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  • Anatomic, physiological, developmental, and behavioral differences between children and adults influence the management of children during a mass casualty event (MCE).

  • During an MCE, emergency department (ED) staff should expect casualties to come in two waves (dual wave phenomenon): The first wave typically appears after about 15 to 30 minutes and largely consists of “the walking wounded”; the second wave typically arrives 30 to 60 minutes after the onset of the event and is comprised of the more critically ill or injured patients.

  • ED leadership and staff should understand their roles within the hospital incident command system to optimize patient care before, during, and after a mass casualty event.

  • Because of physiological and anatomical differences between adults and children, adult MCE triage protocols are inappropriate for use in triaging infants and children.

  • EDs should have guides with predetermined medication dosing based on weight, and equipment sizes based on age, ready for mass casualties, so that staff members do not have to perform calculations during events.

  • Decontamination of children generally takes longer than that of adults. It should be done as a family unit to facilitate a child’s cooperation and minimize psychological impact.

  • Blast incidents can cause unique patterns of injury, including both penetrating and blunt trauma.

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 ...

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