Biomedical Engineering Reference
In-Depth Information
Children are at greater risk of morbidity and
mortality due to traumatic injury. In trauma situa-
tions, the force of the trauma, such as an explosion,
is transmitted over a smaller surface area, thus
magnifying the amount of traumatic injury in the
child [8]. Relative to the adult, a child has a larger
head size that translates into a higher frequency
of head injuries in children with its attendant
sequelae. Pediatric circulation allows maintenance
of a normal blood pressure despite the loss of up
to 50% of blood volume. However, this is at the
expense of underperfusing important organs such
as the liver, gastrointestinal tract, and kidney. This
ability to compensate is due to the generation of
high concentrations of catecholamines in response
to injury [9]. As a result, children managed by inex-
perienced personnel may receive care after adults
who have similar or even lesser injuries in a mass-
casualty situation. Because traumatic force is trans-
mitted to underlying organs through the relatively
plastic pediatric skeleton, children are more apt to
develop pulmonary contusion, an injury that can
be difficult to detect in its early stages.
Children have a higher body surface area to
mass and a more permeable skin than adults. As
a result, they are more prone to serious conse-
quences of dermal exposures from chemical agents
such as nerve gas and vesicants. The large surface
area exacerbates insensible heat loss and fluid loss
in children with burns. Convective heat loss with
hypothermia can be a serious problem in chil-
dren undergoing wet decontamination. Children
also have lower glycogen and fluid reserves and
are more prone to ketosis and dehydration in the
setting of vomiting and diarrhea, a common conse-
quence of biological, chemical and radiological
weapons [6].
The pediatric immune system is less robust,
especially those under 2 years of age. This
makes children more prone to infectious agents
and to agents that compromise immunity such
as vesicant agents and nuclear agents. In addi-
tion, children's bone marrow is more susceptible
to malignant transformation induced by radiation
exposure and chemical mutagens. This suscepti-
bility makes cancer risk higher in children than in
adults with the same exposures [5,10].
Cognitively, children have limited reasoning
ability. They are dependent on adults to recog-
nize danger and avoid hazards. Their psychological
immaturity places them at great risk because they
have limited coping skills. Serious mental illness
can result not only to direct victims of a terrorist
attack but also to witnesses of the attack, even in
the absence of physical injury [11,12].
Ideally, children should be cared for by personnel
with specific training in pediatrics and pediatric
emergency care. However, in a disaster situa-
tion, these resources may be quickly overwhelmed.
Nationwide there are 56 freestanding children's
hospitals and over 5000 general hospitals [13].
Most children's hospitals run at or near capacity
year round. In Connecticut, there are two chil-
dren's hospitals with a combined total of 174 inpa-
tient pediatric medical/surgical beds, 36 pediatric
intensive care beds, and 24 emergency department
beds. These hospitals serve an estimated popu-
lation of 612,816 children less than 19 years of
age [14]. There are 30 remaining general hospi-
tals and one Veteran's Administration hospital that
currently have limited pediatric services. Clearly, a
major disaster of the magnitude of Beslan, Russia
(150 children killed, 500 injured, over 50% criti-
cally) would quickly overwhelm existing pediatric
resources in Connecticut. Therefore, in Connecticut
and elsewhere, it is imperative that general hospi-
tals, including those with limited existing pediatric
resources, develop additional pediatric capacity.
Several key interventions are necessary to miti-
gate negative outcomes for children during disaster
care. Training in pediatric assessment and triage
with pediatric specific protocols, such as the Jump-
START system helps prevent undertriaging of
seriously ill or injured children when they are eval-
uated with adults (Figure 10.1) [15]. Personnel
designated for hospital triage should familiarize
themselves with these protocols and practice
them regularly on simulated pediatric victims
during mass casualty drills. Appropriate treat-
ment of children begins with correct assessment
that identifies critical resuscitation needs. Pediatric
assessment and care is taught in several standard-
ized courses. Table 10.2 summarizes these courses
and the intended audience.
