injectable and oral
Anti-histamines – diphenhydramine – injectable and oral
Anticonvulsants – fosphenytoin, phenobarbital, levetiracetam
Dextrose
Steroids – injectable and oral
2
Note that there are very few pediatric-specific medications – however, pharmacy should assure that safety mechanisms are in place to accurately
dose and dispense medications. Additionally, stocks of liquid or other forms of medication may have to be evaluated to assure adequate stocks for
pediatric use. This process should be part of an all-hazards drug and dosing preparedness strategy rather than a pediatric-specific strategy. These
suggested categories should be a starting point for planning discussions.
14




Sedatives – ketamine, benzodiazepines, etomidate, propofol
Hypertonic saline (3% or 5%, which can be given via peripheral IV)
Local anesthetics – including EMLA, LET, other topical and injectable anesthetics
Consider – hydroxocobalamin for cyanide poisoning, post-exposure prophylaxis for biologic
agents for pediatric use (e.g. amoxicillin for anthrax), ocular drugs such as proparacaine and
topical antibiotics
The facility may wish to consider a disaster ‘pull list’ for the pharmacy that results in certain
medications (especially narcotics, sedation, and intubation medications) being automatically
pulled and sent to the Emergency Department when a mass casualty event occurs.
SPECIAL CONSIDERATIONS – MENTAL HEALTH, FAMILY, PEDIATRIC SAFE AREA, INFECTIOUS
DISEASE, AND DECONTAMINATION
MENTAL HEALTH
Early psychological support for children affected by disaster can facilitate their initial and
subsequent care and potentially reduce longer-term mental health issues. Initially, an escort,
ideally one trained in psychological first aid, should be assigned to unaccompanied pediatric
patients to provide companionship and support through the initial medical treatment process. A
focus on pain relief, comfort measures, and providing as quiet and secure environment as possible
contribute greatly to reducing fear and advancing feelings of well-being. Every effort should be
made to keep families together, and when this is not possible, to re-unite them as quickly as
possible. The Appendix contains hand-outs and reference tools that may be of value in the initial
support of children’s mental health needs.
The use of regional mental health ‘strike teams’ is recommended in order to provide additional
trained mental health support to a hospital and/or community that has experienced a disaster
event. This is especially important when the event involves children. The staffing, mission,
activation, and operations of such teams or personnel should be detailed in advance of an incident.
While awaiting such teams, the hospital should have a plan to bring in facility or other volunteers if
there are a number of unaccompanied pediatric patients that require escort/support. The use of
PsySTART or other psychological assessment and screening is recommended as early as possible
once the child is medically stabilized, and those at risk should have more formal assessment by
professional providers.
HOSPITAL SUPPORT CENTER
Families need to be provided with the most up to date information available in a supportive and
safe environment. This includes having resources and a designated area at the hospital to provide
these services for families of patients, the size of which depends on the event. An outline of
considerations for the Hospital Support Center (HSC) is below.
15
Upon arrival to the HSC, families should be logged in either via an electronic database or sign-in
book. Registered families are updated periodically with information coming into the HSC and may
be referred to community locations/resources if their child is not at the hospital or expected there.
A social worker, or other support staff, should be assigned to families that are identified as
exhibiting overt psychological upset or need to be given bad news. Family re-unification may be
coordinated by public agencies at a site away from the hospital (e.g.: a Family Assistance Center set
up at a school or other location).
Hospital Support Center (HSC)
Primary functions:
1. Provide accurate information to family members through statements issued by the
hospital’s Public Information Officer to:
a. Facilitate family access to community Family Assistance Center (FAC’s)
b. Coordinate communication with local law enforcement and FAC
2. Provide psychological first aid to families
3. Provide temporary childcare in the Pediatric Safe Area for well children awaiting reunification
4. Assist with patient location and reunification of family within the hospital
5. Assist in contacting family members to facilitate re-unification
6. Assist making shelter or community placement arrangements for children that do not have
a safe place to be or a family member who can care for them
7. Provide communications resources for families that need them (phones, e-mail)
8. Protect families from intrusion by media or others
9. Assist in determining location of patients/family at other facilities
Ideal set-up of HSC
 Large reception area with conveniently located restroom facilities, but also with areas of
relative privacy – the area should not have other functions
 Appropriate security and access controls
 Area for group briefings as well as private areas
 Comfortable chairs and waiting areas
 Information desk with message center and phone (including long-distance calling), and
internet connections (including the ability to access email websites which may normally be
blocked by hospital information technology)
 Outlet strips for cell phone and other electronics charging
 Photograph/identification room with limited access (close relatives only)
 Private consultation rooms with table, chairs, telephone, tissues, trash can (may be same
room as photograph/identification room)
 Pediatric Safe Area nearby if possible
 Ability to provide light refreshments and drinks
 Visually isolated from media, triage, and treatment areas
16
Identification of identified or unidentified victims/ family members
 Personal details and pictures of patients are sent to the HSC electronically (MNTrac, email,
other methods as agreed upon by community plan) or via runners from the Hospital
Command Center
 Information is included on all unaccompanied children, both the uninjured and those
receiving medical treatment
 Information on deceased victims should be sent to the community Family Assistance Center
and medical examiner. Policies should be in place on how death notifications are carried out
as well as how viewing and other issues will be handled
 Adults coming to the hospital to claim children must show I.D.; ideally, they should bring a
picture that includes the adult with the child, such as a family photograph. Policies should
define in advance what threshold of proof is required to release a child to a parent, guardian,
or other individual. This may vary with the age of the child and ability to interview the child
 Adult family members of victims not listed as patients at the hospital should be referred to
the community Family Assistance Center (FAC) for more information though an attempt can
be made to determine family member location on MNTrac if more than one hospital is
receiving patients (and/or contact information can be kept if the patient arrives later)
Recommended HSC staffing:
Unit Leader
Public Information Officer (or designee)
Liaison to community Family Assistance Center (FAC)
Runners
Trained and pre-screened support volunteers
Security
Translators as needed
Professional staff (spiritual care, social services, psychology/psychiatry)
INFECTIOUS DISEASE
The facility infectious disease plan should account for pediatric-specific issues. Though it is beyond
the scope of this document to go into detail about infection control and epidemic management, a
few issues worthy of addressing are:





Expectations of parents for compliance with Personal Protective Equipment (PPE)
restrictions when their children are hospitalized and considered highly contagious
Issues with children being able to comply with PPE use
Infection control issues in play areas
Visiting restrictions and sibling visiting restrictions during infectious disease outbreaks
PPE supplies for children (simple masks, hand hygiene, etc.)
17



Cohorting plans for pediatric surge during an epidemic – how and where will cohorting
occur if the pathogen is transmissible by the airborne route? What units will pediatric care
expand to if children are disproportionately affected?
Are there medication issues to address? (availability or compounding of palatable liquid
forms of certain medications, adequate stocks of anti-viral medications and antibiotics, etc.)
Are there plans for contingency staffing if pediatric staff are disproportionately absent due
to infection or ill family members?
DECONTAMINATION
Children may be more susceptible to injury from hazardous materials due to:





Failure to recognize a hazardous material or situation
Failure to recognize signs of exposure or formulate an escape plan
High surface area relative to mass (allows more skin contact)
Higher minute ventilation (allows more inhalation exposure)
Lower height may result in more concentrated exposure to gases with higher vapor
densities
Decontamination for children requires planning and training that must be incorporated into the
facility decontamination plan. A few considerations are:










Families should be kept together and assist each other (though teen aged children may wish
to have privacy from the other family members)
Children will be intimidated by chemical PPE of providers and may resist the
decontamination process
Children will require assistance and escort through the decontamination process, increasing
workload for the decontamination team
Handheld or low showerheads are required for adequate bathing
Temperature control of the water is more critical for children – assure warm water is
provided (ideally, have an in-line temperature monitor on the water supply lines)
Hypothermia is a significant concern – children should be undressed for brief periods of
time and re-dressed as soon as possible – warm blankets should be available
Re-dress kits and gowns in appropriate sizes should be available for use
Baby shampoo should be available if possible to avoid eye irritation
Heavy-duty laundry baskets may be helpful to carry very small children
Parents should not carry their children through the decontamination process as slip and
drop risk is high
18
OPERATIONS – PATIENT CARE
TRIAGE
Pediatric patients can be difficult to triage. Those patients with evident external bleeding or soft
tissue wounds and those who are crying uncontrollably often are assigned to triage categories
higher than justified. Resources are then devoted to these patients at the risk of not having
resources for more seriously injured children. There is also the phenomenon of ‘upside down’
triage by which less injured patients arrive first, and those with more serious injuries that require
extrication or EMS interventions arrive around 30 minutes later, when resources have already
been devoted to the lesser injured.
In general, children with the following should be triaged as ‘Red’ or highest priority, and be cared
for by the most experienced providers in the resuscitation area of the emergency department:



Altered mental status
Respiratory distress
Signs of shock
Advanced Pediatric Life Support (APLS) uses the Pediatric Assessment Triangle (PAT) (Figure 1),
which can be used to briefly initially assess a child for life-threats. The only threat not addressed by
the PAT is a finding of penetrating injury to the chest or abdomen, which should categorize the
patient as ‘Red’ or critical – these may be subtle, and should be looked for carefully in the setting of
any explosion.
Figure 1: Pediatric Assessment
Figure modified from APLS and King County Pediatric Plan, reproduced from the Pediatric Priorities Poster - MDH
Vital signs can be of some help in determining priority, though the normal ranges by age are wide,
and thus, clinical correlation to the injuries / symptoms is required. However, persistent
tachycardia or tachypnea exceeding the ranges below after appropriate analgesia should prompt a
careful evaluation for severe illness/injury.
19
Vital Signs Normal Ranges by Age
Respiratory Rate and Heart
Rate Range by Age
Birth to 1 year
Respiration Rate
(per minute)
30 – 60
Heart Rate
(per minute)
100 – 160
1 to 3 years (toddler)
24 – 40
90 – 150
3 to 6 years (pre-school)
22 – 34
80 – 140
6 to 12 years
18 -30
70 – 120
Early in the assessment, the provider should consider the need for decontamination if the patient
was exposed to hazardous chemicals. It is important to note that those patients exposed to irritant
gases do not require specific decontamination – only those with liquid, solid, or those exhibiting
cholinergic syndrome symptoms (small pupils, excess secretions) require specific decontamination.
Mass psychogenic illness is a syndrome that should also be given consideration; it is usually
mistaken for a hazardous materials release3. It occurs when a stimulus (such as an odor) triggers
one person (usually a school-aged child) to have shortness of breath or nausea and vomiting. The
occurrence of these symptoms triggers others in the group to have similar symptoms.
Communication with fire services at the scene of these events is critical to determine if there are
any dangerous chemicals involved, but usually the symptoms are limited to the sensation of
shortness of breath, headaches, and nausea and vomiting without evident cause or other findings.
Symptomatic treatment is recommended and these patients should not be cohorted together at
risk of exacerbating symptoms. This is differentiated from Medically Unexplained Physical
Symptoms (MUPS) which usually presents on a delayed basis after a suspected exposure and may
involve multiple symptoms and presentations that cannot be explained by a specific injury, toxin,
or syndrome.
TREATMENT
EMERGENCY DEPARTMENT CARE
Red-tagged patients (critical/unstable)
o Place in the most acute (e.g.: resuscitation) beds of the pediatric or, as necessary, adult areas of
the ED
o Management: ED attending physicians; transfer to PICU or pediatric ward attending physicians,
if available (or arrange consultation with referral center)
o Alert surgery (pediatric, when available) or Trauma Team
o Place all other surgical specialties on standby as required / available
3
For example and discussion – a case report of 99 persons presenting to an ED on day one after an unusual odor (no hazardous materials found) in a
school and 71 more the day the school reopened – Jones TF. N Engl J Med 2000;342:96-100
20
Yellow-tagged patients (moderately injured or ill/potentially unstable)
o Place in acute care beds in ED if possible – consider overflow to procedure areas and other
locations per surge capacity plan
o Reevaluate frequently and assign disposition in a timely manner
o Ideally, providers assigned to patients should stay with that patient through the emergency
department course if resources allow
o When sufficient clinical staff are not available, an escort should be assigned to each
unaccompanied child to maintain continuity and safety – unsupervised children should be
avoided at all times
Green-tagged patients (minor or non-injured/stable)
o Triage to secured waiting room, other large waiting area or clinic (if available) with supervision
to ensure safety of unaccompanied children
o Reevaluate frequently - discharge after care is completed to an appropriately identified adult
ED placement:
Color
Category
Clinical
Placement
Red
Yellow
Green
Immediate life threat
Altered mental status,
respiratory distress, signs of
shock, truncal penetrating
injury
Potential life threat (within hours)
No immediate life threat
Generally non-ambulatory with an
injury or injuries that may become
life-threatening if untreated
Generally ambulatory with
isolated injuries that should not
be life or limb-threatening
Resuscitation area
Acute treatment and re-triage area
Waiting area / clinic / urgent
care area4
Emergency evaluation and treatment of pediatric patients follows the general ‘ABCDE’ approach of
trauma triage. Providers should refer to the MDH Pediatric Priorities poster for additional clinical
tips. Early analgesia should be provided including appropriate doses of narcotic analgesia where
needed – this may be given via intranasal and other non-invasive routes. Intra-osseous lines may
be needed when IV access is difficult and adequate supplies of needles, drivers, and connections
sets should be available.
Comprehensive information about pediatric medical care is beyond the scope of this document,
though ten key differences in caring for pediatric patients are:
1. In pre-school children, the cricoid ring is the narrowest portion of the airway – so an
endotracheal tube may pass the cords but hang up below them and require a smaller tube –
cricothyrotomy is contraindicated below school age
2. Endotracheal tube position is more tenuous the smaller the child. Any change in neck
position may result in right mainstem intubation (flexion) or extubation (extension). Head
4
Until thoroughly evaluated, Green patients should not be taken to a remote area of the facility or to an off-site facility as they will need to be retriaged if subtle or evolving injuries are present. Yellow patients will also need re-evaluation and re-triage after initial assessment and treatment.
21
immobilization is recommended in addition to careful securing of the tube. Continuous endtidal CO2 monitoring can protect against an unrecognized dislodged tube
3. Respiratory distress often leads to gastric distension from air-swallowing. All intubated
children should have a orogastric tube placed (nasogastric tubes should be avoided in
trauma)
4. Compensation for shock is much better than in adults, but when shock occurs it is often
precipitous – sustained high heart rates after appropriate analgesia should indicate
compensated shock until proven otherwise
5. Pre-school children and infants are likely to have hypoglycemia when severely injured or ill
– fingerstick glucose should be checked on all pediatric patients
6. Hypothermia occurs quickly due to higher body surface area relative to mass – protect early
against loss of body heat
7. In cases of shock, give 20mL/kg normal saline, if clearly hemorrhagic shock consider early
replacement of 10mL/kg packed RBCs
8. Maintenance fluid rate
a. 4mL/kg/hr first 10kg (40mL/hr)
b. 2mL/kg/hr second 10kg (20+40=60mL/hr)
c. 1mL/kg/hr each kg >20 kg (60 + x mL/hr)
9. Fluids – starting maintenance
a. Neonate D10 ¼ NS
b. 1-5 years D5 ¼ NS
c. > 5 years D5 ½ NS
10. Drug dosing in pediatric patients is subject to errors, which can arise from:
a. Inaccurate weight estimation (use actual weight when possible, length-based
correlate to weight – such as Broselow tape – as secondary method, age-based as last
resort)
b. Inaccurate dose calculation
c. Inaccurate conversion of dose to volume (mg to mL of drug for example)
Providers should refer to course materials for Advanced Pediatric Life Support or textbooks such
as Fleischer’s Textbook of Pediatric Emergency Medicine for more definitive information.
INPATIENT CARE
For hospitals with PICUs:



Admit the most critical cases and/or youngest victims to PICU
Manage overflow patients in monitored beds on ward or adult medical or surgical ICUs.
Expand ICU care to PACU, back to ED, or to monitored beds on pediatric unit with pediatric
RNs
If PICU services are unavailable or resources exceeded, staff physicians will have to manage critical
patients pending transport (in consultation with outside pediatric experts – telephone or
22
telemedicine, or with internal ED, anesthesia and/or adult critical care staff as needed) in the
above areas. Providers with expertise in this area should be determined prior to the incident.
For hospitals with pediatric inpatient services:




Admit moderately injured or ill patients (and especially those < 8 years of age) to pediatric
ward.
Room patients of similar age together whenever possible
As more space is needed, add 1 bed per room, if possible
Consider cohorting older pediatric patients on adult wards but pediatric patients should not
room share with a non-parent adult
For hospitals without pediatric inpatient services:



Arrange transfer to appropriate referral center
If transportation is delayed, provide care in consultation with outside technical experts at
pediatric specialty center and involve community pediatric specialist input as possible
Consider providing ongoing care on adult unit appropriate for acuity – children should not
share rooms with non-parent adults. Rooms should be easily observed and secured
TRANSPORTATION
Within the hospital
Equipment:


Children > 8 years old – adult stretchers may be appropriate
Smaller children – crib or additional personnel with padded adult stretcher – stretcher rails
may allow entrapment/falls if not careful, height may cause significant injury if child falls
Personnel:


