A disaster is a calamitous event that affects a large population and generally results in injury, death, and destruction of property. A disaster can also be thought of as any occurrence that taxes or overwhelms local response resources (e.g., law enforcement, transportation, shelters, etc.). Local resources can be overwhelmed by natural disasters or other events that result in multiple casualties such as earthquakes, fires, large motor vehicle crashes, or terrorist incidents. Because disasters vary, preparation should vary accordingly. Disasters caused by terrorism or accidents (e.g., a multiple car crash on an interstate highway) can occur without warning. In other types of disasters, such as hurricanes, there is usually some time for warning and preparation. Some disasters end quickly, while others can affect large populations over an extended period of time (e.g., a humanitarian disaster involving famine). Disasters can have physical, mental, and emotional effects on a large number of people without regard to age or other factors. This widespread negative impact is what makes terrorist attacks so effective.
An understanding of the many types of disasters (Table 1.1) and the implications of each is essential for preparedness planning. In all cases, terrorism and disaster planning can be divided into three phases:
The lessons learned from past terrorist events and natural disasters should guide plans for future preparation and response. The first lesson is that natural disasters and terrorist events can and do occur in the United States. The second is that bombs, germs, toxic gases, and the forces of nature do not discriminate between children and adults. Despite our best efforts to shelter and protect them, children remain among the most vulnerable victims of terrorism and disasters. A third lesson is that disasters cannot always be predicted or prevented; they have the potential to affect anyone at any time. These lessons underscore the need for preparation by planning a comprehensive system of response that fully addresses and integrates the needs of everyone, including children.
Several terrorist events in recent years have had profound consequences for children and families. When the Murrah Federal Building in Oklahoma City was bombed in 1995, 19 children at the child care center inside the building were killed, and many more were injured. Hundreds of other children lost parents or relatives, and countless more suffered emotionally. Thousands of children lost parents in the terrorist attacks of 2001 at the World Trade Center and the Pentagon.
There are many gaps in knowledge, especially with regard to children, regarding disaster preparation and planning. Historically, the unique characteristics and needs of children have not been adequately addressed in the planning process for response to terrorism. Why is this so? In the past, much of the terrorism response planning in the United States has centered on military preparedness, and therefore, plans have focused on the needs of adults. As we plan for response to terrorism, it is time to reassess education and planning for all disasters and to ensure that children and their families are included. Ensuring appropriate care for children during disasters cannot be accomplished by simply modifying current practices. Basic day-to-day issues that involve families have not been considered previously (e.g., incorporating schools and child care centers into disaster preparation and planning; also, planning for the likelihood that numerous children will become separated from their families) and should now be addressed. (Go to: Chapter 9, Integrating Terrorism and Disaster Preparedness into Your Pediatric Practice and Chapter 11, Conclusion.) The likelihood of a disaster occurring while children are in school or at child care centers is high, and the site of the disaster could even be at the school or child care center.
Incorporating the needs of children and families into terrorism and disaster planning requires multidisciplinary pediatric expertise at all phases. This Pediatric Terrorism and Disaster Preparedness resource presents information on including children and families at all levels of terrorism and disaster planning. A few of the many considerations include the following:
This resource is intended primarily to educate, inform, increase awareness among, and assist pediatricians in recognizing and fulfilling their important roles in disaster preparedness and response. Families and communities turn to pediatricians for anticipatory guidance on all issues involving children. Pediatricians can help families plan their response to disaster by referring them to available resources. The Family Readiness Kit has been developed by a coalition of the American Academy of Pediatrics (AAP), the American College of Emergency Physicians (ACEP), and 27 other State and national organizations to assist families in planning (go to http://www.aap.org/family/frk/frkit.htm).
