PAEDIATRIC

CONISERATIONS IN
MASS CASUALTY
INCIDENTS
GENE ONG
CHILDREN’S EMERGENCY
KK WOMEN’S AND CHILDREN’S HOSPITAL
 Objectives
 Paediatric considerations in both conventional and HazMat mass
casualty incidents

 To understand principles behind paediatric disaster triage systems

 Approach, triage and management of paediatric casualties in both

conventional and HazMat mass casualty incidents.
 Boston Marathon 2013
• As they as they waited for their father to finish the race, an 8-year-old was found dead; his
sister had lost her leg…….
• Children among the injured ….. One was a 2-year-old boy with a bleeding head injury,
who was admitted to the surgical intensive care unit. Another was a 9-year-old girl with a
leg trauma so severe that she spent hours in the operating room…..
Potential Paediatric Mass Casualty Sites
 Schools
 Mosques/Places of Worship
 Shopping Malls/Districts
 Transportation incidents
 Community events/places
 Sporting Events
How are children exposed to Chemical, Biological
Radiological, Nuclear and Explosive (CBRNE)
weapons/agents

 Inadvertently (Classic Thinking)

Secondary victims in terrorist attack
Catastrophic event at chemical/
nuclear plant

 Intentionally targeted (New Thinking)

Is there evidence of intention to
target children?
 “We have not reached parity with [the Americans].
We have the right to kill 4 million Americans – 2
million of them children…” Suleiman Abu Gheith
(2002)

 Russia: terrorists attack a school and take hostages

Importance of Paediatric
Considerations

Ignoring children may compromise

entire preparedness plan
Scenario
 A group of 30 school children were en route with
their teachers via a charted bus for a field trip.

 A speeding cement truck behind the bus crashed

into it when the bus was turning.

 The bus was overturned.

Victim RR Perfusion Mental Status Others
7 year old, 10/min Distal pulse present Groans in response to Lying in wrecked bus
Female pain
40 year 20/min CRT <2s Obeys commands Sitting on the road side,
old, HR 80/min complains of giddiness
Female
7 year old, Talking Distal pulse present Asking for help Walking, clothing torn, no
Male HR 98/min bleeding evident
7 year old, - No pulse Unresponsive Lying in grass 5 m away
Female
7 year old, - CRT >4s Unresponsive Legs trapped under seat in
Male HR 160/min bus
25 year 12/min CRT >4s Eye movement in Appears 6 months pregnant
old, HR 120/min response to stimuli.
Female Not speaking
7 year old, 8/min Distal pulse present Unresponsive Lying near bus
Female HR 60/min
 Half an hour ago, there is a report of a small
explosion followed by some people becoming
rapidly unconscious in a shopping mall.

Victim Respiratory Perfusion Mental Status

Infant Crying, HR 140/min Inconsolable crying
SpO2 100%
Toddler (Pre-schooler), Crying louding HR 100/min Walking around asking for
Female her mother
Toddler (Pre-schooler), RR - CRT 6s Unresponsive
Female SpO2 unrecordable SpO2 unrecordable
In Primary school uniform, RR – CRT absent Unresponsive
Male SpO2 unrecordable SpO2 unrecordable
In Primary school uniform, Weak cry CRT <2s Lethargic, responsive to
Male RR 50/min pain
SpO2 92%
Topics
Triage
What is Triage? Categories

Triage Tools
What is Triage?
 “Triage” means “to sort”
 Looks at medical needs and urgency of each
individual patient
 Sorting based on limited data acquisition
 Also must consider resource availability
Ethical Justification
This is one of the few places where a
"utilitarian rule" governs medicine: the
greater good of the greater number rather
than the particular good of the patient at
hand. This rule is justified only because of
the clear necessity of general public
welfare in a crisis.
A. Jonsen and K. Edwards, “Resource Allocation” in Ethics in Medicine,
Univ. of Washington School of Medicine,
http://eduserv.hscer.washington.edu/bioethics/topics/resall.html
 Why are Resources
Important in Triage?

Disasteris commonly defined as an

incident in which patient care
needs overwhelm local response
resources.
Daily emergency care is not usually
constrained by resource
availability.
 Daily Emergencies
Do the best for each individual.

