2-General Principles
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Transcript 2-General Principles
PDLS©:
General Principles of Disaster
Care: Pediatric Triage Assessment,
Stabilization, Resuscitation
Triage Assessment, Stabilization,
Resuscitation
Learning Objective
At the end of this lecture, the students should be
able to:
- describe differences in triage decision making for children
- describe triage categories
- describe field triage assessment
- describe principles of field triage, stabilization and
-
resuscitation
describe initial field stabilization methods for children
describe organization of field triage, treatment, staging,
and clearing/transportation for children
Oklahoma City – YMCA Day Care
The Scene:
- Multiple injured kids - Delay in finding them
- 4 Children:
2 not breathing, unresponsive
2 sitting, crying
General Principles of Disaster Care
Triage Assessment
Initial Stabilization
Resuscitation
Triage Assessment
Derived from the French “trier” meaning to sort, it
describes a medical decision making process.
Appropriate performance crucial.
Dynamic process, re-triage / re-evaluate at several
stages.
Determination of priority may effect the extent and
quality of care the patient receives.
Triage
Triage in disaster setting may be very difficult
Pediatric population unique challenge
Problems of
Under / Over-Triage
Triage in Prehospital Setting
ICS (Incident Command System)
- Medical Branch
Gain Control of Scene
Triage Officer: Initial Brief Assessment
Initial Evaluation
Ensure scene safety
Establish that disaster exists
Estimate number of victims: adults/children
Initial Evaluation
Notification to medical control: regional
communications, local emergency management /
disaster authority
- type of event
- initial casualty estimate
Make initial request for additional resources
Then begin triage assessment of individual patients
Initial Brief Assessment
Open airway
Control major hemorrhage
Categorize
Triage Categories
Red / Immediate / Emergency
Yellow / Urgent
Green / Non-Urgent / Walking Wounded
Black / Blue
Triage Classifications
Simple Triage And Rapid Treatment
S.T.A.R.T.
JumpSTART
Tool for Rapid Pediatric Multicasualty Field
Triage (children from 1 - 8 years of age)
Triage Classifications and Examples
Red - tension pneumothorax, rib fractures, upper
airway obstruction, hemorrhage, femur fracture,
asthmatic
Yellow - humerus fracture, scalp lacerations,
shoulder dislocation
Green - ankle sprain, simple laceration, orphaned
child, subluxed radial head
Black/Blue - cardiopulmonary arrest, severe open
head injury
Triage Classifications
Consider pediatric anatomy / physiology / age /
development when categorizing child
Familiarity with
- level of expertise of personnel
- numbers and type of transport available
- equipment supplies
- appropriate destination for definitive care
Initial Patient Assessment
Primary Survey of Child
Airway - patency
Breathing - rate, quality
C irculation: Pulse check - quality, rate
D isability: Mental status
Exposure
Airway
First priority even more so than in an adult. Hypoxia main
factor leading to organ dysfunction, ischemia, and
cardiopulmonary arrest.
Consider need for endotracheal intubation in child with
GCS<8, significant maxillofacial trauma, aspiration, or
respiratory distress.
Remember
- Oropharyngeal airway
- ET size/uncuffed
- ET route for delivery of medication (LANE)
Breathing
Children consume oxygen x 2 that of adult
Assess: respiratory rate (infants 40/min, preschool
30/min, school 20/min)
Effort
Auscultate, percuss
Thoracic cage and rib fractures
Tension pneumothorax
Circulation
Normal values: infant 160/min, preschool 140/min, school 120/min.
Systolic BP 80+ (age in years x 2)
Assess:
-
capillary refill
temperature of extremities
color of patient
Circulating blood volume: neonate 90 ml/kg, infant 80 ml/kg, older
child 70 ml/kg, adult 65-70 mg/kg
Bradycardia requires immediate attention, most common cause is
hypoxia, but acidosis and hypovolemia are also factors.
IV Access
Attempt peripheral access if unsuccessful in < 90 sec. consider
IO or cutdown.
Estimated body weight: (age in yr.. x 2) + 10
Blood volume = 80 mls/kg x body weight
Estimate blood loss: # pelvic ring = 10% total blood volume, #
femur up to 20%.
IO access sites
- distal femur
- proximal tibia
- med/lat malleolus
- iliac crests
High success rate, up to 80% in less than one minute
Consider IV Access in the Following:
Time to definitive care 30-60 minutes
Prolonged extrication / entrapment
Dehydration > 15%
Multiple fractures
Scalp lacerations with significant blood loss
Children After Burns
Airway and ventilation a priority in management. Cover burn area
in a clean sheet and wrap patient in a clean blanket.
Calculate percentage burn
Consider specialized facility for following:
- 2/3 degree > 10%
- 2/3 degree face, hands, feet, genitalia, perineum, and major
joints
- 3 degree > 5%
- electrical burns
- inhalation injury
- preexisting medical problems
- associated trauma in which burn injury > risk
Disability
GCS useful in children > 1yr
Exposure
Examine the entire child
Hypothermia may occur secondary to exposure,
sepsis, shock, and may lead to metabolic
acidosis, decreased respiration, bradycardia and
cardiac arrest. Newborns at high risk.
What are your plans for newborns, infants who
have no guardians?
Field Stabilization
Airway - chin lift, jaw thrust, oro- or nasopharyngeal
airway
Breathing - supplemental O2 as available
- limited resources for mechanical/manual ventilation
Circulation - hemorrhage control - direct pressure,
dressings (rotating tourniquets)
- limited resources for IVF
Fracture Stabilization - using resources available
Field Stabilization
There is little role for initiation of CPR in disaster
situations
Consider on site organization of arriving personnel and
arriving resources
Consider establishment of clearing/staging unti:
- triage patients for treatment on site or transport to
hospital/health care facility
- efficient utilization of resources, personnel, and
supplies
Resuscitation/Stabilization
Simple measures that do not require
sophisticated equipment are most appropriate.
Needs must be evaluated and balanced against
available resources.
The principle of “doing the greatest good for the
greatest number”.
Pediatric Trauma Score
Score
Size
Airway
Systolic BP
CNS
Skeletal
Cutaneous
+2
>20 kg
N
>90 mmHg
awake
none
none
+1
10-20 kg
maintainable
30-90 mmHg
obtunded/LOC
closed #
minor
-1
<10 kg
unmaintainable
<30 mmHg
coma/decerebrate
open/multiple #
major/penetrating
trauma
Useful as a triage tool in the multiple injured child.
Score <8 = need for advance level of care, high risk category
~ 30% mortality
>8 = community hospital capable of treating children
Child Likely To Need Specialized Care
Shock SBP <80, HR>130<50
Resp distress RR>30<10, stridor
GCS<9
Mechanism
- MVA
- Pedestrian/bicyclist thrown >15 feet
- Penetrating injury to head, neck, trunk
Child Likely To Need Specialized Care
Specific injuries
skull #
pneumothorax, flail chest
abd trauma with peritoneal signs
amputation / degloving
vascular injury
burn with inhalation
FB aspiration / ingestion
Preplanning
Needs assessment of community
Commitment on part of institutions and key
personnel to treating injured children
Consider children with special needs
Consider evacuation process for NICU/PICU/SCU
for newborns
Lack of supervision
Requirement of children in shelters
Categorize the Following
7 y.o. female, crying, unwilling to move right arm,
1° burn to anterior thigh
10 y.o. male, deformed thigh, pale, pulse 120, BP
30/40, RR 30
20 y.o. female, apneic, severe head injury with
visible grey matter
2 y.o. male, 2-3° burns to face, neck and chest
5 day old infant, found on ground, appears
unharmed