Questions regarding immunization for infectious agents such as smallpox, antibiotic prophylaxis after exposure to infectious agents, coping with the effects of exposure to violence, and disaster preparedness in the home are common. Pediatricians should be ready to provide accurate answers. The AAP Web site includes information, created by the AAP Task Force on Terrorism, on disaster preparedness to meet the needs of children (http://www.aap.org/disaster), as well as links to many other sources of information.
Pediatricians enjoy a high degree of public trust as expert sources of information and support on matters involving the health and well-being of children and families. Therefore, their roles in disaster preparedness and management are extremely important. For example, pediatricians act as first responders and care providers when the emergency medical system and emergency departments become rapidly overwhelmed in the recovery and mitigation phases of incidents of terrorism or disasters. Pediatricians, especially in instances of bioterrorism (such as the case of anthrax in an infant in New York City), could be the first to see victims and determine a diagnosis. This means that pediatricians should acquire further knowledge of infections and the effects of exposure to toxins that most likely they have never seen. Residency training in pediatrics has been limited on subjects such as biological and chemical terrorism, as well as nuclear exposure, and it should be broadened accordingly. Children's hospitals, which serve many communities, should also generate and implement this information.
The pediatric office could also be involved in the first response phase after a disaster. A good first step for the pediatrician is preparation of an office disaster plan that is periodically updated and practiced (Chapter 9, Integrating Terrorism and Disaster Preparedness into Your Pediatric Practice). As the office plan is prepared, pediatricians should consider other roles they might have in the community disaster response and familiarize themselves with liability and licensure issues. Working with an agreement with local/state government agencies to provide disaster services affords the best liability coverage and often allows reimbursement. For a discussion of their liability, pediatricians should review the AAP Policy Statement (reaffirmed in 2004) Pediatricians' Liability During Disasters (Go to: http://aappolicy.aappublications.org/cgi/content/full/pediatrics;106/6/1492).
Recommendations include the following:
Parents turn to pediatricians for help, guidance, support, treatment, and referral regarding mental health issues in the recovery and mitigation phases of disaster. A wide range of reactions can be expected, from anxiety to adjustment reactions and posttraumatic stress disorder (PTSD). The effects can be direct or indirect, affecting children who were not actually involved in the disaster. Parents will turn to pediatricians with many questions regarding how to explain the reasons for disaster, whether to let their children watch the events on television, and what to say about loved ones or acquaintances who have been injured or killed (Chapter 8, Mental Health Issues). Pediatricians should be able to recognize potential symptoms of adjustment reactions and PTSD and to give parents coping strategies and referrals. The role of pediatricians in the mental health care of children after terrorism and disasters is described in a recent article, “Psychosocial implications of disaster or terrorism on children: A guide for the pediatrician,” which is available at: http://pediatrics.aappublications.org/cgi/content/full/116/3/787..
The pediatrician's perspective is well-suited to assist in the community planning process. Pediatricians have an appreciation for children as part of families that comprise communities that become regions, States, and so on. This perspective is valuable, but pediatricians may have limited knowledge and skill in planning and response. Pediatricians should educate themselves, acknowledge their limitations, and/or obtain outside expert input. The role of the pediatrician has been comprehensively described and defined in the AAP Policy Statement The Pediatrician's Role in Disaster Preparedness prepared by the Committee on Pediatric Emergency Medicine (http://pediatrics.aappublications.org/cgi/content/full/99/1/130).
Pediatricians are respected advocates for children. In this role, pediatricians should advocate for resources and products that currently do not exist for children, especially for children with special health care needs (including the chronically ill and technologically dependent). For example, children cannot always be decontaminated in adult decontamination units. Skin decontamination showers that are safe for adults may cause hypothermia in children unless warming equipment (e.g., heating lamps) is provided. Decontamination systems should be designed for use with children of all ages, for the child unaccompanied by a parent, for the nonambulatory child, and for the child with special health care needs. Little protective gear is available for children; when its use has been attempted, such as with gas masks, mishandling has led to fatalities from suffocation.
