Chapter 12 Pepiatric EMERGENCY PREPAREDNESS WA srjectives Discuss current issues and deficiencies in federal and state disaster plans related to the care of special populations. I Identify the differences between caring for children and caring for adults during a disaster. 1 Review select important physiological differences between children and adults. ™@ Describe children’s unique vulnerabilities in certain disaster situations. ™@ Outline the importance of maintaining the family unit during a disaster. 1 Summarize how to adapt current disaster plans to meet the needs of children. EE case Study ncaa pEneeanme eae Atoxin was released near a large elementary school serving children aged 5 through 12 years. ‘The toxin causes both shock and respiratory failure. Of the 300 children exposed, 87 will require high-end tertiary care, including mechanical ventilation. Available in the surrounding area are 30 pediatric intensive care unit beds, 20 open adult intensive care unit beds, and a total of 30 ‘working mechanical ventilators. Eight local pediatric critical care physicians and 6 pediatric emergency medicine physicians have experience in treating shock and respiratory failure in theaffected age group. Detection — What factors make children in this scenario more vulnerable to alrway compromise compared to adults? ~ When a minute counts, what would be the most effective way to triage a large number of pediatric victims during a disaster? Intervention — What antidotes should be used if this is a cholinergic agent and at what doses? Reassessment — Isour current local healthcare system equipped to manage a large number of pediatric patients? ~ What is the next step if the number of pediatric-trained critical care, emergency medicine, or acute care personnel is insufficient?Wi Pediatric Fundamental Critical Care Support Effective Communication ~ Where should a first triage occur? ‘Teamwork ~ Who should be directing where patients should be allocated? | INTRODUCTION Ina disaster, children as a group may be at higher risk for injury than adults due in part to 2 factors: vulnerabilities related to their developmental physiology, including unique psychosocial factors such as mental health needs, school environments, and child care centers; and a disaster planning system that has historically centered on the healthcare needs of adults. Knowledge about terrorism, mass casualty incidents, and disaster response has come primarily from past military experience. For this reason, planning for disasters, including acts of terrorism, has focused almost exclusively on the adult population. In 2010, almost one quarter of the total population of the United States was under the age of 18 years. Because the pediatric : population is generally healthy compared with adults, peacetime | Ina disaster, children may medical systems allocate resources primarily to adults. That 1 beat higher risk fr injury leaves only a few pediatric trauma centers to address critically than adults due in part to 2 injured children and limits the ability of community health systems to promote healthcare and disease-prevention strategies, grounded in a well-child paradigm. Therefore, a disaster that affects the US population will take a higher toll among the factors: vulnerabilities related {to developmental physiology and disaster planning that has vulnerable pediatric population and require more resources than __ historically centered on the are currently available. In previous large-scale natural disasters in healthcare needs of adults. the United States between 1992 and 2001, pediatric patients with = an average age of 4 years represented one-third of all patients a treated by disaster teams. In a recent evaluation of hospital surge capacity in New York State, area hospitals were found to have approximately one-half of the pediatric inpatient surge capacity recommended by US federal disaster-planning authorities and exceeded the recommended surge capacity for adult inpatients. Unlike the established US trauma system, nonpediatric trauma centers, and indeed all hospitals in general, will need to be prepared to receive and triage ill and injured children in a disaster. A recent study indicated that in a major pandemic, current hospital capacity to care for the expected number of critically ill or injured children would not be sufficient, even if capacity was increased by following recommendations for pediatric emergency mass critical care. Thus, hospitals that normally care for a limited number of Jow-acuity children will need to supplement children's hospitals that have reached