PDLSPDLS©©::General Principles of DisasterGeneral Principles of DisasterCare: Pediatric Triage Assessment, Care: Pediatric Triage Assessment, Stabilization, ResuscitationStabilization, Resuscitation

Triage Assessment, Stabilization, Triage Assessment, Stabilization, ResuscitationResuscitation Learning ObjectiveLearning Objective At the end of this lecture, the students should be At the end of this lecture, the students should be

able to:able to:- describe differences in triage decision making for children describe differences in triage decision making for children

- describe triage categoriesdescribe triage categories

- describe field triage assessmentdescribe field triage assessment

- describe principles of field triage, stabilization and describe principles of field triage, stabilization and resuscitationresuscitation

- describe initial field stabilization methods for childrendescribe initial field stabilization methods for children

- describe organization of field triage, treatment, staging, describe organization of field triage, treatment, staging, and clearing/transportation for childrenand clearing/transportation for children

Oklahoma City – YMCA Day CareOklahoma City – YMCA Day Care

The Scene:The Scene:

-Multiple injured kids - Delay in finding themMultiple injured kids - Delay in finding them

-4 Children:4 Children: 2 not breathing, unresponsive2 not breathing, unresponsive

2 sitting, crying2 sitting, crying

General Principles of Disaster CareGeneral Principles of Disaster Care

Triage AssessmentTriage Assessment

Initial StabilizationInitial Stabilization

ResuscitationResuscitation

Triage AssessmentTriage Assessment

Derived from the French “trier” meaning to sort, it Derived from the French “trier” meaning to sort, it describes a medical decision making process.describes a medical decision making process.

Appropriate performance crucial.Appropriate performance crucial.

Dynamic process, re-triage / re-evaluate at several Dynamic process, re-triage / re-evaluate at several stages.stages.

Determination of priority may effect the extent and Determination of priority may effect the extent and quality of care the patient receives.quality of care the patient receives.

Triage in disaster setting may be very difficultTriage in disaster setting may be very difficult

Pediatric population unique challengePediatric population unique challenge

TriageTriage

Problems ofProblems ofUnder / Over-TriageUnder / Over-Triage

Triage in Prehospital SettingTriage in Prehospital Setting

ICS (Incident Command System)ICS (Incident Command System)

- Medical BranchMedical Branch

Gain Control of SceneGain Control of Scene

Triage Officer: Initial Brief AssessmentTriage Officer: Initial Brief Assessment

Initial EvaluationInitial Evaluation

Ensure scene safetyEnsure scene safety

Establish that disaster existsEstablish that disaster exists

Estimate number of victims: adults/childrenEstimate number of victims: adults/children

Initial EvaluationInitial Evaluation Notification to medical control: regional Notification to medical control: regional

communications, local emergency management / communications, local emergency management / disaster authoritydisaster authority

- type of eventtype of event

- initial casualty estimateinitial casualty estimate

Make initial request for additional resourcesMake initial request for additional resources

Then Then begin triage assessment of individual patientsbegin triage assessment of individual patients

Initial Brief AssessmentInitial Brief Assessment

Open airwayOpen airway

Control major hemorrhageControl major hemorrhage

CategorizeCategorize

Triage CategoriesTriage Categories

Red / Immediate / EmergencyRed / Immediate / Emergency

Yellow / UrgentYellow / Urgent

Green / Non-Urgent / Walking WoundedGreen / Non-Urgent / Walking Wounded

Black / BlueBlack / Blue

Triage ClassificationsTriage Classifications

Simple Triage And Rapid TreatmentSimple Triage And Rapid Treatment

S.T.A.R.T.S.T.A.R.T.

JumpSTART JumpSTART

Tool for Rapid Pediatric Multicasualty Field Tool for Rapid Pediatric Multicasualty Field Triage (children from 1 - 8 years of age)Triage (children from 1 - 8 years of age)

Triage Classifications and ExamplesTriage Classifications and Examples

Red - tension pneumothorax, rib fractures, upper Red - tension pneumothorax, rib fractures, upper airway obstruction, hemorrhage, femur fracture, airway obstruction, hemorrhage, femur fracture, asthmaticasthmatic

Yellow - humerus fracture, scalp lacerations, Yellow - humerus fracture, scalp lacerations, shoulder dislocationshoulder dislocation

Green - ankle sprain, simple laceration, orphaned Green - ankle sprain, simple laceration, orphaned child, subluxed radial headchild, subluxed radial head

Black/Blue - cardiopulmonary arrest, severe open Black/Blue - cardiopulmonary arrest, severe open head injury head injury

Triage ClassificationsTriage Classifications Consider pediatric anatomy / physiology / age / Consider pediatric anatomy / physiology / age /

development when categorizing childdevelopment when categorizing child

Familiarity withFamiliarity with

- level of expertise of personnellevel of expertise of personnel

- numbers and type of transport availablenumbers and type of transport available

- equipment suppliesequipment supplies

- appropriate destination for definitive careappropriate destination for definitive care