Vaccines for anthrax and plague are not approved for use in children. The frequency of serious complications after administration of smallpox and yellow fever vaccines is higher in children than in adults; development and approval of safer vaccines are needed (Chapter 4, Biological Terrorism). Antidote kits for use after nerve agent exposure such as the Mark-1 kit (for adults) have only recently been developed for children (Chapter 5, Chemical Terrorism). Common systems for determining drug dosages in children do not include dosages for antidotes. Recently, a liquid preparation of potassium iodide (65 mg/cc) has come on the market for use in preventing radiation-induced thyroid effects after radiation exposure (Chapter 6, Radiological and Nuclear Terrorism and the AAP Policy Statement on Radiation Disasters and Children at http://aappolicy.aappublications.org/cgi/content/full/pediatrics;111/6/1455).
Planning and preparation for terrorism and disasters can be both daunting and challenging. For all, but especially for children, there are many recognized gaps in knowledge, resources, and professional education. This resource has been provided to increase pediatric expertise of those taking on the challenge of preparation and planning. This resource will be invaluable, not only for pediatricians, but also for other pediatric health care providers, public health professionals, health administrators, and policymakers who are committed to ensuring that planning for terrorism and disasters includes the special needs of children.
Many important differences distinguish children from adults and are the origin of the oft-used truism “you can't treat children as small adults.” Children have many unique anatomic, physiologic, immunologic, developmental, and psychological considerations that potentially affect their vulnerability to injury and response in a disaster. Failure to account for these differences in triage, diagnosis, and management of children is most often due to lack of knowledge or experience, or both. Experience has shown that such lack of knowledge and experience can result in grave errors, increasing the child's risk of serious harm, and even death.
An obvious difference between children and adults is size. Children are smaller than adults and vary in size depending on stage of growth and development. Their small size makes them more vulnerable to exposure and toxicity from agents that are heavier than air such as sarin gas and chlorine. These agents accumulate close to the ground in the breathing zone of infants, toddlers, and children.
A child's smaller mass means greater force applied per unit of body area. The energy imparted from flying objects, falls, or other blunt or blast trauma is transmitted to a body with less fat, less elastic connective tissue, and closer proximity of chest and abdominal organs. The result is a higher frequency of injury to multiple organs.
A smaller body has smaller circulating blood volume (on average 80 mL/kg) and less fluid reserve. These differences have several important implications. Volumes of blood loss that would be easily handled by an adult can result in hemorrhagic shock in a child. Children are more vulnerable to the effects of agents such as staphylococcal enterotoxins or Vibrio cholerae that produce vomiting and diarrhea. Therefore, infections that might cause mild symptoms in adults could lead to hypovolemic dehydration and shock in infants, small children, and children with special health care needs.
The child's skeleton is more pliable than that of adults. It is incompletely calcified with active growth centers that are more susceptible to fracture. Orthopedic injuries with subtle symptoms and physical findings are easily missed in preverbal children. Internal organ damage can occur without overlying bony fracture. Serious cardiac or lung injuries without having incurred rib fractures are common.
A child's cervical spine is subject to distracting forces that are more likely to disrupt the upper cervical vertebra and ligaments. Numerous bony anatomic variations render the interpretation of radiographs potentially confusing. Additionally, children can have spinal cord injury without radiographic abnormality.
Head injury is common in children. The head is a larger, heavier portion of a child's body compared with the head of an adult. It accounts for a larger percentage of body surface area (BSA) than it does in adults, and it is a major source of heat loss. It is supported by a short neck that lacks well-developed musculature. The calvarium is thin and vulnerable to penetrating injury, thus allowing greater transmission of force to the growing brain of a child. The brain doubles in size in the first 6 months of life and achieves 80% of its adult size by age 2. During childhood, there is ongoing brain myelinization, synapse formation, dendritic arborization, and increasing neuronal plasticity and biochemical changes. Injury to the developing brain can affect or arrest these processes, resulting in permanent changes.