Disaster Settings
Do the greatest good for
the greatest number.
Maximise survival.
Triage is a dynamic process and
is usually done more than once.
Disaster incidents and patient
surges involving children
 There should be a system of pre-hospital rapid triage for
children as well as adults in a disaster

 All pre-hospital responders who might attend a disaster

scene must be trained to effectively triage and manage
children as well as adults

 Disaster planning must consider children when making

hazard vulnerability assessments and case scenarios
Disaster incidents and patient
surges involving children
 There should be designated sites within the hospital for
decontamination and management of patients in disasters
and this must consider child casualties

 There must be pre-planned process to identify and treat

unaccompanied children

 Equipment for disaster victims must include appropriate

types and size ranges and quantities for children
Disaster incidents and patient
surges involving children
 Emergency medications for disaster victims must include
appropriate formulations, administration devices and
dosing calculation aids for children, including antidotes
and vaccines

 Staff training programs for pre-hospital and hospital

personnel should include coping with surges in pediatric
patients
 Issues in Paediatric Triage

 Unique anatomical/physiologic features

 Differences in vital signs norms in kids versus adults
 Differences in types of injuries sustained in kids
 Airway/breathing very important to establish and stabilise in
children
 First sign of haemodynamic instability is tachycardia instead of
overt hypotension
Practical Differences In the Management of the
Paediatric Airway:

2004
17 Nov
The relatively large head/occiput flexes the neck and results in
airway obstruction in the unconscious child.
Lower Airways more readily obstructed by
oedema, blood, secretions, bronchoconstriction
 Special Considerations In Children
 Disability
 Less mature blood brain barrier
 Immature CNS
 Less classical signs of toxidromes – eg organophosphate poisoning:
nicotinic effects >> muscarinic effects
 Morbidity consequent to a bio-chemical exposure might subsequently
have permanently functional impact

 Physical injuries
 Larger head to body ratio
 Head injuries account for 60% of all mass casualty events & disasters in children
 More pliant and flexible bones
 less bony fractures but higher risk of injury organ injury without fractures
Special Considerations In Children

 Thermoregulation
 larger surface area to body ratio
 Hypothermia is a potentially significant morbidity in the young
 During decontamination (exposure, shower)

 Less glycogen reserves

 More prone to hypoglycaemia
 May be secondary
 Considered as a 5th vital sign
Special Considerations In Children
 Higher Body Surface Area and less keratinised skin
 Potential for increased dermal absorption

 Smaller stature (closer to the ground)

 Potential for greater exposure to settling toxic fumes in the lower
breathing zone

 Emotional trauma
 Fear
 Separation from loved ones
 Risk of post-traumatic stress disorder
Recognition of an
injured or sick child in a
mass casualty situation
Additional Issues In Mass Casualty in
Children
 Thermoregulation(including preventing and being
mindful of hypothermia especially during
decontamination process)

 Importanceof emotional support (specialised

CARE) to the injured child in the field??
JumpSTART Paediatric MCI Triage Tool

Developed by Lou Romig MD, FAAP,

FACEP
Now in widespread use throughout the
US and Canada
Being taught in Japan, Germany,
Switzerland, the Dominican Republic,
Africa, Polynesia
The Smart Triage Tape ®

 Developed in Great Britain

 Proprietary, TSG Associates
 Length-based paediatric MCI triage tape
 Age-adjusted physiologic parameters
 In use in Europe, Africa and some states in the US

www.tsgassociates.co.uk/English/Civilian/products/smart_tape.htm
 Survival Outcomes
 12 = 98%, 11=97%,
 10 = 92%, 9=85%
 8=78%, 7=76%, 6=67%, 5=54%, 4= 30%
 3= 27%, 2=17%, 1=11%, 0=5%

 Validated in 2 papers for paediatrics

 Cross KP, Cicero MX. Head-to-Head
Comparison of Disaster Triage Methods
in Pediatric, Adult, and Geriatric
Patients. Ann Emerg Med 2013 Feb 25.
pii: S0196-0644(12)01912-9
 Cross KP, Cicero MX. Independent
application of the Sacco Disaster
Triage Method to pediatric trauma
patients. Prehosp Disaster Med. 2012
Aug;27(4):306-112012 Aug;27(4):306-11
The Best Tool?

No MCI primary
triage tool has
been validated by
outcome data
from MCIs.
Mass-casualty triage: Time for an evidence-based approach.
Jenkins JL, McCarthy ML, Sauer LM, Green GB, Stuart S, Thomas TL, Hsu EB.
Prehospital Disast Med 2008;23(1):3–8.
Using Paediatric
Assessment Triangle
for Field Triage for
children in an MCI?
Paediatric Assessment Triangle
Paediatric Assessments
Using PAT for Field
Triage for children in
an MCI?
 Recognition -
Importance of quick initial triage
Appearance (TICLS)
• Tone, Interactability, Consolabilty,
Look/Gaze, and Speech/Cry.

Work of breathing
• Colour, Respiratory rates, Pulse oximetry

Circulation
• Colour, Heart rate, Capillary Refill time,
Blood Pressure
Appearance
Work of Breathing
Circulation
Scenario
 A group of 30 school kids were en route with their teachers
via a charted bus for a field trip.

