A well-organized plan with community involvement can have positive effects on disaster response. However, many emergency medical services systems do 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.14 These plans can and 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 family, and for recognizing and addressing post-event mental health needs of children and families.
Ideally, it is best to transport pediatric MCE victims to either a regional pediatric hospital or one that has extensive pediatric expertise. Logistically, this may be impossible, depending upon the type of disaster and the resources of the affected community. An MCE may involve both adults and their children. Ideally, families should stay together. Therefore, hospitals need to consider providing care to the family as a unit. That is, general hospitals need to be able to care for pediatric patients and pediatric hospitals need to be prepared to care for adult parent victims as well.15 It is essential that all healthcare workers and prehospital responders receive proper training and equipment to deal with children, often the most vulnerable victims.
Adult mass casualty triage protocols cannot be universally used for pediatric patients. Physiological differences between adults and children make the adult MCE triage protocols inappropriate for infants and children. Many pediatric-specific triage protocols have been proposed including JumpStart, SALT, SACCO, and the Pediatric Assessment Triangle. Currently, there are limited studies to indicate which protocol works best in the pediatric population. Mass casualty pediatric victims (red: critical care, yellow: walking wounded, green: well) should be reevaluated upon arriving in the ED as their status can rapidly change.16–20
It is extremely important to have an array of infant-, child-, and adult-sized masks, airways, and endotracheal tubes available. One of the challenges in airway management is determining the proper endotracheal tube size. A pediatric emergency measuring tape, such as a Broselow® tape may be useful in estimating the proper equipment size and medication doses. Establishing intravenous access can be difficult and time consuming, especially in the smallest patients. Alternative access sites (scalp, umbilical, central venous sites) and means (ultrasound aided, intraosseous [IO] access) must be considered. Commercial IO devices function like a drill and can rapidly establish access, especially in a critical patient. MCE plans should include provisions for a minimum supply of appropriate pediatric-sized equipment and extra supplies. Some authors recommend having 72 hours supply for the average daily pediatric patient census at all times in a hospital.15 Equipment should be organized and stored in a designated area within the ED where it is easily accessible in an MCE.21
Appropriate medications and antidote administration can be difficult to determine in the pediatric population, especially during an MCE. While most antidotes are not FDA-approved in children, recommendations support the use of such medications when indicated in a disaster or an MCE because the risks outweigh the benefits. The Food and Drug Administration (FDA) recently approved the use of ciprofloxacin and doxycycline in children as prophylaxis against inhalational anthrax and hydroxocobalamin for use in cyanide toxicity.22
Dose calculations can be cumbersome in an MCE because of the emergent need to initiate lifesaving treatment and the inability to obtain accurate weights. One strategy is to have medication names organized in an easy to read chart with pre-calculated doses that is located in a pediatric disaster kit and readily visible. Prepackaged medications, like MARK I autoinjectors containing atropine and pralidoxime, have the advantage of pre-filled medications in an easy-to-use device that does not require intravenous access. However, these are not recommended in children less than 3 years.22,23
The FDA approved pediatric-specific atropine autoinjectors in 2003, but these are not yet mass produced for sale in the United States.24 The Broselow® tape system is available as a color-coded pediatric tape that contains doses for chemical treatment agents, including adult autoinjectors, thus, decreasing the amount of time required to determine doses for victims. It is patterned after the original tape such that it can be used simultaneously.25