maximum surge capacity, and all hospitals will require input from pediatric medical experts to provide care for pediatric patients in a disaster. In the current US healthcare system, because pediatric care is a specialty, only a minimal number of acute care, critical care, and emergency care providers are trained to assess, diagnose, and expeditiously treat severely injured children. Consequently, when a disaster strikes, pediatricians who may not have been trained to handle such situations will need to 12-2Pediatric Emergency Preparedness EE take leadership roles in treating pediatric patients in critical conditions, Given that pediatric emergency skills will diminish if not used or practiced, regular exercises in disaster response are critical. Equipment must be available in a range of sizes to accommodate children’s differences in age, development, welght, and size. Although the majority of large medical centers may have appropriate supplies, specialty equipment may not be available at hospitals that do not routinely treat and triage children. These deficiencies in equipment and training also are reflected in disaster medical assistance teams. In the interest of efficiency, US federal and regional medical supply stockpiles have adopted a one-size-fits-all approach. This is problematic because adult drugs may prove harmful in the younger population. Pediatric dosing requirements cannot be achieved due to how medications are stored, packaged, and prepared. The US Strategic National Stockpile of medical supplies has been modified so that a 12-hour push pack designed to supplement local supplies can be immediately dispatched after an emergency. The push pack contains medications that are approved by the Food and Drug Administration for use in children, but many of those medications arrive in adult-dose aliquots. Moreover, antidotes for chemicals used in terrorist attacks are not approved for children because significant questions remain regarding effective, nontoxic pediatric dosages. To have sufficient quantities of appropriate medicines available for children’s needs in a disaster, altered standards of care would need to include dosage adjustments, changes to expiration dates, and guidelines for the use of adult-specific medications in children. TL UNIQUE PHYSIOLOGIC VULNERABILITIES IN CHILDREN Because the needs of the pediatric population tend to be u - overlooked in disaster planning, healthcare leaders need to sen revisit disaster plans to ensure that they include appropriate Children are less able to escape care for children. Children are less able to escape disaster and disaster and are morelikelyto more likely to suffer severe injury and require special care in the aftermath of disaster. Even in day-to-day situations, spec carein the oftermath age-related physiological differences among children can complicate the work of providers without experience in of disaster. pediatric assessment and triage (Appendix 1), Substantial oe a differences based on size and physiologic and cognitive ama development also may Increase the impact of a disaster on children. suffer severe injury and require A. Respiratory Vulnerabilities Because children are closer to the ground than adults, they are at increased risk for severe airway injury from inhaling chemical agents that are heavier than air, such as chlorine and ammonia. A child's rapid respiratory rate and small body surface area increase the intake of agents that act on. the respiratory system and the metabolic effect of those agents. Inhalational agents that cause ‘mucosal irritation and airway edema may have more impact on children than on adults. Airway resistance increases proportionately to the fourth power of the airway’s radius, so a small amount of edema or mucus can obstruct a child's airway and lead to severe respiratory compromise and death (Chapter 2). 12-3Hil Pediatric Fundamental Critical Care Support In addition, children’s short stature may make them more vulnerable to drowning during flooding, Over 90% of pediatric deaths during the Tohoku earthquake and tsunami were attributed to drowning. Aspiration of water contaminated with bacteria, soil, and chemicals seen in victims of near drowning episodes will most likely predispose them to develop pneumonia and pneumonitis. This is referred to as tsunami lung and is well described in both the 2004 tsunami in Southeast Asia and the 2011 earthquake in Japan. ‘The compliant chest wall and relatively underdeveloped intercostal muscles found in infants and young children require the diaphragm to play a greater role in