Initial Patient AssessmentInitial Patient AssessmentPrimary Survey of ChildPrimary Survey of Child

AA irway - patencyirway - patency

BB reathing - rate, qualityreathing - rate, quality

CC irculation: Pulse check - quality, rateirculation: Pulse check - quality, rate

DD isability: Mental statusisability: Mental status

EE xposurexposure

AirwayAirway First priority even more so than in an adult. Hypoxia main First priority even more so than in an adult. Hypoxia main

factor leading to organ dysfunction, ischemia, and factor leading to organ dysfunction, ischemia, and cardiopulmonary arrest.cardiopulmonary arrest.

Consider need for endotracheal intubation in child with Consider need for endotracheal intubation in child with GCS<8, significant maxillofacial trauma, aspiration, or GCS<8, significant maxillofacial trauma, aspiration, or respiratory distress.respiratory distress.

RememberRemember -- Oropharyngeal airwayOropharyngeal airway

-- ET size/uncuffedET size/uncuffed

-- ET route for delivery of medication ET route for delivery of medication (LANE)(LANE)

BreathingBreathing

Children consume oxygen x 2 that of adultChildren consume oxygen x 2 that of adult

Assess: respiratory rate (infants 40/min, preschool Assess: respiratory rate (infants 40/min, preschool 30/min, school 20/min)30/min, school 20/min)

EffortEffort

Auscultate, percussAuscultate, percuss

Thoracic cage and rib fracturesThoracic cage and rib fractures

Tension pneumothoraxTension pneumothorax

CirculationCirculation Normal values: infant 160/min, preschool 140/min, school 120/min.Normal values: infant 160/min, preschool 140/min, school 120/min.

Systolic BP 80+ (age in years x 2)Systolic BP 80+ (age in years x 2)

Assess:Assess:

- capillary refillcapillary refill

- temperature of extremitiestemperature of extremities

- color of patientcolor of patient

Circulating blood volume: neonate 90 ml/kg, infant 80 ml/kg, older Circulating blood volume: neonate 90 ml/kg, infant 80 ml/kg, older child 70 ml/kg, adult 65-70 mg/kgchild 70 ml/kg, adult 65-70 mg/kg

Bradycardia requires immediate attention, most common cause is Bradycardia requires immediate attention, most common cause is hypoxia, but acidosis and hypovolemia are also factors.hypoxia, but acidosis and hypovolemia are also factors.

IV AccessIV Access Attempt peripheral access if unsuccessful in < 90 sec. consider Attempt peripheral access if unsuccessful in < 90 sec. consider

IO or cutdown.IO or cutdown. Estimated body weight: (age in yr.. x 2) + 10Estimated body weight: (age in yr.. x 2) + 10 Blood volume = 80 mls/kg x body weightBlood volume = 80 mls/kg x body weight Estimate blood loss: # pelvic ring = 10% total blood volume, # Estimate blood loss: # pelvic ring = 10% total blood volume, #

femur up to 20%.femur up to 20%. IO access sitesIO access sites

- distal femur distal femur - proximal tibiaproximal tibia- med/lat malleolusmed/lat malleolus- iliac crestsiliac crests

High success rate, up to 80% in less than one minuteHigh success rate, up to 80% in less than one minute

Consider IV Access in the Following:Consider IV Access in the Following:

Time to definitive care 30-60 minutesTime to definitive care 30-60 minutes

Prolonged extrication / entrapmentProlonged extrication / entrapment

Dehydration > 15%Dehydration > 15%

Multiple fracturesMultiple fractures

Scalp lacerations with significant blood lossScalp lacerations with significant blood loss

Children After BurnsChildren After Burns Airway and ventilation a priority in management. Cover burn area Airway and ventilation a priority in management. Cover burn area

in a clean sheet and wrap patient in a clean blanket.in a clean sheet and wrap patient in a clean blanket. Calculate percentage burnCalculate percentage burn Consider specialized facility for following:Consider specialized facility for following:

- 2/3 degree > 10%2/3 degree > 10%- 2/3 degree face, hands, feet, genitalia, perineum, and major 2/3 degree face, hands, feet, genitalia, perineum, and major

jointsjoints- 3 degree > 5%3 degree > 5%- electrical burnselectrical burns- inhalation injuryinhalation injury- preexisting medical problemspreexisting medical problems- associated trauma in which burn injury > riskassociated trauma in which burn injury > risk

DisabilityDisability

GCS useful in children > 1yrGCS useful in children > 1yr

ExposureExposure

Examine the entire childExamine the entire child

Hypothermia may occur secondary to exposure, Hypothermia may occur secondary to exposure, sepsis, shock, and may lead to metabolic sepsis, shock, and may lead to metabolic acidosis, decreased respiration, bradycardia and acidosis, decreased respiration, bradycardia and cardiac arrest. Newborns at high risk.cardiac arrest. Newborns at high risk.

