Pediatric Considerations in Mass Casualty Care
The Importance of the Pediatric Orthopedic Surgeon in a Disaster Plan Activation
When a mass casualty disaster occurs, hospitals must be prepared to immediately provide crucial support to their community. Depending on the type of disaster, pediatric patients should be anticipated. It is understood that different age groups will require different levels of pediatric expertise. While the middle school/high school age group may be more straightforward for a general hospital to manage, the infant and preschool age group, with their age-specific equipment and dosing protocols, will not be. And all minors carry with them issues with consent and post-care disposition that may be anything but straightforward during a disaster. Therefore, any regional disaster management plan must include procedures to manage pediatric trauma victims and all the facets of care that come with that demographic.
Mark Sinclair, MD, pediatric orthopedic surgeon at Children’s Mercy Kansas City, leads the orthopedic disaster preparedness planning effort at Children’s Mercy and is helping other pediatric centers better understand how to create their own disaster management plans.
National Initiative Reveals Need for Pediatric Emergency Planning
National Pediatric Readiness Project is a multiphase quality improvement initiative to ensure that all U.S. emergency departments (EDs) have the essential guidelines and resources in place to provide effective emergency care to children. It’s a partnership between the federal Emergency Medical Services for Children (EMSC) Program, the American Academy of Pediatrics (AAP), the American College of Emergency Physicians (ACEP) and the Emergency Nurses Association (ENA). Of the 4,146 EDs that participated in the 2013 National Pediatric Readiness assessment, only 47% responded that they have a disaster preparedness plan in place that addressed the unique needs of children.
Pediatric Social and Physiologic Factors that Increase Vulnerability
Different age groups of children will require different services. Young children have an increased vulnerability in disasters, given their social dependency for care on adults who may also be victims. In addition, their unique physiology can predispose them to injury and exposures that may not be as significant in adult patients.
Specific physiologic vulnerabilities of young children include:
- Lower circulating blood volume
- More systemic side effects from fluid loss (caused by vomiting/diarrhea/burns)
- Increased ratio of head and body surface area to mass predispositions to head injuries and hypothermia with exposure
- Immature immune systems and potentially incomplete or unknown vaccination protection
The Role of Orthopedics in an Earthquake
The most common injuries following a significant earthquake event are fractures, traumatic wounds (potentially associated with fractures) and head injuries due to collapsing structures. A case study of the 2010 Haiti earthquake illustrates the key role of orthopedics in a disaster.1 The Swiss Disaster Medical Assistance Team that responded to the earthquake recorded its experience in Port-au-Prince for 43 days:
- 471 of 796 treated patients were under age 18. Each was assigned to a surgical group or a medical group based on the medical care required.
- Patients were evaluated on when they presented for care – either the early period (first 10 days after disaster) or the late period (days 11-43 post disaster).
- 134 of 147 early patients (91%) were surgical, and 88% of the surgical patients required orthopedic care.
- 110 of 324 late patients (34%) were surgical, with the remaining 214 (66%) medical.
Other studies of earthquake-induced mass casualty events led to similar findings, with a massive surge of orthopedic injuries in the pediatric population requiring surgical care within the first 10 days. These studies underscore the need for preparation and rapid deployment of pediatric orthopedic providers in this specific disaster scenario.
Children's Mercy Increases Its Disaster Readiness
Children’s Mercy is designated as a Level 1 Pediatric Trauma Center by the state of Missouri. The hospital is increasing its disaster preparedness as it goes through the American College of Surgeons (ACS) pediatric trauma center verification process. Such preparation is vital for the population located in the large geographic area around Kansas City served by the hospital. This area’s primary disaster risk is from severe weather outbreaks that can produce damaging tornadoes. But Children’s Mercy is required, as are all hospitals, to take an “all-hazards” approach to disaster preparation, so that the hospital can provide the region the services required to cope with any disaster or mass casualty event that may occur.
Profile of a Recent Disaster: The Joplin Tornado2
- >750 injuries, >150 fatalities
- Children’s Mercy (150 miles north of Joplin) received 10 patients in transfer
- Traumatic brain injuries were the most common reason for transfer, followed by orthopedic and maxillofacial injuries
- 7 out of 10 patients required surgery
- 8 out of 10 patients required PICU hospitalization
- Average length of stay: 19.4 days (14 hours to 94 days)
Disaster Planning Gets National Attention
In 2019, Dr. Sinclair presented at the Presidential Symposium of the American Academy of Orthopaedic Surgeons (AAOS) meeting on the importance of pediatric disaster planning. He co-chaired a two-hour seminar on this important topic during the Pediatric Orthopaedic Society of North America (POSNA) virtual meeting that opened in May 2020. He has co-authored a chapter on this topic that will be included for the first time in Orthopaedic Knowledge Update (OKU): Pediatrics 6. This resource should be available in spring 2021 to help other pediatric centers develop effective disaster management plans.
Learn More About Disaster Planning at Children's Mercy
Mark Sinclair, MD
mrsinclair@cmh.edu • (816) 234-3693
transformpeds.childrensmercy.org
Children’s Mercy Kansas City is an independent, non-profit, 390-bed pediatric health system, providing over half a million patient encounters each year for children from across the country. Children’s Mercy is ranked by U.S. News & World Report in all ten specialties. We have received Magnet® recognition five times for excellence in nursing services. In affiliation with the University of Missouri-Kansas City, our faculty of nearly 800 pediatric specialists and researchers is actively involved in clinical care, pediatric research and educating the next generation of pediatricians and pediatric subspecialists. The Children’s Mercy Research Institute (CMRI) integrates research and clinical care with nationally recognized expertise in genomic medicine, precision therapeutics, population health, health care innovation and emerging infections. In 2021 the CMRI moved into a nine-story, 375,000-square-foot space emphasizing a translational approach to research in which clinicians and researchers work together to accelerate the pace of discovery that enhances care.
References:
Gamulin A, Armenter-Duran J, Assal M et al. Conditions Found Among Pediatric Survivors During the Early Response to Natural Disaster: A Prospective Case Study. J Pediatr Orthop 2012;32:327-333.
Watts J. Pediatric Injuries Treated at a Level 1 Trauma Center after an F5 Tornado. Pediatr Emerg Care 2018;34:783-786.