ventilation than it does in adults. The work of breathing may thus consume a large portion of a child's available energy and predispose them to respiratory distress and failure. A child's oxygen demand per kilogram of body weight is twice that of an adult (6-8 mL/kg as opposed to 4 mL/kg), so hypoxemia will occur more rapidly with inadequate alveolar ventilation. Compared with adults, a child’s tongue is larger in proportion to the oropharynx and may obstruct the airway in response to a minimal amount of lethargy. The trachea is flexible and narrow, which permits the airway to kink with flexion (as in inappropriate resuscitation techniques). Anatomic differences in a child’s airway result in a narrow range of open airway positions, and airway occlusion with secretions or edema is common. B. Circulatory Vulnerabilities child's circulating blood volume is a larger percentage of total body weight than it is in adults (70 to 80 mL/kg versus 65 mL/kg). Due to a child’s relatively small total blood volume, what may be seen as minor bleeding for an adult can be substantial blood loss in a child. Relative to body surface area, a child has a smaller fluid reserve and immature kidneys, which combine to leave the child mote prone to hypovolemia and hypovolemic shock. From a global perspective, diarrhea leading to hypovolemia and shock is responsible for 17% of all deaths of children younger than 5 years. In the aftermath of a disaster, contaminated food and water supplies may contribute to severe gastrointestinal illness, causing significant morbidity and mortality in exposed children. Children have a significant ability to compensate for volume loss by increasing heart rate. They also have a strong vascular motor response, which preserves preload. Tachycardia and vasoconstriction can mask the recognized signs of shock, like hypotension, until a child is nearly moribund. Uncompensated shock progresses more rapidly to death in children than in adults. C. Neurologic Vulnerabilities — Children suffer a different constellation of injuries due to trauma. A child's head is larger than an adult's, and the cranial bones and blood vessels are thinner relative to body size. This coupled with poor muscle strength in the neck predisposes children to head and neck trauma, Fractures of the Cl and C2 vertebrae account for 70% of neck fractures in the pediatric population and only 15% in the adult population. During a disaster with severe shock forces or a high-velocity explosion, children may be prone to severe, debilitating injuries that would result in their being placed ina Jow-priority category during triage. 12-4Pediatric Emergency Preparedness Myelinization is incomplete in smaller children, which makes assessment of neurological injury and recovery potentially more difficult. Immaturity of esterase enzymes, including acetyicholinesterase, may make small children more vulnerable to pesticides and nerve agents. Children are also more prone to seizures than adults, so smaller doses of toxic agents are likely to have far greater negative consequences in terms of both morbidity and resource utilization. D. Musculoskeletal Vulnerabilities ‘Achild’s liver and spleen are relatively large and not as well contained within the rib cage as in adults, which causes these organs to be more vulnerable to blunt trauma, Because a child's ribs are flexible, they rarely break, and the force ofan impact is transmitted to the underlying and unprotected vascular organs, which increases the risk of internal injury with hemodynamically significant hemorrhage. A child's body surface area is largely in relation to weight, and the layers of skin are thinner than in adults. Both factors place children at increased risk for significant chemical and thermal burns and for hypothermia in response to environmental exposure. They also have consequences for treatment: large-volume, unheated adult decontamination showers will likely result in significant hypothermia in a small child. E. Developmental and Psychological Vulnerabilities Children are more vulnerable during a disaster simply because they are often unable to recognize or escape _‘Figure 12-1. Rescuer in Protective Clothing danger. They may even be drawn toward dangerous situations because they are interesting. Paradoxically, they may flee rescuers due to the often frightening appearance of people in protective clothing (Figure 12-1). Small children are often unable to verbalize what they have experienced, which may confuse or mislead responders and result in inappropriate care. It may be more difficult to decontaminate and