The mediastinum is very mobile in children. Subsequently, a tension pneumothorax can quickly become life-threatening when the mediastinum is forced to the opposite side, compromising venous return and cardiac function.
The thoracic cage of a child does not provide as much protection of upper abdominal organs as that of an adult. Hepatic or splenic injuries from blunt trauma can go unrecognized and result in significant blood loss leading to hypovolemic shock.
The airway differs between children and adults. The tongue is relatively large compared with the oropharynx, which creates the potential for obstruction of a poorly controlled airway. The larynx is higher and more anterior in the neck, and the vocal cords are at a more anterocaudal angle. The epiglottis is omega-shaped and soft. The narrowest portion of the airway is the cricoid ring, not the vocal cords as in adults. Airway differences combine to make the child's airway more difficult to maintain as well as to intubate. The short length of the trachea increases the risk of a right mainstem bronchus intubation. The lungs are smaller and subject to barotraumas, resulting in pneumothorax with inappropriate ventilation.
The BSA to mass ratio is highest at birth and gradually diminishes as the child matures. The distribution of BSA also differs between children and adults. Children have a higher percentage of BSA devoted to the head relative to the lower extremities. This should be taken into account when determining the percentage of BSA involved in burn injuries and in treating or preventing hypothermia.
The higher BSA to mass ratio also leads to more rapid absorption and systemic effects from toxins that are absorbed through thinner, less keratinized, highly permeable skin.
Children differ physiologically in many ways from adults. They can compensate and maintain heart rate during the early phases of hypovolemic shock; this false impression of normalcy can lead to administration of too little fluid during resuscitation. This can be followed by a precipitous deterioration with little warning.
Vital signs, including heart rate, respiratory rate, and blood pressure, vary with age. Caregivers should be able to quickly interpret whether a child's vital signs are normal or abnormal for age. Temperature is an often forgotten but important vital sign in injured children. The child's ability to control body temperature is affected not only by the BSA to mass ratio but also by thin skin and lack of substantial subcutaneous tissue. These factors increase evaporative heat loss and caloric expenditure. In fact, hypothermia is a significant risk factor for poor outcomes in many illnesses/injuries. Considerations of methods to maintain and restore normal body temperature are critical to the resuscitation of children. These can include thermal blankets, warmed resuscitation rooms, warmed intravenous fluids, and warmed inhaled gases.
Children have a higher minute ventilation per kilogram of body weight than adults. This means that over the same period of time, they are exposed to relatively larger doses of aerosolized biological and chemical agents than are adults. The result is that children suffer the effects of these agents much more rapidly. Children are also more likely to absorb more of the substance from the lungs before it is cleared or diffused through ventilation.
Fluid resuscitation, drug dosages, and equipment sizes are based on the child's weight. Estimating the weight of a child can be difficult, particularly for health care workers with limited pediatric experience. An easy, quick method for determining a child's weight is to use the Broselow-Hinkle Pediatric Resuscitation Measuring Tape®. This tool rapidly provides many common drug dosages and fluid resuscitation volumes. Health care providers should also make appropriate fluid choices for resuscitation. Children who receive large volumes of hypotonic fluid are at risk of hyponatremia and seizures.
Limited glycogen stores and a higher relative metabolism in children than in adults puts children at a higher risk of hypoglycemia. Children compensate for cardiovascular and pulmonary problems with tachycardia and tachypnea (their ability to increase stroke volume and tidal volume is limited).
Children have an immature immunologic system, which places them at higher risk of infection. Immunologically, children have less herd immunity from infections such as smallpox and a unique susceptibility to many infectious agents. For example, Venezuelan equine encephalitis is usually a brief, self-limiting infection in adults. In children, it can be severe, and life-threatening encephalitis develops in 4% of victims. Children immunized with the current smallpox vaccine are over-represented with serious side effects such as encephalitis.