Parents or adult caregivers should stay with children
If no parent is available, appropriate personnel must be identified to supervise pediatric
patients
o Children < 8 years – continuous 1:1 supervision, unless in crib
o Children ≥ 8 years – assess ability to follow safety rules while on stretcher
o A child separated from other children requires 1:1 observation
From hospital to other facilities
Patients requiring ICU care who cannot be accommodated at the facility should be transferred to
referral centers. Priority should be given to those with the most critical injuries and those < 8 years
of age. Rotor-wing (helicopter) transfer to an appropriate referral center should be considered
depending on distance and road conditions. Parents should accompany the child whenever
possible.
23
Neonatal transport should be arranged with the receiving specialty center and an appropriate
rotor-wing, fixed wing, or ground transport team should be arranged. There are few circumstances
where an ill neonate should be transported without the services of such teams – if the team is
delayed by weather, specialty consultation should be obtained to advise on interim care measures.
Close coordination with EMS in the affected community and with the receiving region is important
to assure appropriate and timely arrival of transportation. It may be more effective to have units
from the receiving community come to the affected area depending on local EMS capacity.
Hospitals should consider alternatives to ambulances for safe pediatric transfers in a disaster
situation.
1. Stable patients:
Arrange for car seats (see options in table below)
i.
Donations
ii.
Purchases
iii.
Identify local sources as needed
iv.
Conduct just-in-time survey of employees re: available car seats
Transport vehicles
i.
Cars, vans, city or private buses with car seats, as indicated
ii.
School buses for children ≥ 5 years who can sit up
iii.
Driver must have cell phone or radio to communicate with hospital
iv.
Appropriate medical personnel must accompany patients
v.
Mental health or social service personnel should ideally accompany the patients
2. Unstable or potentially unstable patients:
Appropriate transport vehicles – arrange in consultation with pediatric expertise and EMS
1. BLS/ALS ambulance with:
a. Accompanying physician, CRNA, or other staff skilled in pediatric airway and
resuscitation
b. Equipment appropriate for age and acuity of patient
2. ALS/BLS ambulance with normal EMS staff for less critical patients
3. Specialty pediatric transport teams from referral pediatric institutions
4. Rotor-wing (helicopter) or fixed wing (airplane) ambulance
24
Appropriate Use and Type of Car Seats
Age Group
Type of Seat
General Guidelines
Infants / toddlers
All infants and toddlers should ride in a Rear-Facing Car Seat until they are 2
years of age or until they reach the highest weight or height allowed by their car
safety seat's manufacturer.
School Aged Children
Rear facing only
seats and rear
facing convertible
seats
Convertible seats
and forwardfacing seats with
harness
Booster Seats
Older Children
Seat Belts
Toddlers / preschoolers
All children 2 years or older, or those younger than 2 years who have outgrown
the rear-facing weight or height limit for their car seat, should use a ForwardFacing Car Seat with a harness for as long as possible, up to the highest weight
or height allowed their car seat’s manufacturer.
All children whose weight or height is above the forward-facing limit for their
car seat should use a Belt-Positioning Booster Seat until the vehicle seat belt
fits properly, typically when they have reached 4 feet 9 inches in height and are
between 8 and 12 years of age.
When children are old enough and large enough to use the vehicle seat
belt alone, they should always use Lap and Shoulder Seat Belts for optimal
protection. All children younger than 13 years should be restrained in the
rear seats of vehicles for optimal protection
Source: American Academy of Pediatrics
TRACKING
Early registration and tracking of pediatric patients is of paramount importance for family reunification as well as clinical operations. Because younger children cannot participate verbally in
their care there may be difficult assigning names – thus pictures of all unaccompanied children
should be taken and a numeric system used until identity can be confirmed. A template for
information collection for unaccompanied children can be found in Appendix 13. ALL
unaccompanied children < 18 and all children checked into the Pediatric Safe Area should have this
sheet filled out, and, unless they are an emancipated minor, they must await a parent or guardian
prior to being discharged.
A colored band system should be used to help identify the child’s status – a suggested system is:




Purple bands signify the child is with a parent/guardian
White bands signify a child without a parent/guardian
A child with a patient band has/is receiving medical care at the facility – a white or purple
band may accompany the patient band to show the child’s status
Blue bands may be used to identify the children that belong to staff members who required
childcare in order to respond to the emergency
If the child is referred to another institution, a tracking sheet should note the transporting crew,
the destination hospital (and ideally unit and receiving staff), time of departure, and any
belongings and/or parents or caregivers accompanying the child. (See Appendix 13)
A child who is a patient and unaccompanied should be discharged to the Pediatric Safe Area after
medical care is complete – the discharge should reflect the destination to assure that
parents/caregivers can find the child in the PSA.
25
APPENDICES
APPENDIX 1: PEDIATRIC SAFE AREA CHECKLIST (this should be done prior to an incident but re-checked
when opening the PSA)
Needle boxes at least 48 inches off the floor?
Plug-in covers for electrical outlets?
Strangulation hazards removed (cords, wires, tubing, curtain/blinds drawstrings)?
Can you contain children in this area (consider stairwells, elevators, doors)?
Games and distractions available? (age and gender appropriate movies, games, toys)?
Ingestion hazards removed? (cleaning supplies, Hemoccult developer, choking hazards should be
removed or locked away)
Med carts and supply carts removed or locked?
Do you need to create separate areas for various age groups?
Do all relevant departments understand the role of the PSA and its activation?
Do you have a plan for security for the area?
Do you have a plan to identify the children?
Do you have a plan for assessing mental health needs of these children?
Are there any fans or heaters that pose a danger?
Do you have an onsite or nearby daycare that could help you?
Do you have enough staff to supervise the number of children? (Younger children require more staff)
(MN Rule 9503.0040 for childcare requires a staff to child ratio of 1:7 toddlers or 1:15 school-age
children)
Do you have a sign-in, sign-out sheet for all children and adults who enter the area?
Will children need to be escorted away from safe area to bathrooms?
Are age-appropriate meals and snacks available?
Are wipes and various-sized diapers available?
Does the PSA have hand hygiene supplies?
Are there cribs, cots or beds available for children who need to sleep?
Are blankets available for warmth and comfort?
Does the PSA have a policy/protocol for handling minor medical needs in children (Tylenol dosing,
administering routine meds, Band-Aid replacement, etc.)?
Do you have wrist bracelets for recognized severe food allergies?
Do you know how to summon medical assistance (both emergently and non-emergency) to the PSA?
Do you have an EpiPen® available for allergic reactions?
Do you know the evacuation plan for the PSA?
26
APPENDIX 2: SAMPLE MENU FOR PEDIATRIC PATIENTS
This sample menu does not address parenteral nutrition. Advanced dietary issues should be discussed with dietitians
on staff if these types of feeding are provided at your facility. The table below is a discussion document for use with
your food services and nutrition staff.
Infants (0-12 months): Infant formula (oral or tube feed) – standard formulas and consider stocking limited amounts
of specialty formulas
12 months and older requiring tube feeds (adolescents usually can receive adult tube feed formulations)
Resource® Just for Kids
PediaSure®
Nutragen Jr.
SAMPLE PEDIATRIC DISASTER MENU
The following sample diet for pediatric patients lists foods that require the minimal amount of preparation or power
supply to maintain temperatures.
Day 1
Day 2
Day 3
Breakfast
Breakfast
Breakfast
0-6 months
Regular or Soy Formula
Regular or Soy Formula
Regular or Soy Formula
Baby Cereal
Baby Cereal
Baby Cereal
6 months – 1 yr.
Jarred Baby Fruit
Jarred Baby Fruit
Jarred Baby Fruit
Regular or Soy Formula
Regular or Soy Formula
Regular or Soy Formula
Cheerios (or Substitute)
Cheerios (or Substitute)
Cheerios (or Substitute)
Warm cereal (1-2 years)
Warm cereal (1-2 years)
Warm cereal (1-2 years)
1 yr. and above
Powdered Milk (> 2 years)
Powdered Milk (> 2 years)
Powdered Milk (> 2 years)
Diced Canned Fruit
Diced Canned Fruit
Diced Canned Fruit
Lunch
Lunch
Lunch
0-6 months
Regular or Soy Formula
Regular or Soy Formula
Regular or Soy Formula
Jarred Baby Meat
Jarred Baby Meat
Jarred Baby Meat
Jarred Baby Vegetable
Jarred Baby Vegetable
Jarred Baby Vegetable
6 months – 1 yr.
Jarred Baby Fruit
Jarred Baby Fruit
Jarred Baby Fruit
Regular or Soy Formula
Regular or Soy Formula
Regular or Soy Formula
Cream Cheese/Jelly Sandwich
Macaroni and Cheese
Cheese Wiz©
Jarred Baby Vegetable
Jarred Baby Vegetable
Jarred Baby Vegetable
1 yr. – 2 yrs.
Diced Peaches
Diced Pears
Diced Fruit Cocktail
Bread/Crackers
Bread/Crackers
Bread/Crackers
Warm Cereal
Warm Cereal
Warm Cereal
Cream Cheese/Jelly Sandwich
Macaroni and Cheese
Peanut Butter/Jelly Sandwich*
Diced Peaches
Diced Pears
Diced Fruit Cocktail
2 yrs. plus
Graham Crackers
Graham Crackers
Graham Crackers
Powdered Milk
Powdered Milk
Powdered Milk
Dinner
Dinner
Dinner
0-6 months
Regular or Soy Formula
Regular or Soy Formula
Regular or Soy Formula
Jarred Baby Meat
Jarred Baby Meat
Jarred Baby Meat
Jarred Baby Vegetable
Jarred Baby Vegetable
Jarred Baby Vegetable
6 months – 1 yr.
Jarred Baby Fruit
Jarred Baby Fruit
Jarred Baby Fruit
Regular or Soy Formula
Regular or Soy Formula
Regular or Soy Formula
Cheese Slices – Chopped
Canned Chicken - Chopped
Cheese Ravioli
Jarred Baby Vegetable
Jarred Baby Vegetable
Jarred Baby Vegetable
1 yr. – 2 yrs.
Applesauce
Bananas
Baby Fruit
Bread/Crackers
Bread/Crackers
Bread/Crackers
Warm Cereal
Warm Cereal
Warm Cereal
Cheese Sandwich
Canned Chicken Sandwich
Cheese Ravioli
Diced Fruit Cocktail
Diced Peaches
Diced Pears
2 yrs. plus
Graham Crackers
Graham Crackers
Graham Crackers
Powdered Milk
Powdered Milk
Powdered Milk
Source: New York City
*Watch for symptoms of rare incidence of peanut allergy
27
APPENDIX 3: CHILDREN AND CRISIS – BEHAVIORAL HEALTH HANDOUTS
Psychological First Aid for Disaster Survivors
Re-create sense of safety
 Provide for basic needs (food, clothing, medical care)
 Ensure that survivors are safe and protected from reminders of the event
 Protect them from on-lookers and the media
 Help them establish a “personal space” and preserve privacy and modesty
Encourage social support
 Help survivors connect with family and friends (most urgently, children with parents)
 Educate family and friends about survivors’ normal reactions and how they can help
Re-establish sense of efficacy
 Give survivors accurate simple information about plans and events
 Allow survivors to discuss events and feelings, but do not probe
 Encourage them to re-establish normal routines and roles when possible
 Help resolve practical problems, such as getting transportation
 Discuss self-care and strategies to reduce anxiety, such as grounding and relaxation techniques
 Encourage survivors to support and assist others
Some children are more likely to have emotional reactions to the events (See below for “After a
Disaster: Possible Reactions of Children”)
 Children who witnessed the event firsthand or whose parent, relative of friend was killed or injured
 Children who are displaced from their home or school
 Children with a past history of emotional problems
 Children with a past history of trauma, either as victim or witness to violence or abuse
 Children with an adult in their life who is having difficulty with their emotions, was a witness to
violence or victim of domestic violence
Helpful hints to assist children during a disaster
For children under age 5:
 Ask what makes them feel better
 Give plenty of hugs and physical reassurance
For children older than age 5:
 Don’t be afraid to ask them what is on their mind and answer their questions honestly
 Talk to them about the news and any adult conversations they have heard
 Make sure they have opportunities to talk with peers if possible
 Set gentle but firm limits for acting out behavior
 Listen to child’s repeated retelling of the event
28
After a Disaster: Possible Reactions of Children
Children aged 5 and younger may:
 Have fears of being separated from a parent
 Be unusually fearful, “fussy”, clingy, and have crying spells
 Regress to outgrown behavior, such as bed-wetting or baby talk
 Have nightmares or problems sleeping
 Have stomachaches, headaches or other physical complaints that do not have a medical basis
 Startle easily
 Have a loss or increase in appetite
Children aged 6 to 11 may:
 Engage in repeated play that depicts the disturbing events