evacuate children because they cannot be expected to follow group directives and require continuous psychological support. Children may have adverse reactions to caregivers, sometimes owing to fear of strangers or pain. Certain procedures, such as open wound management, will be more time-consuming in frightened children. With their larger body surface areas, children will also lose heat more rapidly than adults, which may lead to hypothermia, Members of the care team with experience in calming and reassuring children should be placed in charge of such situations, Because they are unable to care for themselves, large numbers of children who are not injured may wander around and require shelter. 12-5[ii rediatric Fundamental Critical Care Support III. TREATING CHILDREN’S DISASTER-RELATED INJURIES AND ILLNESSES Despite their greater vulnerabilities, children with acute injuries or illnesses are more likely than adults to respond to rapid and efficient medical care and so will significantly benefit from appropriate preparation. In a disaster, most care will be supportive. Simple interventions such as supplemental oxygen and appropriately delivered intravenous fluids will save many injured children. We will address children’s specific needs in a variety of disaster situations. A. Exposure to Chemical Agents Children are vulnerable to injury from chemical agents in gaseous form due to their rapid respiratory rates. Gases that are heavier than air, like chlorine and ammonia, may accumulate in the small child's breathing space more rapidly than in an adult's. Nerve agent intoxication may manifest differently in children than in adults. During acetylcholine overload caused by nerve agents, children may be more prone to dehydration and shock from fluid loss due to gastrointestinal secretions, Children are also more likely than adults to have seizures during cholinergic crisis. Antidotes to nerve agents and pesticides are often available in auto-injectors, but both the dose and the needle length may be inappropriate for children. Neither pralidoxime nor atropine has been extensively tested in children, and newer antidotes have not been tested in children at all. In cases of severe exposure, if adult-size Mark 1 auto-injectors are the only source of antidote, they should be used in even the smallest children. Dosing recommendations for atropine and pralidoxime in children are given in Table 12- With their thin skin, children may be more vulnerable to the effects of vesicants, which place them at increased risk for systemic absorption. Given their higher ratio of body surface area to weight, children may lose a larger percentage of their skin than adults when exposed to the same volume of chemical agent. Children with large chemical burns are thus at higher risk for dehydration, hypovolemic shock, and hypothermia They may inhale vesicants, such as mustard agents, that are delivered in explosive blasts; these agents may more readily cause occlusion of children's small airways. Decontamination may be more difficult because children cannot follow directions and may need to be held throughout the procedure. High-pressure washing may injure small children, and cold-water washing may cause hypothermia and shock. Children are best decontaminated by attendants using warm water, but such a labor-intensive approach may not be practical during a disaster without meticulous advance planning and dedicated teams of responders at the scene. 12-6Pediatric Emergency Preparedness BPD Antidote Dosing for Anticholinesterase Exposure in Children : act Auto-Inector | Dosing for Severe Symptoms | Tyeers—Bt4years.—>tdyears | Agent Daseand Management oriBkg org or aSOkg | vox O05ma/aV 0: M formaderately severe symptoms, 1 nestor injectors Sinjoctors upto 01 mg/kg Wor Min lar caine esis delvers deliver diver fcy2.5 min asreeded formarked sectors, OOBOT3mgkg — OOBOTI gy <1 ma/ky broncospasns, hipxi resistor compromise i | Praldoxime 20-50 mg/kg IV or IM to @ maximum 1g o2 gM {injector injectors injectors | | chloride "may opeat every 30-0 min for wecknessohigh dalvers dave deliver : | apne eiramntup to 200 mg/h redsimgkg 448 mag «BB Diazepam 005-03 ma/kg WV Loraropam 0.1 mag IV or MM Midgzalam —01-0:2 mg/kg WV or M IV, intravenous; IM, intramuscular; N/A, not available Classified using data from America’s Children in Brief: Key national indicators of well-being, Federal Interagency Forum on Child and Family Statistics; 2012. http:/ /www.childstats.gov/americaschildren/demo.asp. Accessed November 14, 2012. Rotenberg JS, Newmark J. Nerve agent attacks on children: diagnosis and management. Pediatrics, 2003;112:648-658. 