Developmental differences between children and adults are also readily apparent. Children, especially infants and toddlers, might be unable to describe symptoms or localize pain. Children rely on parents or others caregivers for food, clothing, and shelter. Infants especially are vulnerable when their food sources are eliminated or contaminated.
In situations of disaster, caregivers can be injured, killed, or simply not present. Children, especially infants and toddlers, are limited in their verbal ability to communicate their wants and needs. Children also have motor skills that are insufficient to escape from the site of an incident. Additionally, their cognitive development may limit their ability to figure out how to flee from danger or to follow directions from others, or even to recognize a threat. The developing brain has emotional instability with an inadequate ability to interact in stressful situations and an emotional state frequently dictated by that of their caregivers. A child's reaction to danger or threat is influenced by their developmental stage, which means that responders should be familiar with age-appropriate interventions.
Younger children are unable to take care of their needs for activities of daily living, so an adult caregiver must oversee them. Children with special needs often cannot perform some activities of daily living or medical interventions by themselves. Planning/response must allow for adult caregivers.
The psychological effects of disaster on children are neither uniform nor universal in nature (Chapter 8, Mental Health Issues). Important factors in the psychological effect of a disaster on children include the nature of the disaster itself, the level of exposure to the disaster, the extent to which the children and those around them are personally affected, and individual characteristics of each child. In addition, children are unique because they are affected not only by their own reaction to the trauma of the event but also by their parent's fears and distresses. Because children depend on adults for their emotional and psychological needs, any effects of trauma on adults can magnify the psychological impact on children.
Children are still undergoing psychological development at the time of disaster. Their developmental stage characterizes their response and is responsible for the wide degree of variability in adjustment to traumatic events. This means that therapeutic interventions should be developmentally appropriate.
The response of younger children is characterized by changes in mood and behavior and by anxiety. Younger children may exhibit regressive behaviors, increased temper tantrums, and symptoms of clinginess and difficulty with separation or sleep. Even infants whose lives have been disrupted by a disaster manifest symptoms of crying and irritability, separation anxiety, and a hyperactive startle response.
School-age children may exhibit depression, anger, and despair. Their anxiety may be exacerbated by unrealistic fears for parents, families, and friends. They also may develop problems at school or somatization symptoms, typically with complaints of headache or abdominal pain.
Adolescents differ from adults in their psychological response because they are in a period of development characterized by complex physical, psychological, and social transitions. They are especially vulnerable to the development of major psychiatric disorders such as depression. Of significant importance is the likelihood of engaging in risk-taking behaviors such as drug abuse or sexual relationships. Adolescents are also particularly vulnerable to impulsive behaviors including suicide. In addition, adolescents may try to hide their feelings or symptoms for fear of being perceived as abnormal. It is imperative that these symptoms not be minimized or overlooked because adjustment reactions left unrecognized and untreated can lead to lifelong behavioral and emotional problems.
The anatomic, physiologic, immunologic, developmental, and emotional differences between children and adults give rise to many practical considerations for planning.
Emergency medical services (EMS) agencies should consider adopting triage tools such as JumpSTART® (http://www.jumpstarttriage.com) that use physiologic decision points adapted for ranges of pediatric normals and that consider apnea as a potentially salvageable respiratory emergency. The AAP has prepared a resource and course that provides training equipment guidelines for prehospital providers in the care of children, Pediatric Education for Prehospital Professionals (http://www.peppsite.com).
Surge capacity is the ability of a hospital or other health care facility to expand quickly beyond normal services to meet an increased demand for medical care in the event of bioterrorism or other large-scale public health emergency. Converting a hospital or other health care facility from its current capacity to surge capacity is a daunting task. In addition to ensuring that essential supplies, staff, and services are available, planners also must ensure that facilities can accommodate the needs of vulnerable groups, such as children, the elderly, and the disabled.