Have nightmares or problems sleeping






Have unusual outbursts of anger
Withdraw from friends and family
Be fearful, anxious or preoccupied with safety and danger
Return to behavior they have outgrown
Express feelings of guilt
Have frequent stomachaches, headaches or other physical complaints that do not have a medical
basis
Have problems concentrating
Experience persistent, disturbing feelings and memories when reminded of the event


Children aged 12 to 18 may exhibit:
 Appetite changes
 Headaches, gastrointestinal problems
 Loss of interest in social activities
 Sadness or depression
 Feelings of inadequacy and helplessness
 Feelings of anger and aggression
 Isolation from others, less interest in friendships
 Repetitive behaviors such as hand-washing
29
After a Disaster: A Guide for Parents and Caregivers
(From the National Institute of Mental Health)
Natural disasters such as tornados, or man-made tragedies such as bombings, can leave children feeling
frightened, confused, and insecure. Whether a child has personally experienced trauma or has merely seen
the event on television or heard it discussed by adults, it is important for parents, care-givers, and teachers
to be informed and ready to help if reactions to stress begin to occur.
Children respond to trauma in many different ways. Some may have reactions very soon after the event;
others may seem to be doing fine for weeks or months, then begin to show worrisome behavior. Knowing
the signs that are common at different ages can help parents and teachers to recognize problems and
respond appropriately.
Preschool Age
Children from one to five years in age find it particularly hard to adjust to change and loss. In addition, these
youngsters have not yet developed their own coping skills, so they must depend on parents, family
members, and teachers to help them through difficult times.
Very young children may regress to an earlier behavioral stage after a traumatic event. For example,
preschoolers may resume thumb sucking or bedwetting or may become afraid of strangers, animals,
darkness, or "monsters." They may cling to a parent or teacher or become very attached to a place where
they feel safe.
Changes in eating and sleeping habits are common, as are unexplainable aches and pains. Other symptoms
to watch for are disobedience, hyperactivity, speech difficulties, and aggressive or withdrawn behavior.
Preschoolers may tell exaggerated stories about the traumatic event or may speak of it over and over.
Early Childhood
Children aged five to eleven may have some of the same reactions as younger boys and girls. In addition,
they may withdraw from play groups and friends, compete more for the attention of parents, fear going to
school, allow school performance to drop, become aggressive, or find it hard to concentrate. These children
may also return to "more childish" behaviors; for example, they may ask to be fed or dressed.
Adolescence
Children ages twelve to fourteen are likely to have vague physical complaints when under stress and may
abandon chores, school work, and other responsibilities they previously handled. While on the one hand
they may compete vigorously for attention from parents and teachers, they may also withdraw, resist
authority, become disruptive at home or in the classroom, or even begin to experiment with high-risk
behaviors such as drinking or drug abuse.
These young people are at a developmental stage in which the opinions of others are very important. They
need to be thought of as "normal" by their friends and are less concerned about relating well with adults or
participating in recreation or family activities they once enjoyed. In later adolescence, teens may experience
feelings of helplessness and guilt because they are unable to assume full adult responsibilities as the
community responds to the disaster. Older teens may also deny the extent of their emotional reactions to
the traumatic event.
30
How to Help
Reassurance is the key to helping children through a traumatic time. Very young children need a lot
of cuddling, as well as verbal support. Answer questions about the disaster honestly, but don’t
dwell on frightening details or allow the subject to dominate family or classroom time indefinitely.
Encourage children of all ages to express emotions through conversation, drawing, or playing and
to find a way to help others who were affected by the disaster.
Try to maintain normal routines and encourage children to participate in enjoyable activities.
Reduce expectations temporarily about performance in school or at home, perhaps by substituting
less demanding responsibilities for normal chores.
Finally, acknowledge that you, too, may have reactions associated with the traumatic event, and
take steps to promote your own physical and emotional healing.
When to Seek More Help
Consultation with a mental health professional may be useful at any of these times. However,
psychiatric consultation should be sought if any of the following is exhibited:






Excessive fear of something terrible happening to their parents or loved ones
Excessive and uncontrollable worry about things, such as unfamiliar people, places or
activities
Fear of not being able to escape if something goes wrong
Suicidal thoughts or the desire to hurt others
Hallucinations
Expressing feelings of being helpless, hopeless, and worthless
31
APPENDIX 4: MDH PEDIATRIC PRIORITIES POSTER
MDH Pediatric Priorities Poster – available on web at:
http://www.health.state.mn.us/oep/healthcare/pedspriorities.pdf – for posting in ED and use in
other reference materials. Also see MDH Scarce Resources card set information on pediatric mass
casualty care and triage.
32
APPENDIX 5: PEDIATRIC REFERRAL RESOURCES
Facility Name
Notes – Peds
related
Contact /
consultation
Trauma Level
PICU Services
3
3
1
Yes
Yes
Yes
866-755-2121
888-543-7866
800-424-4262
1
1 (adult)
2 (peds)
Yes
888-588-9855
Yes
800-230-2413
Metro
Children’s Healthcare
University of MN – Amplatz
HCMC
Regions / Gillette
North Memorial
Primarily
800-828-8900
orthopedic
If additional referrals required contact Metro RHRC for other hospitals with inpatient capacity
Mercy
2 (adult)
No
1
Yes
800-533-1564
3
No
877-225-5475
(One Call)
Sanford Children’s Hospital,
Sioux Falls, SD
2
Yes
General Peds beds
- 42; PICU beds –
12; NICU beds - 58
605-333-1000
Rice Memorial Hospital,
Willmar
3
No
8 beds
320-235-4543
2
Yes
Sanford Medical Center Fargo
2
Yes
Essentia Health – Fargo, ND
2
NICU, neurology,
surgery
NICU
Altru Hospital, Grand Forks,
ND
2
NICU
South East
Mayo Eugenio Litta Children’s
Hospital
South Central
Mayo Clinic Health System Mankato
South West
Central / West Central
CentraCare
888-387-2862
North West
877-647-1225
(One Call)
800-437-4054
855-425-8781
(One Call)
North East
33
Facility Name
St. Luke’s
Essentia Health-St. Mary’s
Medical Center
Fairview University Medical
Center - Mesabi
Trauma Level
PICU Services
2 (Adult)
No
2
Yes
3 (Adult)
No
Notes – Peds
related
PICU and operative
services including:
burn, plastics, ENT,
NICU, toxicology
Contact /
consultation
218-249-7870
218-786-7777
218-362-6621
34
APPENDIX 6: HOSPITAL TRAINING MATRIX – PEDIATRIC PREPAREDNESS
Example staff for training – to be modified by facilities according to their resources and role in the community
Awareness
Healthcare assistants,
aides, respiratory therapy,
selected providers and inhouse nursing staff
Knowledge
Physicians, nurses, other
providers with a disaster
response role
Proficiency
Physicians, nurses, other
providers expected to
provide pediatric
emergency care on a
routine basis
Orientation materials –
equipment location, facility
plan summary
X
X
X
Introduction to pediatric
preparedness
X
X
X
X
X
Scenario discussion
Skill stations / simulation
X
Certification*
X
*Certification requirements are determined by the institution via their job requirements / privileging (for example –
Advanced Pediatric Life Support (APLS) certification)
35
APPENDIX 7: PEDIATRIC PATIENT TRAINING SCENARIOS
Scenario 1
EMS report: 5 year-old boy riding his bike was hit by a car. He was unresponsive on arrival of first responders with
pupils 5mm and sluggish bilaterally. No response to pain. He had good respiratory effort. Blood was suctioned
from the mouth and nose, oxygen was applied by mask. No IV access was able to be obtained. PMH/Allergies
unknown.
Primary survey:
A – minimal blood to nares, patent, breathing spontaneously
B – clear lungs bilaterally, oxygen saturations 98% on O2, during transition to ED O2 fell to 90%
C – capillary refill intact, color good, heart sounds normal, peripheral pulses palpable
D – no response to pain x4 – GCS 1 + 1 + 1 = 3, pupils 4mm L, 6mm R sluggish
VS – 100/70, 128, 16, 98% on mask O2
Initial assessment and expected actions:
 Recognize severe head injury and potential for multi-system injury
 Activation of referral process / rotor-wing or other retrieval unless at definitive care center
 Call for additional help
 Obtain IV access – rapid progression to IO if any difficulties – discuss sites including tibia (proximal and
distal), distal femur and humeral head
 Intubation – talk through equipment, size of blade/tube, doses of medications (sedation – e.g. ketamine or
etomidate for sedation, paralysis – succinylcholine or rocuronium – avoid propofol due to potential for
hypotension)
 Ongoing sedation and/or paralysis
 Management of increased intracranial pressure – consider mild hyperventilation
 (temporary) and administration of (e.g. hypertonic saline 3% at 2ml/kg or mannitol 1g/kg)
 Re-assessment and evaluate for signs of shock (persistent tachycardia, poor color, signs of poor
perfusion)
 Further diagnostics and evaluation – ultrasound, CXR, pelvis XR, cervical spine xray – to be done if there
is time while waiting for transport. Please be sure to send copies of all images with the transport team.
 Spinal precautions maintained throughout – regardless of any CT findings
 OG placed
 Indwelling urinary catheter
 Dosing for analgesics
 Consideration of anti-epileptic medications (fos-phenytoin 18mg/kg)
 Packaging for transport
 Labs – emphasize importance of checking glucose on all critically injured/ill children (very little reserve),
Hgb, serum CO2 value / base deficit
Secondary survey:
1. Possible abdominal firmness to palpation
2. Abrasions R shoulder and upper back
3. Swelling and tenderness R wrist
Secondary considerations:
 Discuss if pupils do not equalize consider CT head on-site if available and if will not delay transport
(especially if will intervene on-site)
 Discuss seizure management including use and dosing of IM benzodiazepines (midazolam 0.1mg/kg, for
example) and IM fos-phenytoin if IV access not easy to obtain. Use intranasal versed 0.4mg/kg for
seizures if no IV access – can use as both of the initial 2 doses of benzodiazepines in the status pathway.
36
Scenario 2
EMS report: 10 year old riding on ATV was thrown off at about 30mph when the driver hit a log in tall grass, crying,
complaining of pain to the R forearm and R hip area and nausea. BP 100/p, HR 120, deformity and laceration to R
mid forearm noted – bandaged and splinted. C-collar and long board. No IV access obtained in field. Father
reports asthma medical history, albuterol inhaler prn, no drug allergies.
Primary survey:
A – protecting airway, crying, breathing spontaneously
B – clear lungs bilaterally, oxygen saturations 98% on room air
C – capillary refill intact, color slightly pale skin, heart sounds normal, peripheral pulses palpable
D – awake, alert, anxious and crying, moving all extremities, neuro intact x4, pupils normal
VS – 100/70, 128, 16, 98% on room air
Initial assessment and expected actions:
 Activation of referral process / rotor-wing or other retrieval unless at definitive care center
 Call for additional help
 Obtain IV access – rapid progression to IO if any difficulties – discuss sites, too old for distal femur (<6),
but could use tibia (proximal or distal) or humeral – for humeral need adult needle – if patient is
hemodynamically stable – hold on IO access but have the IO available for any decompensation
 Need for symptom management - analgesia – IV/SQ/intra-nasal (consider fentanyl 2ug/kg intra-nasal, for
example), anti-emetic - ondansetron
 Need to re-assess vitals after analgesia – is tachycardia and poor color related to shock, or pain and
nausea?
 Re-assessment and evaluate for signs of shock (persistent tachycardia, poor color, signs of poor
perfusion)
 Spinal precautions maintained
 Further diagnostics and evaluation – ultrasound, CXR, pelvis XR, cervical spine xray
 Indwelling urinary catheter - if expected to have prolonged wait for transport
Secondary survey and diagnostics:
1. Abdomen/pelvis – tenderness to low abdomen, soft, pain with any manipulation of RLE referred to hip
(pelvis not compressed during exam due to risk of fracture)
2. Open, deformed R both-bone forearm fracture, pulses, motor/sensory intact, bleeding controlled
3. CXR – possible early pulmonary contusions (watch out for increased oxygen requirement and consider
early intubation if exhibits hypoxia – children often will not fracture ribs but have severe pulmonary
contusions)
4. Pelvis XR – symphaseal diastasis, ? R acetabular fracture, R sacroiliac joint widened (growth plates can
make interpretation / diagnosis of acetabular fracture tough – compare the two sides)
Secondary considerations:
 Will fracture need reduction? If so, and you are comfortable, what sedative would you choose? (propofol =
bad choice in patient who you are uncertain of borderline shock due to vasodilation, ketamine probably
best choice overall at 0.5-1.0mg/kg IV)
 What can you do for the pelvis injury? – pelvic immobilizer perhaps, but for kids likely best to sheet wrap
unless immobilizer designed for them.
 With pelvis fracture, obtain additional IV access and consider sending blood (if available) in transit with
patient – refer to center capable of interventional radiology if possible
 Watch VS and clinical condition carefully for evidence of evolving shock
 Watch for any evolving hypoxia – do not generally provide supplemental oxygen to kids (unless you have
access to end tidal CO2 monitoring), titrate to oxygen saturations
 Do not over-resuscitate with intravenous crystalloid – if heart rate is not coming down after 20ml/kg of
saline and adequate analgesia (and pelvic compression) give the next 20ml/kg bolus while
considering/ordering packed red blood cells 10ml/kg. Do not wait for blood prssure drop to treat shock in
children.
37
Scenario 3
EMS report: 7 year-old boy backseat unrestrained passenger in rollover MVC. No loss of consciousness. Good
respiratory effort. No IV access was able to be obtained. Crying, difficult to localize pain, but seems more central
than extremities. C-collar did not fit well so not applied. Long back boarded. Motor/sensory intact x4 extremities,
pupils equal, no external head trauma. Mask oxygen applied, saturations 100%. BP not obtained, HR 130. Per
mother no significant medical history or allergies.
Primary survey:
A – Alert, protecting, patent, breathing spontaneously
B – Difficult exam as crying, apparently clear lungs bilaterally, oxygen saturations 98% on O2, during transition to
ED O2 fell to 90%
C – capillary refill slight delay?, color slight pallor, heart sounds normal, peripheral pulses palpable
D – Alert, awake, crying, moving all extremities, GCS 15
VS – 100/70, 128, 20, 96% on mask O2
Initial assessment and expected actions:
 Activation of referral process / rotor-wing or other retrieval unless at definitive care center
 Call for additional help
 Primary concern is whether child has significant oxygen requirement – 96% on room air very different than
requiring 10lpm by mask to maintain 96%!
 Obtain IV access – rapid progression to IO if any difficulties – discuss sites including tibia (proximal/distal),
distal femur (borderline age for this, usually <6) and humeral head
 Spinal precautions maintained throughout – regardless of any CT findings, find and apply c-collar if
possible, if not, consider taping head, sandbags, etc.
 Further diagnostics and evaluation – ultrasound, CXR, pelvis XR, cervical spine xray
 Dosing for analgesics and route (consider intra-nasal or SQ prior to IV access)
 Re-assessment and evaluate for signs of shock (persistent tachycardia, poor color, signs of poor
perfusion)
 Labs – emphasize importance of checking glucose on all critically injured/ill children (very little reserve),
Hgb, serum CO2 value / base deficit
Secondary survey:
1. Chest seems to exhibit some tenderness diffusely
2. Possible upper abdominal tenderness
3. No evident extremity/head injury
4. CXR – hazy R>L lung with evident R pneumothorax (small on AP chest) – no evident fractures
5. Attempt transition to nasal cannula oxygen – sats falling to mid 80s
Secondary considerations:
 Asymmetric haziness with pneumothorax suggests hemothorax (but either way,
 Likely also has pulmonary contusions which will worsen over time
 Needs a right chest tube – option to do this without intubating, but with a significant oxygen requirement
early after injury should be intubated – will make procedure easier – since relatively stable can prep for
chest tube, intubate, then complete chest tube procedure
 Size of ET tube age/4 + 4 = 5.5 (roughly) – should be cuffed. Chest tube should be 4x ET size or about
24F
 Intubation – talk through equipment, size of blade/tube, doses of medications (sedation – e.g. ketamine,
paralysis – succinylcholine or rocuronium – avoid propofol due to potential for hypotension)
 Landmarks for chest tube, use of local anesthesia (and toxicity of local anesthetics – max about 7mg/kg
lidocaine with epinephrine, 4mg/kg without), consider sedation with ketamine or etomidate to minimize
further trauma if hemodynamically stable, drainage/suction set-up
 Ongoing sedation and/or paralysis
 OG placed
 Indwelling urinary catheter
 Packaging for transport
38
APPENDIX 8: TEMPLATE PEDIATRIC MASS CASUALTY ANNEX
1. Policy / reference number:
2. Purpose: Describe the resources available and actions to be taken during a pediatric mass casualty
incident.
3. Scope:
a. This annex is a supplement to, not a replacement for, the response actions and resources
described in the facility Emergency Operations Plan and provides additional details relevant to an
incident that involves significant numbers of pediatric casualties.
b. This annex is limited to no-notice incidents. Pediatric issues during evacuation and infectious
disease incidents involve different considerations and are included in those annexes.
4. Planning assumptions:5
a. Non-pediatric facilities will receive children from mass casualty events
b. Families should be kept together during all phases of care whenever possible
c. In large incidents, or when access to the facility is an issue, we may have to provide ongoing care
pending arrival of sufficient transportation or treatment resources
d. If the event involves more than one facility regional coordination will be required with the Regional
Healthcare Resource Center
e. Priority is to transfer the most critical and then youngest patients (<8 years old) as early as
possible to an appropriate referral center
f. Our facility has stabilization supplies for:6
i. X Critical patients less than 8 years old and X critical infants
ii. Yellow (serious) and Green (minor) patients under age 18 are also considered under this
plan
5. Concept of Operations:
a. Patients will be triaged and receive initial treatment in the Emergency Department
b. Designated pediatric disaster supplies should be brought to the ED resuscitation area from
_____________
c. Hospital Command Center should quantify transportation and referral needs early in the incident
and communicate these to EMS, jurisdictional EOC, or RHRC depending on the current state of
activation and role of these entities.
i. EMS Dispatch phone ____________________
ii. Local EOC phone
____________________
iii. RHRC/RHPC phone ____________________
5
This annex is not intended to be used at pediatric hospitals, where the EOP should reflect pediatric content – these hospitals may benefit from
adding an adult annex
6
Recommendations – see Pediatric Primer for additional information:
Facility Trauma Level
Critical < 8 years
4
2
3
4
2
6
1
8
*Age <18, Yellow = serious, Green = minor injuries
Critical infants
Yellow patients*
Green patients*
1
2
3
4
5
10
15
20
10
15
20
30
39
d. Pediatric Technical Specialist should be appointed by Incident Commander (below) – See
Appendix 9 for Job Action Sheet
e. If multiple patients require transportation and some will have to stay temporarily at the hospital, the
Inpatient Unit Leader and Pediatric Technical Specialist should work with the Incident
Commander, Operations, and Planning section chiefs to determine the priority for transport
and what additional staffing and resources will be required. An emphasis will be placed on
transferring the most critical victims and those <8 years of age to pediatric referral centers (See
pediatric triage card in MDH Scarce Resources set:
http://www.health.state.mn.us/oep/healthcare/standards.pdf).
f. The Regional Healthcare Preparedness Coordinator (RHPC) should be notified at:
_______________ when:
i. More than one regional facility receives victims
ii. Transportation or referral resources cannot rapidly meet the incident demands
6. Organization - Responsibilities / roles:
a. Activation – the Pediatric Emergency Team (PET) is activated by:
(list page group, other method here) and consists of:
(note staff including at least one physician that can perform triage/transport prioritization
as the Pediatric Technical Specialist)
b. Staffing – the following are sources of staff with pediatric-specific training7
Pager, page group
Phone
Notes
Pediatric Technical
Specialist (and alternate)
Physicians
Nurses
Other
c. Space – pediatric patients should be placed in the following areas for inpatient care 8
Beds / room / unit
Additional supplies required
Intensive Care (conventional)
Intensive care (contingency)
Floor Care (conventional)
Floor Care (contingency)
Cot-based care (crisis)
Minor / walking wounded care
7
This is intended for a smaller facility – larger facilities should list key individuals or group paging lists, etc.
Note that institutions that do not usually provide pediatric intensive or inpatient care will delete rows here to indicate only contingency beds – for
a small hospital, the only contingency intensive care will likely be in the ED.
8
40
d. Supplies – the following are designated pediatric disaster supplies by type and location
Type
Location
Notes
Resuscitation9
General patient care
Nutrition
Decontamination
Social / Family Support
e. Special
i. Pediatric decontamination – see HAZMAT annex (X) for specific supplies and instructions
1. Children should be kept with parents if possible (though teen-aged patients may
be uncomfortable being decontaminated with family).
2. If less than 2 years old, decontaminate with baby shampoo and carry in laundry
basket
3. Additional personnel will be needed to escort and assist children during
decontamination
4. Children will be fearful of personnel and process and may resist
5. Children are much more sensitive to hypothermia than to adults
ii. Pediatric Safe Area
1. Pediatric Safe Area is located at: (describe)
2. Incident commander or designee assigns Pediatric Safe Area Unit Leader –
obtain Job Action Sheet (Appendix 11) and assign additional personnel to the
area as requested
3. Assure ALL children are wearing bands as described:
a. Purple – Parents are patients (identifier number on band) – parent should
have purple band with matching identifier. 2 parents = 2 bands.
b. White – Without apparent parent / caregiver (see below)
c. Blue – Belong to staff (disaster daycare) – staff to wear number-matched
bracelet while child is in Safe Area
d. Children who are/were patients should wear their hospital ID band in
addition to above
4. Children are logged in and logged out of the Safe Area by band number and
caregiver/personnel accompanying. (Appendix 12)
iii. Family re-unification
1. Parents with purple bands matching may retrieve child from the pediatric safe
area when they are capable of doing so or work with the coordinator to arrange a
safe place to stay if they require hospitalization and are unable to care for the
child.
2. Children with white bands should have an ‘Unaccompanied child’ form (see
9
Refer to Pediatric Primer for resuscitation supplies, this may refer to caches or be a more specific list depending on facility
resources/needs – a full list may be included as an appendix
41
3.
4.
5.
6.
Appendix 13) filled out and a digital photo taken. This information should be
collected and shared with the Hospital Command Center.
Hospital command center will establish a Hospital Support Center at: (location)
(See Hospital Support Center Leader Job Action Sheet – or other facility
resource).
Family Support Center will determine ‘matches’ for children in the Safe Area.
Parents should be able to produce a picture of the child with them or other
concrete identifiers prior to any reunion/release if the child is not able to identify
their parent and provide assent.
Hospital support center should plan to demobilize the safe area and work with
local EOC to determine plans for children remaining unaccompanied after 12
hours.
Any child without an apparent match at 12 hours should be reported to the
clearinghouse of the National Center for Missing and Exploited Children as well as
the Hospital Command Center, jurisdictional EOC, and Red Cross or other
assisting community agencies. At this time, the child should undergo a physical
and behavioral health screening per usual facility policy.
iv. Triage
1. Children may not evidence signs of shock until later than adults – careful
evaluation is required
2. However, there is a tendency to ‘over-triage’ children, especially when they have
visible significant wounds and/or are extremely distressed – this may divert
resources from patients that are more critical (less external wounds, lethargic,
etc.) – be careful not to over-commit resources because of first impressions of
distress / wound appearance.
3. Pediatric providers should target care of those <8 years of age as they are most
likely to benefit from specialty care
v. Treatment
1. Provide usual triage and initial treatment, triage for transport / referral / ongoing
treatment as appropriate. See MDH Scarce Resource Pediatric card and Pediatric
Priorities poster for basic information.
2. Off-site technical experts – if needed, consultation for ongoing care / referral
questions should be made to:
PICU Capacity /
Floor capacity /
Specialty / Notes
Phone
Surge Capacity
surge capacity
Facility 1
Facility 2
Facility 3
3. On-site technical experts - in select situations, it may be an advantage for
specialty staff to come to the affected hospital with one of the transport units to
stay until the evacuation of children has been completed. If desired, this should be
arranged with a referral facility or via the RHRC (in larger incidents).
vi. Transportation
1. Neonatal and some specialty patients may require specialized transport teams.
2. Patients that require referral that are able to sit may require car seats. Car seats
for patients that do not have them can be obtained from:
a. (List facility options - consider polling staff for loans, area stores, Red
Cross, etc.)
42
3. The Transport Officer or designee is responsible for assuring that:
a. Car seats are safely installed
b. Children are appropriately restrained in the seat prior to transport
4. Hospital Command Center will work with EMS and/or the Regional Healthcare
Resource Center / RHPC to coordinate appropriate transportation assets and
staffing. Pediatric Technical Specialist should assist Command Center with patient
lists and priorities
5. Follow EOP for coordination of other transportation and staging, other needs and
issues.
6. See Minnesota Pediatric Referral Resources (Appendix 5) for referral facility
capacities and contact information.
vii. Tracking
1. Assure child and destination are tracked according to usual facility MCI lists.
Attempt to keep families together when possible.
2. Provide transfer information to Family Support Center as soon as possible if
parents were not available at time of transfer.
7. Command, control, coordination, communication:
a. When the facility disaster plan is activated for a pediatric event the Pediatric Emergency Team
(PET) should be activated by ______. This team consists of providers with pediatric-specific
training.
b. The following HICS positions may be assigned (in addition to usual HICS positions – assure that
Mental Health Branch Director, PIO, and Liaison Officer are appointed to manage family and
information issues):
i. Pediatric Technical Specialist (See Appendix 9 for template Job Action Sheet)
ii. Pediatric Services Supervisor (See Appendix 10 for template Job Action Sheet)
iii. Pediatric Safe Area Unit Leader (See Appendix 11 for template Job Action Sheet)
c. The following HICS positions have pediatric-specific considerations in their Job Action Sheet 10
i. Inpatient Unit Leader
ii. Outpatient Unit Leader
iii. Clinical Support Services Unit Leader
iv. Nutrition / Food Services Unit Leader
v. Mental Health Branch Director
vi. Victim Decontamination Unit Leader
vii. Family Support Unit Leader
viii. Access Control Unit Leader
8. Review, authorities, references:
Approval date:
Modification date(s):
Authorizing signature:
43
APPENDIX 9: PEDIATRIC TECHNICAL SPECIALIST (JOB ACTION SHEET)
You report to: _________________________________ (Incident Commander or Planning Section Chief)
Command Center location___________________________ Phone number______________________
MISSION: To provide guidance and develop policy on pediatric triage, treatment, transportation (including
priority for transportation), and referrals/consultation during an emergency with significant
numbers of pediatric patients
IMMEDIATE (0-2 hours):
____ Read this entire job action sheet
____ Obtain briefing from IC/Operations Section Chief or other assigning individual
____ Document activities, actions and decisions in an Operational Log (HICS form 214)
____ Gather information from Casualty Care Supervisor/ED Charge Nurse regarding:
____ Number of expected pediatric patients and their conditions
____ Hazardous materials or decontamination issues
____ Equipment, staff, or medication shortages/issues
____ Determine number of patients that may require transfer
____ Determine patients that may be cared for at the facility and assure appropriate staffing and location with
Inpatient Area Supervisor
____ Determine additional staff or materials needed based on expected patient volume and communicate with
Logistics Section Chief as required
____ Liaison with community EOC or Regional Healthcare Preparedness Coordinator if multiple hospitals
affected to determine transportation resources and timeline
____ Determine best use of pediatric-capable staff with Pediatric Services Supervisor
____ Coordinate referral consultation with Casualty Care Supervisor and other pediatric inpatient locations and
assist with arranging inpatient transfers and transportation
____ Provide expert input into decisions about priority for transfer to referral facility when transportation /
referral capacity is limited.
INTERMEDIATE (2-12 hours):
____ Assess on-going staff and materials needs based on patient status reports
____ Assist Logistics and Planning Section Chiefs in detailing/obtaining additional resources
____ Recommend substitutions and adaptations as required
____ Provide policy guidance when pediatric resources must be triaged due to patient volumes or
resource shortfalls
____ Provide talking points to Public Information Officer to share with media and parents relative to the incident,
victim care, decontamination / infection control, or other relevant issues
____ Provide guidance on any just-in-time training required
44
____ Ensure pediatric identification and tracking systems are implemented with Pediatric Services Supervisor
____ Coordinate with Logistics and Planning Section Chiefs to expand/create additional Pediatric Patient Care
areas, if needed
____ Facilitate referrals and consultations as required with other facilities
____ Continue to prioritize and assist with transfer coordination including priority for transfer, safe means of
transport, staffing requirements, and in-transit care requirements
____ Determine, with pharmacy, if any pediatric-specific dosing or formulation issues require action and provide
guidance to address these issues
____ Provide guidance and support as needed to clinical areas caring for pediatric patients
EXTENDED (>12 hours):
____ Participate in planning meetings and briefings as required by the Incident Commander or Planning Section
Chief
____ Document activities, actions and decisions in an Operational Log (HICS form 214)
____ Continue to support facility needs for clinical policies and guidance
____ Monitor and anticipate staff and supply issues and work with Logistics and Planning Section Chiefs to
remediate issues
____ Monitor and provide support for any ongoing transportation/transfers
____ Provide support for on-site pediatric care issues and consultations
____ Work with Public Information Officer on messages for the public, families, staff, and patients
____ Assure rest, nutrition, and psychological support are available for staff, families, and patients
____ Coordinate with Mental Health Branch Director for support and, if needed, evaluations of mental health of
volunteers and children
____ Track issues (successes and opportunities) for after-action analysis
____ Upon shift change - brief your relief - including situation update, actions taken, issues and problems to be
addressed, key contacts, and anticipated actions for the subsequent operational period
DEMOBILIZATION/RECOVERY
____ Return all assigned HICS equipment
____ Upon deactivation of your position, ensure all documentation and operational logs (HICS 214) are
submitted to the Operations Section Chief or Incident Commander as appropriate.
____ Brief the Operations Section Chief or Incident Commander as appropriate on problems, outstanding issues,
and follow-up requirements
____ Submit comments to Operations Section Chief or Incident Commander, as appropriate for discussion and
possible inclusion in the after action report. Topics include:




review of pertinent positions descriptions
operation checklist
recommendation for procedure changes
section accomplishments and issues
45
APPENDIX 10: PEDIATRIC SERVICES SUPERVISOR (JOB ACTION SHEET)
You report to: ____________________________________________________ (Operations Chief)
Command Center location_____________________ Phone number_________________________
MISSION: To ensure that the pediatric treatment and holding areas are properly assigned, equipped, and
staffed during an emergency
IMMEDIATE (0-2 hours):
____ Read this entire job action sheet
____ Obtain briefing from Operations Chief / Medical Care Branch Director
____ Document activities, actions and decisions in an Operational Log (HICS form 214)
____ Gather information from Casualty Care Supervisor/ED Charge Nurse regarding:
____ Number of expected pediatric patients and their conditions
____ Whether decontamination is indicated
____ Expected time of patient arrival
____ Current total number of ED patients
____ Determine number of available pediatric beds [in-patient] and report to Operations Chief for planning
purposes
____ Determine on-site pediatric qualified staff members (MD, RN, others)
____ Determine additional staff needed based on expected patient volume
____ Alert Discharge Unit Leader to institute early discharge/or internal/external transfer of patients to open
appropriate beds for pediatric patients as needed
____ Activate Pediatric Emergency Team as per plan:
____ Predetermined Physicians (Pediatric/Family Practice/ Staff/ Community)
____ Predetermined Nurses (with pediatric experience and/or PALS/ENPC certification)
____ Predetermined ancillary technicians/others with pediatric experience
____ Determine if Pediatric Safe Area should be activated
____ Assign Pediatric Safe Area Coordinator and determine staffing if required
____ Communicate with Operations Chief to assure coordination with non-pediatric ancillary/support personnel
____ Assure preparation of required pediatric patient care areas:
____ Clear area and designate each specific area per plan and based on expected casualties
____ Assure support personnel are assigned to each area
____ Assure delivery of medical and non-medical pediatric equipment
____ Assure set-up of pediatric equipment by clinical staff
____ Coordinate with Casualty Care Supervisor and other pediatric inpatient placement and assist with
inpatient transfers and transportation as needed
46
INTERMEDIATE (2-12 hours):
____ Assess on-going staffing needs based on patient status report from:
____ Pediatric healthcare personnel (emergency department, in-patient, OR)
____ Non-pediatric ancillary /support personnel
____ Pediatric Safe Area Coordinator and supplemental staff
____ Assess additional medical and non-medical pediatric equipment/supply needs
____ Communicate with Logistics in coordination with Medical Care Branch Director
____ Assure delivery of needed pediatric supplies
____Obtain status of pediatric casualties (discharges, admissions, transfers, and Pediatric Safe Area) and
report to Operations Chief
____ Provide information to Liaison Officer and Hospital Support Center on all admits
____Assure information flow from Pediatric Safe Area to Hospital Support Center and via Liaison Officer to
community Family Assistance Center
____ Ensure pediatric identification and tracking systems are implemented, to include identified, unidentified
and unaccompanied children/victims
____ Obtain Pediatric Registration forms from all pediatric patient areas for unidentified and/or unaccompanied
minors
____ Report any unidentified or unaccompanied pediatric patients to Operations Section and Hospital Support
Center
____ Determine timing and process for demobilizing the Pediatric Safe Area and where remaining children will
be sent until re-unified with caregiver
EXTENDED (>12 hours):
____ Assure rest, nutrition, and psychological support are available for staff
____ Coordinate with Mental Health Branch Director for support and, if needed, evaluations of mental health of
volunteers and children
____ Track issues (successes and opportunities) for after-action analysis
____ Upon shift change - brief your relief - including situation update, actions taken, issues and problems to be
addressed, key contacts, and anticipated actions for the subsequent operational period
DEMOBILIZATION/RECOVERY
_____ Ensure return/retrieval of equipment and supplies and return all assigned HICS equipment
_____ Brief Operations Section Chief on current conditions, issues, and follow-up requirements
_____ Submit comments to the Pediatric Services Supervisor for discussion and possible inclusion in the after
action report