 A speeding cement truck behind the bus crashed into it

when the bus was turning.

 The bus was overturned.

 The nearest hospital is yours.

Victim RR Perfusion Mental Status Others
7 year old, 10/min Distal pulse Groans in response to Lying in wrecked bus
Female present pain
40 year 20/min CRT <2s Obeys commands Sitting on the road side,
old, complains of giddiness
Female
7 year old, Crying, Distal pulse Asking for help Walking, clothing torn, no
Male talking present bleeding evident
7 year old, - No pulse Unresponsive Lying in grass 5 m away
Female
7 year old, - CRT >4s Unresponsive Body trapped under seat in
Male bus
25 year 12/min CRT >4s Eye movement in Appears 6 months pregnant
old, response to stimuli. Not
Female speaking
7 year old, 8/min Distal pulse Unresponsive Lying near bus
Female present
HAZMAT AND THE
PAEDIATRIC
PATIENT
Do we really need to worry about mass
exposure of children to Chemical,
Biological Radiological, Nuclear and
Explosive (CBRNE) weapons / agents?

In a deliberate chemical agent attack eg in the

Tokyo Sarin incident; how many of the affected
would be in the paediatric age group if it occurred in
in a bus / train?
Bhopal - The world's worst
industrial disaster
 Chemical Warfare
– A thing of the Past?
Think again……
What is the major
difference between
conventional vs
HazMat MCIs?
What is the major difference between
conventional vs HazMat MCIs?
 Conventional MCIs
 Explosion
 Trauma - Blast injury, burns, physical objects (falling/penetrating)
 Maximal injuries at the onset
 Importance of rapid stabilisation

 HazMat MCIs
 Ongoing injury
 Cumulative dose
 Importance of rapid evacuation and decontamination
17 Nov
2004
 Gloves – Check pulse?
REALITY CHECK Writing triage cards

Concept of field assessment in HazMat

MCIs

- LOOK – YES

- LISTEN – ASCULTATION NO

- FEEL – PULSE CHECK NO, CRT YES

Suggestion – portable pulse oximetry

(pulse rate, SpO2)
 Children who are able to walk
are assumed to have stable,
well-compensated physiology,
regardless of the nature of their
injuries or illness.
To exclude the paediatric P0
casualties
 Assess for airway and breathing
 No breathing, open airway
 Ifbreathing present only after opening airway or abnormal breathing
(bradypnoea or tachypnoea) : tagged red (P1)
 If no breathing, check circulation
 No signs of circulation : Po (tagged black)
 Circulation present: give 5 rescue breaths
 Breathing present after 5 rescue breaths, tagged red (P1)
 Still no breathing after 5 rescue breaths, tagged black (P0)
Non-Walking Infants and
Special Needs Children
•All developmentally non fully ambulant young infants and
non-ambulant with special needs (even if asymptomatic)
will be automatically be assigned to assess ABCDs
• Usually pre- or non verbal
• Increased vulnerability to significant exposure
• Unable to move away from harm
• Minimally P2
 Basis of Paediatric Triage in a
HazMat situation
 Ifwalking : Tagged green (P3)
 Non-walkers: minimal P2
 Any Airway / Breathing / Circulation /
Disability significantly abnormal, tag P1
 Exclude deceased paediatric casualties(P0)
Approach to a Paediatric HazMat Casualty by the Basic Provider
CBRN?
Sixth senses, chem detection,
Yes On-scene info No

H.I.A. Injury?

Yes No
Paediaric HazMat casualties

Uninjured holding
Paediatric Mass
Walker Non-Walker area
Casualty Triage
*Exclude P 0

1 survey

Decon

Paediatric Mass Casualty

Triage

2 survey(± N.A. antidotes)

Evacuate Evacuate
 No spontaneous breathing * To exclude a
Airway adjunct / manoeuvre
paediatric P 0 casualty

Reassess breathing
NOT breathing Signs of circulation Present
Bag-Valve-Mask X 5 for 15s
Assess circulation
(1 in 3s)
NO signs of
circulation
P 0 Reassess breathing
NOT breathing
Breathing Present
Airway adjunct /
manoeuvre

P 1
Differences in Paeds and Adult
 Half an hour ago, there is a report of a small
explosion followed by some people becoming
rapidly unconscious in a shopping mall.