Ambulances, clinics, and hospital emergency departments typically carry only limited quantities of pediatric equipment. Sufficient supplies and equipment should be readily available to treat large numbers of pediatric victims. Because equipment choices and drug dosages, including intravenous (IV) rates, depend on the child's size, a quick, convenient system to guide appropriate choices should be in place. The system used should be comprehensive enough to include dosages for antidotes and other medications that may be relevant during a terrorist event. A surge in pediatric victims can quickly overwhelm hospital, regional, and even State pediatric capacity, so strategies should include solutions that involve hospital, regional, State, and Federal planning to manage such surges. Plans should also consider that pediatric victims will present as families when injured adults refuse to be separated from their children.
The resuscitation of children can be further complicated by the technical difficulty of procedures such as intubation and intravenous access. Alternative methods for maintaining and securing the airway should be considered. When veins are small and/or constricted from shock or hypothermia, the equipment for alternative methods, such as intraosseous access, should be readily available.
Planning should consider all potential aspects of a child's life. Therefore, it should account for children who are at home, in school or child care, or in transit, as well as for children who cannot be reunited with their families. School disaster plans should coordinate with community plans and should also consider post-incident stress management during the recovery phase. Child care centers and community youth centers should have disaster plans that focus on ensuring safety, accessing and interacting with community emergency responders, notifying guardians, and reuniting families.
Children are predisposed to illness and injury after a disaster for a variety of reasons. There can be lack of adult caretaker supervision, and the usual resources of school or child care may be unavailable. Environmental hazards can be increased from collapsed buildings or dangerous tools or from chemicals or availability of weapons. Increased stress on adults might lead to a higher risk of domestic violence or child abuse. Contagion present in the community, especially infections such as respiratory syncytial virus or influenza, may spread rapidly in group shelters. Contaminated food or water can lead to epidemic outbreaks of infectious diseases, resulting in gastroenteritis and dehydration. Changes in the environment can lead to heat-related illness or hypothermia. Use of alternative sources for heating or generators can lead to carbon monoxide exposure. Children with asthma may have acute exacerbations due to stress or environmental contaminants. Medications may be forgotten or the supply may be exhausted, resulting in exacerbations of chronic illnesses. Stress can produce a variety of symptoms in children including headaches, abdominal pain, chest pain, vomiting, diarrhea, constipation, changes in sleep, and changes in appetite.
Many considerations in planning are prompted by the possibility of children in shelters. These include supplies and services such as diapers, infant formula, other child-appropriate food, and games and other distractions for children. Staffing is an issue with regard to supervision. Shelters should be childproofed to promote safety for children as well as the elderly. Sick children should be isolated. Children should be protected from environmental hazards such as weapons, alcohol, and cigarette smoke. Children with special health care needs, especially those that depend on technology for survival, are particularly vulnerable and should be considered in shelter planning. Also, parents/single parents with sick children cannot be caregivers simultaneously for both a hospitalized child and non-hospitalized, sheltered children.
Planning should also include pregnant women, the fetus, and the newly born. The stress of a disaster can contribute to premature labor and delivery. Infection acquired by the fetus in utero can lead to fetal death or to devastating consequences if the fetus survives. The risk of developing cancer is higher in children who have been exposed to radiation in utero. Radioactive iodine is transmitted to human breast milk and threatens infants who are breastfeeding. Cow's milk can also be quickly contaminated if radioactive material settles onto grazing areas, threatening alternative sources of nutrition.
As demonstrated by past events, there is ample opportunity to improve preparedness for children involved in disasters (both man-made and natural). This Pediatric Terrorism and Disaster Preparedness resource contains information needed for pediatricians to be prepared for disasters at all phases of planning, response, recovery, and mitigation. The role of the pediatrician should not be minimized, underestimated, or overlooked in disaster planning and response. Pediatricians, based on their traditional roles in prevention, anticipatory guidance, and advocacy, can make a difference in comprehensive public health plans for disaster.
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