What are your plans for newborns, infants who What are your plans for newborns, infants who have no guardians?have no guardians?

Field StabilizationField Stabilization

Airway - chin lift, jaw thrust, oro- or nasopharyngeal Airway - chin lift, jaw thrust, oro- or nasopharyngeal airwayairway

Breathing - supplemental O2 as availableBreathing - supplemental O2 as available

- limited resources for mechanical/manual ventilationlimited resources for mechanical/manual ventilation

Circulation - hemorrhage control - direct pressure, Circulation - hemorrhage control - direct pressure, dressings (rotating tourniquets)dressings (rotating tourniquets)

- limited resources for IVFlimited resources for IVF

Fracture Stabilization - using resources availableFracture Stabilization - using resources available

Field StabilizationField Stabilization

There is little role for initiation of CPR in disaster There is little role for initiation of CPR in disaster situationssituations

Consider on site organization of arriving personnel and Consider on site organization of arriving personnel and arriving resourcesarriving resources

Consider establishment of clearing/staging unti:Consider establishment of clearing/staging unti:

- triage patients for treatment on site or transport to triage patients for treatment on site or transport to hospital/health care facilityhospital/health care facility

- efficient utilization of resources, personnel, and efficient utilization of resources, personnel, and suppliessupplies

Resuscitation/StabilizationResuscitation/Stabilization Simple measures that do not require Simple measures that do not require

sophisticated equipment are most appropriate.sophisticated equipment are most appropriate.

Needs must be evaluated and balanced against Needs must be evaluated and balanced against available resources.available resources.

The principle of “doing the greatest good for the The principle of “doing the greatest good for the greatest number”.greatest number”.

Pediatric Trauma ScorePediatric Trauma ScoreScoreScore +2+2 +1+1 -1-1SizeSize>20 kg>20 kg 10-20 kg10-20 kg <10 kg<10 kgAirwayAirway NN maintainablemaintainable unmaintainableunmaintainableSystolic BPSystolic BP >90 mmHg>90 mmHg 30-90 mmHg30-90 mmHg <30 mmHg<30 mmHgCNSCNS awakeawake obtunded/LOCobtunded/LOC coma/decerebratecoma/decerebrateSkeletalSkeletal nonenone closed #closed # open/multiple #open/multiple #CutaneousCutaneous nonenone minorminor major/penetratingmajor/penetrating

traumatrauma

Useful as a triage tool in the multiple injured child.Useful as a triage tool in the multiple injured child. Score <8 = need for advance level of care, high risk categoryScore <8 = need for advance level of care, high risk category

~ 30% mortality~ 30% mortality >8 = community hospital capable of treating children>8 = community hospital capable of treating children

Child Likely To Need Specialized CareChild Likely To Need Specialized Care Shock SBP <80, HR>130<50Shock SBP <80, HR>130<50

Resp distress RR>30<10, stridorResp distress RR>30<10, stridor

GCS<9GCS<9

MechanismMechanism

- MVAMVA

- Pedestrian/bicyclist thrown >15 feetPedestrian/bicyclist thrown >15 feet

- Penetrating injury to head, neck, trunkPenetrating injury to head, neck, trunk

Child Likely To Need Specialized CareChild Likely To Need Specialized CareSpecific injuriesSpecific injuries

skull #skull # pneumothorax, flail chestpneumothorax, flail chest abd trauma with peritoneal signsabd trauma with peritoneal signs amputation / deglovingamputation / degloving vascular injuryvascular injury burn with inhalationburn with inhalation FB aspiration / ingestionFB aspiration / ingestion

PreplanningPreplanning

Needs assessment of communityNeeds assessment of community

Commitment on part of institutions and key Commitment on part of institutions and key personnel to treating injured childrenpersonnel to treating injured children

Consider children with special needsConsider children with special needs

Consider evacuation process for NICU/PICU/SCU Consider evacuation process for NICU/PICU/SCU for newbornsfor newborns

Lack of supervisionLack of supervision

Requirement of children in sheltersRequirement of children in shelters

Categorize the FollowingCategorize the Following

7 y.o. female, crying, unwilling to move right arm, 7 y.o. female, crying, unwilling to move right arm, 1° burn to anterior thigh1° burn to anterior thigh

10 y.o. male, deformed thigh, pale, pulse 120, BP 10 y.o. male, deformed thigh, pale, pulse 120, BP 30/40, RR 3030/40, RR 30

20 y.o. female, apneic, severe head injury with 20 y.o. female, apneic, severe head injury with visible grey mattervisible grey matter

2 y.o. male, 2-3° burns to face, neck and chest2 y.o. male, 2-3° burns to face, neck and chest

5 day old infant, found on ground, appears 5 day old infant, found on ground, appears unharmedunharmed