Mass Casualty Events

Maria Cristina Esperanza

KEY POINTS

Mass casualty events (MCEs) from natural or terroristrelated events affect a significant number of children.

Children have unique anatomic, physiologic, developmental, and psychological needs compared with adult victims of MCEs.

Pediatric disaster response requires multiagency cooperation.

A universal pediatric disaster triage tool needs to be developed, applied, and studied.

A significant portion of the healthcare and private community sectors still lack pediatric disaster readiness.

All hospitals and physicians, regardless of training, should be prepared to treat pediatric victims of MCEs.

Secondary transfer of patients for definitive care is part of the pediatric response. Facilities with PICUs should support neighboring facilities that do not have PICU resources.

Awareness of surge plans, equipment, supply availability, and staffing patterns during an MCE is required of all healthcare workers.

Pediatric victims of terror-related events utilize more healthcare resources than the general trauma population.

Rapid and thorough decontamination of victims exposed to a chemical or radiological event is the single most important facet of treatment.

Pediatric victims of MCEs have increased mental health needs after the event.

With the effects of climate change and the presence of political unrest in many areas of the world, there is an increasing number of events with multiple casualties. There were 211 million people affected by natural disasters (1) and 54,000 terroristrelated casualties (2) in 2008. With 74 million children in the United States in 2011 (3,4), the odds of having significant pediatric casualties are high.

The healthcare community has been developing an increasing awareness of the need for disaster preparedness. Mass casualty events (MCEs) are nondiscriminatory. They are not limited by geographic boundaries nor do they target a specific population demographic. During MCEs, the local health systems may be easily overwhelmed, requiring redistribution of casualties and request for external assistance. Collaboration and resource sharing among regional hospitals will provide the most optimal response. Every hospital and healthcare provider should be familiar with the management of victims of MCEs.

Pediatric emergency care expertise and resources are not uniformly accessible even in the United States (5,6). With children accounting for one-third of the victims of MCEs, provisions for children in community, hospital, state, and federal disaster planning should be made. Pediatric intensive care physicians are looked to as a valuable resource in the planning and management of MCEs. An understanding of the status of pediatric emergency preparedness, general principles of disaster medicine and epidemiology, and management of disasterrelated injuries is essential. It is impossible to exhaustively cover the breadth of literature on disaster preparedness and terrorism. This chapter will provide the clinician with a framework to understand the public health and clinical management issues surrounding terrorism and disaster preparedness. At the end of this chapter, one will be able to:

Describe the status of pediatric emergency preparedness
Discuss the principles of mass casualty medicine as it pertains to planning, triage, and surge capacity
Describe unique aspects of children with regard to patterns of injury and management
Describe the presentation, characteristics, and management of different agents of terrorism.

BACKGROUND

An MCE is an incident that results in multiple injuries or deaths and that can have an impact on health care and access to vital services. It affects at least 10 patients, with 3-4 severely wounded patients arriving to the same hospital (7). MCEs can be due to natural or man-made disasters (Table 34.1).

While infrequent, MCEs have the capacity to overwhelm and paralyze healthcare delivery systems. Therapeutic capacities of local healthcare services are exceeded, and external assistance is required. Access may be prevented because the local infrastructure such as roads or hospital buildings may be destroyed. Sustained effects on the community may lead to changes in environmental hazards such as an increased susceptibility to infections or to respiratory diseases (e.g., after the 2001 attack on the World Trade Center [WTC]) (8,9). Events may also cause large population movements (e.g., after Hurricane Katrina). The geographic areas with population surge may not have the resources to handle the healthcare needs of
the displaced segment of the population and perpetuate the MCE (10).

TABLE 34.1 CAUSES AND EXAMPLES OF DISASTERS AND MASS CASUALTY EVENTS

Nature and weather-related disasters	Earthquakes Tornadoes Hurricanes Flooding Tsunamis
Transportation accidents	Airplane crash Train derailments/collision Multiple car collisions
Civilian disasters	Bridge collapse Building collapse Fires
Terrorist-related	Bombings Chemical disaster Radioactive/nuclear disaster
Pandemics	SARS Small pox Influenza Anthrax
SARS, severe acute respiratory syndrome.

The nature of the event dictates the scope, type, and severity of injuries. Much of the emergency response to MCEs is directed toward the management of trauma-related injuries. Emergency and critical care providers must also be ready to deal with environmental effects such as hypothermia, heat stroke, electrolyte imbalance, dehydration, infections, and psychological stress. An increase in mental health services is particularly necessary due to the prevalence of psychological stresses on the population (4,10,11,12,13). A multidisciplinary team is best equipped to deal with victims of MCEs.