review of pertinent positions descriptions
operation checklist
recommendation for procedure changes
section accomplishments and issues
47
APPENDIX 11: PEDIATRIC SAFE AREA (PSA) UNIT LEADER (JOB ACTION SHEET)
You report to: _______________________________________ (PEDIATRIC SERVICES SUPERVISOR)
Command Center location __________________________ Phone number ____________________
Mission: To ensure that the pediatric safe area is properly staffed and stocked during an emergency, and to
ensure the safety of children requiring the PSA until an appropriate disposition can be made.
Immediate (0-2 hours):
____ Receive appointment from Pediatric Services Supervisor
____ Read this entire job action sheet
____ Obtain briefing on the situation
____ Document activities, actions and decisions in an Operational Log (HICS form 214)
____ Determine if the pre-designated pediatric safe area is available
____ If not immediately available, take appropriate measures to make the area available as soon as possible or
determine if a back-up area will be used
____ Gather information about how many children may present to the PSA and likely timeframe for family
members to arrive to claim them
____ Assure enough staff is available for PSA (minimum staff: patients - <5yrs 1:7, >5yrs 1:15)
____ Assure adequate security staff is available for PSA
____ Establish adequate communication between PSA and the Hospital Support Center
____ Establish registry (sign in/out log) for PSA
____ Make sure that all items in PSA checklist have been met; if there are any deficiencies, address them as
soon as possible and report them to the Pediatric Services Supervisor
Intermediate (2-12 hours):
____ Determine the need for ongoing staff or other support (food, bedding, entertainment, etc. for PSA)
____ Maintain registry of children in PSA as they arrive or are released to appropriate adult, complete
unidentified and/or unaccompanied children registration forms
____ Determine expected duration of need for PSA and plans for demobilization – where will remaining children
be sent?
____ Communicate with Pediatric Services Supervisor for planning/resource needs
____ Determine if there are any medical or non-medical needs of children in PSA
____ Provide informational updates for the children in the PSA
____ Sleeping space and supervision if needed
____ Snack and meal support as needed
____ Report frequently to Pediatric Services Supervisor concerning status of PSA
48
Extended (>12 hours):
____ Make sure that PSA staff have breaks, water, and food during their working periods
____ Coordinate with Mental Health Branch Director for support and, if needed, evaluations of mental health of
volunteers and children
____ Document all action/decisions
____ Identify issues for after-action analysis
Demobilization / Recovery
_____Ensure that all children in PSA have been released to an appropriate adult
_____Return all supplies, equipment, etc.
_____Return room to original condition
_____Turn over PSA registry to Pediatric Services Supervisor
_____Brief Pediatric Services Supervisor on current conditions, issues, and follow-up requirements
_____Submit comments to the Pediatric Services Supervisor for discussion and possible inclusion in the after
action report