8. Aadiation Exposure The same factors that increase a child’s risk of inhaling chemical agents also increase the risk of inhaling radioactive gases, Radiation-induced cancers occur more often in children than in adults exposed to the same dose. In utero exposure to radiation can cause intellectual disability and other congenital anomalies. Human breast milk is quickly contaminated with radiation, so infants of exposed mothers may not be able to breastfeed. Treatment with potassium iodide is recommended for children younger than 17 years and for pregnant and lactating women at lower exposure levels than those for other adults. To protect the thyroid from radioactive iodine, treatment with potassium iodide is indicated if the exposure projected by government sources is >0.05 Gy (25 rad). Neonates treated with potassium iodide should have their thyroid function checked between 2 and 4 weeks after a single dose. C. Exposure to Biological Agents The signs and symptoms of exposure to biological agents in children will be similar to those seen in adults. Fluoroquinolones and tetracycline (both used for anthrax and plague exposure) are contraindicated in growing children. See Table 12-2 for acceptable alternative treatments. 12-7Bi Pediatric Fundamental Critical Care Support Infectious Agent Pediatric Prophylaxis Pediatric Therapy Notes Inhalational antvax Gprooxacin 10-15 mg/kg PO evry 12h Cipraforacn 10-15 mg WV every 12h Patents who aecincaly | (maximum 500 ma/dose) fr 60 cays © (maximum 400 ma/dose) or stable con be switched to or doryysine 2.2 mg/kg PO avery 12h danyyelne 22 mgkg WV every 12h single oral agent (maximum 100 may) or 80 days (maximum 100 mg/day and (Cpofixacn or clindamycin 10-15 mg/kg Vevey 8h doxyayene) to compete an penclinG 250-500 U/kg/6ay 60-day course of therapy Givided every 4h cutanaous anthrax Pericilin 25-50 ma/k/day PO due a teroism Givded every Gh or amoxcin 0-80 mg/kg/day PO tivided ever B hor ‘prftaxacin 10-15 mg/kg PO limaximum 7 g/day) every 12 ot i Aoxvoyeine 2:2 mg/kg PO every 12 h : [maximum 100 mgday Gastinestinl Same as inhalational antrax | enthex P Plague Gentamicin 2.5 mg/kg IV every 8h Gentamicin 2.8 mg/g NV every Bh Chloramphenicol may or onyeycine 22 mg/kg V orsteptanyen 1Smg/gIM every 12h be peferble in plaque {axa 200 3) ar ciprofloxacin 15 mgkgV every 12h meningitis use in oreiroinzcin 1 mqkg Imari 400 g/d or Young ciren ny be daxyeyelina 22 mg/g Vevey 12h assonated with serious maximum 200 mia or sie effens chlraphoriol 25 mg/kg ovary h iaximum 4 fay E Tularemia Same as for plague © Bots Supportive cae anton om COC | Buelsis TMP/SWX30 mag FO evry 12 for 6 week course and rifampin 15 mg/kg every 24h or gentamicin 7.5 mg/kg IM every day for 5 days JN, intravenous; PO, by mouth; IM, intramuscular; CDC, Centers for Disease Control and Prevention; TMP/SMX, teimethoprim and sulfamethoxazole Classified using data from America’s Children in Brief Key national indicators of well-being. Federal interagency Forum on Child and Family Statistics; 2012. htp://www.childstats.gov/americaschildren/demo.asp. Accessed November 14, 2012. Children may be at increased risk for infection with smallpox because they have no immunity to the virus, whereas adults who were vaccinated as children may be protected. Children are efficient vectors for infectious agents spread by droplets and may be affected in numbers out of proportion to the global population. Due to their increased susceptibility to respiratory failure, in an epidemic of respiratory illness, children may have an increased need for mechanical ventilation and be at increased risk for fatal outcomes. Oseltamivir phosphate, which may be effective against influenza when used within the first 48 hours of symptom onset, is not approved for use in children younger than 2 weeks of age. Moreover, there is very little research to support the use of oseltamivir before, during, or after a pandemic. Zanamivir, another neuraminidase inhibitor approved for pediatric use in those as young as 7 years, has a more promising profile than oseltamivir for seasonal as well as pandemic flu. Those strains have not shown any resistance to zanamivir. 