It is critical that emergency departments (EDs) adequately prepare for mass casualty events (MCEs). EDs must not only have the capability to recognize, stabilize, and care for pediatric victims of MCEs involving traumatic injuries, but also pediatric victims of biological, chemical, and radiological/nuclear agents. For any MCE, there are unique considerations regarding children who require differences in practices than those used for adults, such as triage and decontamination.

An MCE is an event characterized by an imbalance between the needs and resources available within a health care system which may occur suddenly or evolve over days to weeks.¹ The inciting event can be due to natural disasters, transportation-related failures, civil disturbances, war, terrorist-related activities, or less commonly, weapons of mass destruction that involve biological, chemical, and/or radiological/nuclear agents. Whether the MCE is trauma related or due to a biological, chemical, or radiological/nuclear attack, children have anatomic, physiologic, developmental, and behavioral differences from adults that influence their management.²

Once EDs are notified of a mass casualty event, there are several immediate actions that should take place. First, the ED should inform hospital leadership, who will initiate the hospital incident command system, thereby ensuring a hospital wide comprehensive approach to caring for the victims. Required by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), the hospital incident command system assigns aspects of the incident response management in a uniform manner consistent with other federal, state, and local governments and organizations. The ED staff should also prepare by rapidly discharging those who are ambulatory and admitting to the floor units patients who require hospital care. A systematic process for triage and retriage needs to be instituted because victims’ injuries may cause rapid decompensation. EDs should also implement their hospital patient-tracking plan for receiving victims who might not be able to identify themselves. Security and evidence collection protocols will need to be in place, as the event may be considered a crime.³

During an MCE, ED staff should expect casualties to come in two waves, known as a dual-wave phenomenon.⁴ The first wave typically appears after about 15 to 30 minutes and largely consists of the “walking wounded” who are able to get to the ED by car or on foot. In the second wave, patients more critically ill or injured who may have needed to be extricated arrive by ground or air transport 30 to 60 minutes after the onset of the event.^4,5

AGE, SIZE, WEIGHT

While there is no consensus regarding the upper limit of age that defines a child, the pediatric population is generally considered to consist of patients from birth to 18 years of age.^6,7 An MCE involving pediatric victims demands a wide range of skills, an understanding of child development, and the availability of equipment to accommodate a range of sizes and weights. In terms of clinical management, age is often considered a surrogate for size and weight. Medications like antibiotics, vaccines, or antidotes need to be dosed according to the age, size, and/or weight of a child. Because of the metabolic differences in children compared to adults, response to medication treatments may vary (Table 150-1).⁷

DEVELOPMENTAL AND BEHAVIORAL CONSIDERATIONS

The stage of motor and cognitive development of a child will influence a responder’s ability to communicate with and care for a victim. Nonverbal children are not able to voice their complaints or injuries and may not be able to cognitively distinguish between strangers who are helping and those who are hurting. Non-ambulatory children will not be able to flee a dangerous situation and may need to be carried away. Depending on the age and cognitive development of a child, he or she may refuse to move or may even run toward a threat.^2,4

Children may lack the decisional capacity to follow directions from first responders. They may suffer anxiety owing to separation from their family or primary caretakers during a disaster.⁸ Every effort should be made to reunite family members with the child as soon as possible. Treating parent and child victims of an MCE together in the same facility is a logical strategy.

Children need to be reassured that their reactions are not a result of something right or wrong, but a normal reaction to an abnormal event. Taking photos or noting the clothing or personal articles on the child may be useful in helping parents identify their children.⁹ Children rarely carry personal identification and some are preverbal, which makes the process of identifying victims and later reuniting families challenging.⁸

Physicians and other health care professionals need to be vigilant about recognizing the signs and symptoms of children who are at risk for developing posttraumatic stress disorder (PTSD) after an MCE. It is known that children suffer varying degrees of psychological disturbances after an MCE. However, long-term effects are not well understood.¹⁰

Somatization is common, and parents may not identify symptoms as psychological in nature. While physicians may not feel qualified to treat these disorders, mechanisms should be in place to help children address their reactions to disaster. Mental health workers should work with children and families immediately or soon after an event and intervene as necessary.²

PHYSIOLOGIC DIFFERENCES

Several unique physiological differences make children potentially more vulnerable to exposures to agents that may be involved or released in an MCE. For example, children have increased respiratory rates, which can lead to increased absorption of aerosolized chemicals, and thus may develop more severe illness. Also, because of their small size, children are generally closer to the ground and so are potentially more vulnerable to agents that either settle on the ground or do not become airborne. Further, because children are smaller, they have an increased body surface area and thinner skin relative to adults and are therefore at risk for increased absorption of toxic agents.² It is important to recognize these differences to allow for timely triage and identification of victims who may require immediate care (Table 150-1).

PROVISION OF CARE

A well-organized plan with community involvement can have positive effects on disaster response. However, some emergency medical services systems may not have pediatric-specific plans or general plans that adequately account for pediatric requirements. In one study, only 248 out of 1808 prehospital emergency medical services surveyed had any specific plans for the care of children.¹¹ These plans should include recommendations for the use of a pediatric-specific mass casualty triage protocol, pediatric-sized equipment and supplies, proper decontamination guidelines, plans for reunification of children with their families, and for recognizing and addressing post-event mental health needs of children and families.