Victim Respiratory Perfusion Mental Status

Infant Crying, HR 140/min Inconsolable crying
SpO2 100%
Toddler (Pre-schooler), Crying louding HR 100/min Walking around asking for
Female her mother
Toddler (Pre-schooler), RR - CRT 6s Unresponsive
Female SpO2 unrecordable SpO2 unrecordable
In Primary school uniform, RR – CRT absent Unresponsive
Male SpO2 unrecordable SpO2 unrecordable
In Primary school uniform, Weak cry CRT <2s Lethargic, responsive to
Male RR 50/min pain
SpO2 92%
Disaster preparedness and the
need to involve children

Children don protective hats in a disaster drill in Japan

17 Nov
2004
17 Nov
2004
Applicability -
Decontamination
of a 6 month old?
Stabilisation in the pre-decontamination
setting
 Scoop and run

 If evacuation is not readily available (triage duties

completed) or resuscitation / basic management
can be considered en route during evacuation

 Stabilise ABs
BASIC APPROACH

 Categorise Patients According to Severity :

P1 / P2 / P3 / P0
 AssessIndividual Chemical Agent’s Clinical
Severity and divide into :
No Exposure / Mild Exposure / Moderate
Exposure / Severe or Life-Threatening
Exposure
General Paediatric Management
 Bronchospasm
 Nebulised Bronchodilators:
 <1 year: Salbutamol (Ventolin) 0.5ml: Ipratropium (Atrovent) 0.5ml: 2-3ml
Saline (nebulised via 8L/min)
 >1 year: Salbutamol (Ventolin) 1ml: Ipratropium (Atrovent) 1ml: 1-2ml Saline
(nebulised via 8L/min)

 Seizures
 Supplemental oxygen, positioning
 Diazepam
 Rectal (<10kg: 2.5mg; >10kg: 5mg)
ANTIDOTES

 Predecontamination setting use

limited to availablility and training
- Should not delay evacuation and
decontamination
 Focus on triage, stabilising ABCDs
Paediatric HazMat Tape
 Developed for cyanide, blistering agents
and nerve agent management
 Uses length-weight correlation for paediatric
antidote dosing
 Paediatric HazMat Considerations
 Special circumstances
 Toxidromes may not be classical in younger children
 Eg Cholinergic poisoning eg Nerve Agent
 Unlike in adults, nicotinic effects may predominate
 May not have the classical 3Ds
 Many manifest with bradycardia or tachycardia
 CNS and MSK effects may predominate
 Assume same agent affecting children if there are nearby adult
cases with Classical 3Ds
 Support ABCs, abort seizures
Autoinjectors for Nerve Agent
Poisoning
 Autoinjectors are meant for adult use

 Note that atropine doses are higher than required for conventional
resuscitation (0.05-0.1mg/kg vs 0.02mg/kg).

 Based on case reports of children 1-5 years who had unintentionally

injected themselves with adult autoinjectors and had minimal
adverse and expert consensus, it is recommended that they can be
used if the patients are significantly symptomatic.
17 Nov
2004
17 Nov
2004
Asymptomatic or Mild Nerve Agent
Poisoning
 Mild upper respiratory involvement with or
without miosis

 Reassess for progression

 Moderate Nerve Agent Poisoning
 Localised swelling, localised muscle fasciculations,
nausea and vomiting, mild weakness, mild shortness
of breath.
 Utilise auto-injectors if available.
 Use HazMat Tape if available

Estimated Age Atropine Autoinjector (if available) 2-PAM Autoinjector

IV / IO / IM Atropine : 0.05mg/kg IV / IO / IM Pralidoxime: 15-25mg/kg
Infant (<1 year) AtroPen 0.25mg Autoinjectors not recommended

Toddler (1-5 yrs) AtroPen 0.5mg Mark I kit X 1 (600mg)

Child (6-11 yrs) AtroPen 1mg

Teenagers(>12 yrs) Mark I kit or Duodote X 1 (2mg) Mark I kit or Duodote X 1 (600mg)
 Severe Nerve Agent Poisoning
 These include rapidly progressive signs or significant altered
mental status, convulsions, severe respiratory distress or
failure, generalised fasciculations and flaccid paralysis.
 Stabilise ABCDs first
 Use HazMat Tape if available

Estimated Age Atropine Autoinjector (if available) 2-PAM Autoinjector/IM

IV / IO / IM Atropine : 0.05-0.1mg/kg IV / IO / IM Pralidoxime: 25-50mg/kg
Infant (<1 year) Autoinjector (AtroPen 0.5mg) Autoinjectors not recommended

Toddler (1-5 yrs) 2 mg IM/IV or 1 Autoinjector (Mark I kit / Use 1 autoinjector (600mg)
Child (6-11 yrs) Duodote)

Teenagers (>12yrs) 4 mg IM/IV or 2 Autoinjectors (Mark I kit / Use 2 autoinjectors (1200mg)

Duodote)
 SUMMARY
 Uniquefactors in Paediatric
Trauma and HazMat
exposure
 PaediatricTriage Principles
 The ABCDs of Resus Always
Apply
 Dose-Dependent Antidotes &
Resus Measures (drugs plus
equipment