TABLE 34.2

PEDIATRIC-SPECIFIC VULNERABILITIES DURING MASS CASUALTY EVENTS

Increased susceptibility to effects of exposure to terrorism-related agents	Increased respiratory exposure	▪ Higher minute ventilation ▪ Located closer to the ground
	Increased dermal exposure	▪ Thinner, more permeable skin, less fat ▪ Larger BSA/mass ratio
	More virulent disease manifestations from infectious agents	▪ Immature immune system
	Less capable of escaping attack and taking appropriate protective actions	▪ Motor and cognitive immaturity ▪ Dependence on caregivers
More susceptible to development of secondary medical problems	Increased risk of dehydration due to toxin-induced vomiting and diarrhea	▪ Decreased intravascular volume, larger BSA/mass ratio ▪ May be dependent on caregivers for access to fluids
	Increased risk of hypothermia	▪ Larger BSA/mass ratio ▪ Immature temperature regulation in infants
	Increased incidence of multiple organ injury	▪ Thoracic cage less developed ▪ Small size with more force applied per unit body area ▪ Less fat protecting internal organs
	Increased incidence of head injury	▪ Larger head-to-body ratio ▪ Thinner calvarium
	Increased fractures	▪ Incomplete ossification of skeletal system ▪ Smaller body mass
	Increased mental health needs	▪ Separation from primary caregiver, need for reunification ▪ Developmental immaturity
Adapted from Henretig FM, Ciesiak TJ, Eitzen EM Jr. Biologic and chemical terrorism. J Pediatr 2002;141:311-26.

The National Commission on Children and Disasters in its 2010 report to the US President and Congress called for the development of a National Strategy for Children and Disasters. A unified platform for the development of short- and long-term goals, objectives, and capabilities to cohesively address gaps in disaster preparedness, response, and recovery for children is needed. The “at-risk” population designation for pediatrics has not drawn sufficient attention and resources to its needs. Pediatrics has not always been viewed as a separate and distinct stage in growth and requires separate study and planning (14). Modifications to existing plans formulated for the adult population are not enough given the unique needs and vulnerabilities of children. These needs could be predicted and planned for. All disaster management agencies should be required to have distinct and separate plans for pediatrics in their daily and disaster response activities (15) (Table 34.2).

THE STATE OF PEDIATRIC EMERGENCY PREPAREDNESS

MCEs usually consist of 8%-30% of the victims under the age of 17 (16,17,18). Emergency department (ED) utilization rates are high, ranging from 61% to 97% of victims, and admission rates are also higher than normal at 13%-58% (19).

It is well recognized that pediatric healthcare delivery is uneven. Knowledge, logistical, and infrastructure support is

highly variable. This problem extends to the state of pediatric emergency preparedness. MCEs require a high level of coordination among prehospital and hospital personnel, and local, regional, state, and federal agencies. Any weakness in planning and execution at any level severely affects the disaster response. The National Commission on Children and Disasters
recognizes the gaps in knowledge, training, and access to health care in their 2010 report (15).

State and regional emergency preparedness plans are crucial in MCE events because local conditions will delay federal and neighboring state responses to the event. In 1997, the Federal Emergency Management Agency (FEMA) showed that no state had pediatric-specific plans for disaster response (20). In 2002, most states (94%) reported the presence of a statewide disaster plan, but only half were tested by activation and only one-third of the plans contained a bioterrorism component. A minority of states, 10%, required disaster training of medical professionals (21). A decade later, only 17 states have plans for four key components of the pediatric disaster response: evacuation/relocation, family and child reunification, children with special needs, and a K-12 multiple disaster plan. Five states have not met any of the standards (22).

Prehospital provider preparedness in pediatric MCEs is still uncertain. Prehospital providers receive limited disaster, MCE (23), and pediatric training (24). As children make up very few ambulance calls, prehospital providers have very little practical experience in general pediatrics let alone pediatric MCE events. Participation in disaster drills can fill this gap; however, only half of the drills included pediatric victims (25). While most (72%) prehospital EMS agencies have a written disaster plan, only 13% had a pediatric-specific plan. Only 19% utilize pediatric triage protocols, and the majority do not address MCEs at schools, or have accommodations for people with special healthcare needs (25

Only gold members can continue reading. Log In or Register to continue