12-8Pediatric Emergency Preparedness O. Triage During a disaster when resources are limited, hospitals must have rapid and reliable triage systems to prioritize the care of patients by severity and resource availability. Without an effective triage system, any emergency room can be quickly overwhelmed during a mass casualty incident. Here, we discuss a few popular triage systems that may be applied during a disaster when the main goal becomes allocating limited resources quickly to salvageable patients. Figure 12-2, JumpSTART Pediatric Mass Casualty Triage ‘The Simple Triage and Rapid Transport (START) triage algorithm, developed os “tuteteons fin in 1983, has an inherent Meee SESE advantage during atime of ma resource scarcity because it is quick and requires only Goo no. [Fay] BREATHING vital signs and observational + upper aay | data. Later, Romig lem developed JumpSTART, a | + modified version of START | [Patpabte putse?| “| for pediatric patients | = cae infancy and young | sueone adulthood (early puberty) ves| sce ju (Figure 12-2). Differences fe gine between STA ana | ~ JumpSTART algorithms { reflect physiological tL differences between adults and children. For example, achild with apnea is more likely to have a primary respiratory problem than an adult with apnea. Nevertheless, a child is more likely to be salvageable with Tus restoration of ventilation and oxygenation. Itis “P Gnaporopiate) “posuiinco oI important to remember that no prehospital mass- casualty incident triage Ro nee roprate) system has been validated ouromigno, 2002 for use for patients of any age during a disaster. AVPU, alert, verbal, painful (stimuli), unresponsive ‘Reproduced with permission from Lou E. Romig, MD, FAAR FACEP and ‘Team Life Support, Inc. The JumpSTART Pediatric MCI Triage Tool Web site. http:/ /www:jumpstarttriage.com/JumpSTART_and_MCI_Triage php. ‘Updated May 29, 2012. Accessed November 20, 2012. 12-9[i Pediatric Fundamental Critical Care Support While START and JumpSTART are examples of primary triage systems, the purpose of tertiary triage is to determine where the patients will be ultimately placed in the hospital (Le., emergency room, inpatient ward, operating room, or critical care unit) or to determine if the patient must be stabilized and transferred to another facility with greater capacity or capabilities. Thus, tertiary triage helps to utilize limited resources in the most effective way during a disaster. The Sequential Organ Failure Assessment (SOFA) score is a relatively new organ failure score system developed to measure outcomes of intensive care unit patients. The mean and highest SOFA scores during an intensive care unit stay have been uo shown to be particularly reliable predictors of mortality, whereas an initial SOFA score higher than 11 can predict a mortality rate >90% (lable 12-3). A SOFA score and keen clinical judgment may help intensivists to determine which patients will most likely survive and which will not. The original SOFA score has not been validated in pediatric population. No such score exists for children, and the difficult issue of predicting mortality in this population is made more difficult due to both this and to the special emotional bonds adults share with children. Both under- and over-triage, however, will cause | ee ga significant additional mortality and morbidity during a disaster, Sequential Organ Failure Assessment Score Simple interventions, such as supplemental ‘oxygen and appropriately delivered intravenous ‘fluids, will save many injured children. : Score i System 0 1 2 3 4 | Respiratory: Pat/Fo, 3400 400 300 200 100 Renal: creatinine mol/L} 110 110-170 171-299 300-440, 440; rine wine ouput ‘output 500 mi/lay <0 mL/day Hepatic ilubin (mol) a 0.32 33101 102204 204 i | Caniovascuar: hypotension No Map Dopamine <6, Dopamine>§ Dopamine >15* : hypotension <0 mm Hg dobutamine" or pinephrine or epinephrine i (any dose) sD1or 20 oF orepinephrine norepinephrine at > | Hematologic: platelet count >180, 150 100 0 20 | Neurologic: Glasgow Coma 5 13.14 1042 69 3 Seale score "Adrenergic agents administered for at least 1 hour (doses given are in yg/kg/min). MAP mean arterial pressure Reproduced under the terms and conditions of the Creative Commons Attribution License. Zygun D, Berthiaume 1, Laupland K, et al. SOFA is superior to MOD score for the determination of non-neurologic organ dysfunction in patients with severe traumatic brain injury: A cohort study. Cri Care, 2006;10:R115, 12-10Pediatric Emergency Preparedness RED IV, PRESERVING THE FAMILY UNIT Children are not self-sufficient and depend on family and caregivers. Adult patients will often place the needs of children above their own, and it may be difficult or inadvisable to separate children from adults in a disaster situation. If children must be separated from parents and families, specific ‘measures must be taken to reunite them, particularly ifthe children are young and preverbal. It may be more