review of pertinent positions descriptions
operations checklist
recommendation for procedure changes
section accomplishments and issues
49
APPENDIX 12: PEDIATRIC SAFE AREA REGISTRY
Name
Parent / Guardian
Name
Contact Phone
Category*
Time
in
Time
out
Released to:
Notes
* P=with parent, W=without parent, ID#=patient (may have ID number and designation of P/W), S=child of staff
50
APPENDIX 13: PEDIATRIC SAFE AREA REGISTRATION SHEET (FOR UNACCOMPANIED MINORS)
Hospital Unaccompanied Minor Form
Minor’s Last Name:
_______
First Name:_____________________________
Date:
Middle Name:__________________________________ Nickname:____________________________________
Time:
Address:
Date of birth:
Age, Check if Estimated: 
Home phone: (________)-_________-__________
Cell phone: (________)-_________-__________
Parent/Guardian Name(s):
Parent(s) Phone Number(s):
1. (_______) _______-____________
Address:
2. (_______) _______-____________
City:
State:
Other Relative:
Unidentified Minor
Eye Color:
Race:
Hair color:
Weight:
Height:
Scars/birthmarks/Identifying features:
Gender:
Minor’s Photo
Any other identifying clothing, etc.:
☐ Parent/Guardian Inpatient?
Hospital:
Unit:
Siblings /Names/Ages:
How arrived at ED
☐EMS Agency:____________________________________ Unit #:___________
☐ Private vehicle - name(s) of person(s) who brought the child
☐Law Enforcement Agency:_____________________ Unit #:___________
☐Other:________________________________________________________________
Sources of Information (if more than one source please indicate):
☐ Child
☐ EMS
☐ Parent
☐ Daycare/Babysitter
☐ Bystander
☐ Friend
Person completing the form:
Name:
☐ School/Preschool
☐ Sibling
☐ Medical Records
☐ Other
Title:
Agency:
Phone: (_______) _______-____________
Admitted: Unit Name ___________________________________________________________________
Released to: Full Name: _______________________________________ Known to Child? Yes  No 
Relationship:___________________________________
Phone: (_______) _______-____________
ID: Yes  No 
Type ID:_____________________ Address on ID:___________________________________________________ City:___________________________ State:_________
51
APPENDIX 14: PEDIATRIC PATIENT IDENTIFICATION AND TRACKING FORM
Purpose: To assist in identifying, tracking and reunifying pediatric patients during a disaster
Note: All information within this form is confidential and should not be shared except with those assisting in the care of the patient.
Developed by the Illinois EMS-C
Date of Arrival: __/__/____
Time of Arrival:
AM/PM
Tracking number:
Patient’s Name (Last, First):
Patient’s Phone:
Patient’s Full Home Address:
Parent/Guardians’ Names:
Presented with patient? □ Yes □ No
Patient’s DOB:
/
/
□ Age: ___Years ___Months □ Estimated
Gender: □ Male □ Female
Unknown
Race, if known: □ White non-Hispanic □ Black, non-Hispanic □ Asian
Language: □ English □ Spanish
□ Hispanic □ Middle Eastern □ Native American □ Other □ Unknown
□ Nonverbal □ Other ________________
□ Accompanied
Describe where patient was found (be Items worn by or with patient when
□ Unaccompanied
as specific as possible, including found (describe color, pattern, type)
neighborhood/street address):
□ Pants:___________________________
How patient arrived at hospital
□ Shirt:____________________________
(list name if available):
□ Dress: ___________________________
□ EMS:_______________________
□ Shoes: ___________________________
□ Private medical transport
□ Socks: ___________________________
service
□ Coat/Jacket: ______________________
(ambulance/flight):______________
□ Jewelry:__________________________
_____________________________
□ Glasses:__________________________
□ Law Enforcement: ____________
□ Medical Devices:___________________
_____________________________
□ Other: ___________________________
□ Private Vehicle
□ Other: ___________________________
□ Walk-in
□ Other: ___________________________
□ Other_______________________
Description of the patient
Hair Color: □ Blonde □ Brown
□ Black □ Bald □ Other________
Eye Color: □ Brown □ Blue
□ Green □ Other__________
Height:
□Estimated
Weight:
□Estimated
Other markings:
□ Scars_____________________
□ Moles____________________
□ Birthmarks _______________
□ Tattoos___________________
□ Missing teeth______________
□ Braces___________________
□ Special needs______________
□ Other____________________
□ Other
Attach photo here
Patient Tracking Log
Hospital/Facility
Name
Location (city, state)
Phone Number
Arrival Date
Fax Number
( )
( )
( )
( )
( )
( )
( )
Departure Date
__/__/____
__/__/____
__/__/____
__/__/____
__/__/____
__/__/____
__/__/____
( )
__/__/___
ID Band #/ ID Band
(If patient has ID bands from other facilities and they need to
be removed to provide care, attach ID band in this area)
Attach ID Band Here
Attach ID Band Here
Attach ID Band Here
Attach ID Band Here
52
Complete if Child was Accompanied:
Name of Person Accompanying Patient:
Relationship to Patient:
□ Parent □ Guardian □ Sibling
□ Aunt/Uncle/Cousin □ Grandparent
□ Unknown □ Other ____________
□ Adult □ Child/Minor
Attach Copy of ID
ID Checked? □ Yes □ No
Form of ID (list):_____________________
If accompanied by adult, was child living with this adult prior to the emergency? □ Yes □ No
Does this adult have any proof of legal guardianship or relationship? □ Yes □ No
If yes, make copy and attach to this form.
If child and adult were separated after arrival at current facility, where is accompanying adult now?
If accompanied by someone other than parent/guardian, what is known about the parent/guardian’s current
whereabouts?
□ Nothing at this time □ Their current location is:
Is it known if there are orders of protection or other custody issues? □ No known custody/protection issues
□ Issue(s) identified:
Complete if Child was Unaccompanied
Are the whereabouts of the parent/guardian currently known? □ No □ Yes
Location:
Phone:
Email Address:
Where and when was the parent/guardian last seen:
Has the parent/guardian been contacted: □ No □ Yes
Contacted by:__________________________________________ Date: __/__/____ Time: _________
Plans for reuniting child with parent/guardian:
Additional steps to verify guardianship if reunited at hospital:
□ Does parent/guardian describe child accurately?
□ Does parent/guardian pick correct child out from a group of pictures?
□ Does parent/guardian have a picture of them with the child?
□ Does the child respond appropriately when reunited with parent/guardian?
Medical History and Treatment while at this Facility
Does the patient have any pre-existing medical conditions/medical problems/previous surgeries/special needs?
□ No □ Unknown □ Yes (list):
Is the patient on any medications? □ No □ Unknown □ Yes (list):
Does the patient have any allergies? □ No □ Unknown □ Yes (list):
Did the patient receive medical care for an injury/illness while at this facility?
□ No □ Yes (list):
Was the patient admitted to this facility? (Be specific as to room or location)
□ No, he/she was taken to the Safe Area at: ___________________________________________________________________
□ Yes, he/she is currently: _________________________________________________________________________________
Disposition
□ Patient was released to an individual: □ Parent □ Guardian □ Other:_____________________________
Name:
Phone:
Address:
□Permanent □ Temporary
Was consent obtained from parent/guardian if released to another adult? □ Yes □ No (explain):_________________________
□ Patient was transferred to another facility/agency
Facility/Agency Name:
Address:
Phone:
Contact Name:
Transported by:
□ Signature of individual patient released to:
Date:__ / __/ ____ Time:
53