efficient to leave family units together so that even injured adults can participate in the care of small children. When family members are separated, children are at greater risk for intentional injury, exposure, and accidents in the post-disaster period. If family members must be separated, emergency workers must get complete identification, and personnel must be assigned to the task of caring for the child until the family can be reunited. Attention must be given to caring for the entire family unit. After Hurricane Katrina, children ‘who were separated from their parents during the evacuation remained separated afterward and suffered psychological trauma. When children are evacuated with adults, the relationship between the children and their adult caregivers must be identified, and guardianship status Ina disaster that occurs without warning, must be determined. children may be at school or day care. Disaster a ve ve plans should not assume that children will | Ifchildren must be separated from parents and be in the custody of their parents when E families, specific measures must be taken to reunite disaster strikes. Planning must take into them, particularly ifthe children areyoungand account children who are not injured but : di 4 preverbal. It be more efficient to leave famil need sheltering and evacuation. Although iP bed cf Family that may not be the job of hospital-based | _uits together so that even injured adults disaster healtheare providers, pediatricians an sil participate inthe care of small children. need to ensure that local and regional planning, -n-0=--ww aes accounts for the requirements of those WhO AEE uo not injured but cannot take care of themselves, V. ADAPTING DISASTER PLANS TO ADDRESS THE NEEDS OF CHILDREN The needs of children are consistently overlooked in planning for disaster in part because there are already so many other shortcomings in the planning process. Many preparations made for adults ‘may apply to children when disaster plans are tailored to include the pediatric population. A. Emergency and Prehospital Planning for Children : Pediatric-specific triage protocols should be taught to and practiced by first responders at the local, state, and national levels, and support for their development must come from the federal level. The specific educational needs of physicians, nurses, and respiratory care providers who will likely care 12-11Wi Pediatric Fundamental Critical Care Support for children in a disaster should be assessed. Emergency medical services personnel and response vehicles should be furnished with pediatric-specific equipment and medications. Pathways for communication, referral, and transport should be assessed and bolstered as necessary. B. Hospital Planning for Children Disaster planning that considers the needs of children must prepare for situations in which the number of children who require medical care is out of proportion to normal numbers. When children are affected in proportion to their share of the total population, the hospital census will show a higher than normal percentage of pediatric patients. Ifa disaster occurs at a school, at a day care center, or on a school bus, the number affected could be even greater. In many cases, children may need to be cared for in nonpediatric units. In general, hospitals that do not routinely care for large numbers of children need to include pediatricians on their disaster management planning teams. If pediatricians lack specific training in disaster management, appropriate education should be provided. The pediatricians, in turn, can identify and enhance areas of planning where the needs of children differ from those of adults. Plans to manage the surge of pediatric patients during a disaster may include organizing i care providers with pediatric-specific skills supervise those without such skills. Communication and modes of transport between community hospitals and children’s hospitals should be detailed, including written transfer agreements that specify triage criteria. Equipment Disaster planning that includes the needs of and pharmaceutical supplies should be evaluated children must prepare for situations in which for appropriateness for children, In institutions the number of children who require medical that do not regulary care for children, supplies ares out of proportion to usual numbers. may need to be augmented with pediatric-specific equipment, pharmaceuticals, and supplies (e.g., decontamination units and Mark 1 kits). Drills that include pediatric patients should be conducted. Ghildren’s hospitals must serve as referral centers that take the majority of pediatric | casualties when feasible and set the standard In some cases, when large numbers of families are fey pediatric disaster management. affected, units that normally do not care for entire families may need to be adapted. Such changes need to be planned and drilled in advance. i eae 12-12Pediatric Emergency Preparedness Key Points acedness EEA Pediatric Emergency Pr 1 The unique physiology of the developing child requires that disaster responders be familiar with the differences between children and adults with respect to disaster planning and response. A child’s position within a family unit requires disaster planners and responders to plan for caregiving and family reunification, 1 tis incumbent on caregivers and medical professionals to help families develop plans for disaster response well in advance of any incident. 1 Disaster drills must be conducted with the child's unique physiology and position within the family unit in mind, 1 The child’s need may disrupt other elements of a disaster plan, as key personnel may not be available because they are taking care of their own children. Mechanisms to care for children of key personnel should be considered when developing site-specific disaster plans. BM sugested feadings 1. American Academy of Pediatrics Committee on Environmental Health. Radiation disasters and children. Pediatrics. 2003;111:1455-1466. 2. Black RE, Mortis SS, Bryce J. Where and why are 10 million children dying every year? Lancet. 2003;361:2226-2234, 3, Dolan MA, Krug SE. Pediatric disaster preparedness in the wake of Katrina: lessons to be learned. lin Pediatr Emerg Med, 2006;7:59-66. 4, Eichelberger MR. Pediatric Trauma: Prevention, Acute Care, Rehabilitation. St. Louts, MO: Mosby; 1993. 5, Ferreira FL, Bota DB Bross A, Melot C, Vincent JL. Serial evaluation of the SOFA score to predict outcome in critically il patients JAMA, 2001;286:1754-1758. 6. Furhman B, Zimmerman J, eds. Pediatric Critical Care. 3rd ed. St. Louis, MO: Mosby; 2005. 7. Hagan JF; American Academy of Pediatrics Committee on Psychosocial Aspects of Child and Family Health; Task Force on Terrorism. Psychosocial implications of disaster or terrorism on children: a guide for the pediatrician. Pediatrics, 2005:116;787-795. 8. Jenkins JL, McCarthy ML, Sauer LM, et al. Mass-casualty triage: time for an evidence based approach. Prehosp Disaster Med, 2008;23:3-8. 9. Kanter RK. Strategies to improve pediatric disaster surge response: potential mortality reduction and tradeolls. Crit Care Med, 2007;35:2837-2842, 10, Kanter RK, Moran JR. Pediatric hospital and intensive care unit capacity in regional disasters: expanding capacity by altering standards of care. Pediatrics, 2007:119;94-100, 11. lynch EL, Thomas TL. Pediatric considerations in chemical exposures: are we prepared? Pediatr Emerg Care. 2004;20:198-208, 12-13Wi Pediatric Fundamental Critical Care Support 12-14 12, Mace SE, Bern AI. Needs assessment: are disaster medical assistance teams up for the challenge of a pediatric disaster? Am J Emerg Med. 2007;25:762-769. 13. Middleton KR, Burt CW, Availability of pediatric services and equipment in emergency departments: United States, 2002-2003. Adv Data, 2006;367:1-16. 14, National Commission on Children and Disasters. 2010 Report to the President and Congress. AHRQ Publication No. 10-M037, October 2010. Rockville, MD: Agency for Healthcare Research and Quality; 2010. http:/ /archive.ahrq.gov/ prep/ncedreport. Accessed April 23, 2013. 15, Romig LE. The JumpSTART pediatric MCI triage tool and other pediatric disaster and emergency ‘medical resources. http://www.jumpstarttriage.com. Accessed April 23, 2013. 16, Rotenberg JS, Newmark J. Nerve agent attacks on children: diagnosis and management. Pediatrics. 2003;112:648-658. 17, Waisman Y, Amir L, MorM, et al. Prehospital response and field triage in pediatric mass casualty incidents: the Israeli experience. Clin Pediatr Emerg Med. 2006;7:52-58. 1. Chemical Hazards Emergency Medical Management. U.S. Department of Health & Human Service. http://chemm.nim.nih.gov/ 2. Chemical Terrorism. New York State Department of Health. http://www.health.ny.gov/ environmental/emergency/ chemical_terrorism/posterhtm. 3. Children and Disasters. American Academy of Pediatrics. http://www2.aap.org/disasters/. 4, FEMA for Kids, US Department of Homeland Security Federal Emergency Management Agency. http:// www.fema.gov/kids/. 5, Helping Kids Cope with Disaster. US Department of Homeland Security Federal Emergency Management Agency. http://www.fema.gov/ coping-disaster#4,