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Pediatric Decontamination: More Than Just A Bath. Lou Romig MD, FAAP, FACEP Pediatric Emergency Medicine West Kendall Baptist Hospital Miami, FL. Disclosure. The speaker has declared no conflict of interest. Topics. Why worry about deconning kids? What makes deconning kids different?

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pediatric decontamination more than just a bath

Pediatric Decontamination: More Than Just A Bath

Lou Romig MD, FAAP, FACEP

Pediatric Emergency Medicine

West Kendall Baptist Hospital

Miami, FL

disclosure
Disclosure

The speaker has declared no conflict of interest.

topics
Topics
  • Why worry about deconning kids?
  • What makes deconning kids different?
    • Behavior
    • Logistics
  • Pediatric decon in the field
  • Pediatric decon at the hospital
nebraska alliance for drug endangered children http www nebraskadec org protocols html
Nebraska Alliance for Drug-Endangered Childrenhttp://www.nebraskadec.org/protocols.html
risk factors for exposure
Risk factors for exposure

Kids:

  • make terrifying targets
  • may not recognize danger
  • may not be able to self-rescue or defend themselves
  • may not report exposure
  • come in bunches
  • put things in their mouths and noses
risk factors once exposed
Risk factors once exposed
  • Close to the ground
  • More permeable skin
  • Larger body surface area
  • Higher minute ventilation
risk factors once exposed1
Risk factors once exposed
  • Susceptibility to fluid losses
  • Underdeveloped immune system
  • Rapidly dividing cells
risk factors once exposed2
Risk factors once exposed
  • Medical providers inexperienced in pediatric care
  • Inadequate preparation by rescuers and responders, including hospitals
  • Inadequate forms and stocks of antidotes
behavior personnel
Behavior: Personnel
  • Need for adult supervision
  • Must deal with caregivers
  • Emotional involvement of responders
  • Crowd management
behavior the kids
Behavior: The kids
  • Difficulty communicating
  • Difficulty following directions
  • Hesitancy to disrobe
  • Fear!
logistics
Logistics
  • Personnel intensive
  • Increased decon time/slowed through-put
    • ≥10-15 min/pediatric pt total time
  • Prevent hypothermia
    • Adequate pre- and post-decon garb
    • Water temp 98-100° F
    • Warmed decon facility
logistics1
Logistics
  • Prevent injury from water spray
    • 60 psi
  • Avoid using chemicals
  • Prevent slips and falls
logistics2
Logistics
  • Unaccompanied children
    • Identification
    • Supervision
  • Prioritization
    • All children first?
    • Based on medical triage?
  • Maintain privacy/security
pediatric decon in the field
Pediatric decon in the field
  • Usually high-volume/low pressure
  • Warm water?
  • Adequate drying and post-decon coverings to prevent hypothermia?
  • Transport all deconned for medical evaluation?
  • Protocols for pedi decon?
  • Drills for pedi decon?
pediatric decon at the hospital1
Pediatric decon at the hospital
  • Never assume you won’t get pediatric patients
  • Include pediatric considerations in your decon plans (and all disaster plans!)
  • Train and retrain
  • Include children and families in all disaster drills and training
  • Failure to prepare may shut down your facility and endanger staff and patients
arrival
Arrival

When notified of an event involving potentially contaminated victims, activate your decon plan early.

Protect your facility!

arrival1
Arrival
  • Never assume all contaminated patients will arrive via EMS, already grossly decontaminated and triaged
  • Children are portable!
  • The closest hospital is at greatest risk
  • Don’t assume a person knows they’ve been contaminated
  • Not everyone who thinks they’re contaminated has really been exposed
arrival2
Arrival
  • ID and separate contaminated vs possibly contaminated vs grossly deconned vs clean pts
  • Whenever possible, keep children with family members
  • Potentially contaminated unaccompanied minors must be supervised by protected personnel
arrival3
Arrival
  • Determine decon priorities
    • Rapid (re)triage by protected personnel
    • Life saving interventions by protected personnel
      • AW opening
      • Control bleeding
      • IM antidotes (autoinjector)
    • Most critical deconned first?
    • Children deconned first?
pre shower
Pre-shower
  • ≥90% of contamination is removed with clothing
  • Toys, backpacks, jewelry and comfort items must be bagged and tagged
  • Provide adequate coverage for warmth and modesty between disrobing and showering
  • Record EMS triage tag number for ID and tracking
pre decon garb
Pre-decon garb

Courtesy UMHealth Systems

pre shower1
Pre-shower
  • Permit family members to stay together unless critical medical issues take priority
  • Family processed at the level of highest medical priority of any single member
  • Consider taking digital photos of unaccompanied minors who can’t identify themselves before disrobing. This may assist in identification/reunification.
wet decon gender issues
Wet decon: Gender issues
  • Gender separation preferred for children older than 8 years of age
  • Same gender personnel preferred if needed for assistance in wet decon
wet decon age issues
Wet decon: Age issues
  • 0-2 years
    • Never assume a caregiver can decon his/herself and their child/children
    • Highest risk for hypothermia
    • Monitor child’s airway during decon
    • Do NOT permit decon in-arms
    • Two personnel to decon if no caregiver
    • One hand on an infant at all times.
wet decon age issues1
Wet decon: Age issues
  • 2-8 years (“guestimate” age)
    • This group will likely take the longest
    • Not critical to separate genders but preferred
    • Gender-matched personnel preferred
    • Older children in this age group may be able to decon themselves with supervision and encouragement
wet decon age issues2
Wet decon: Age issues
  • 8-18 years (“guestimate” age)
    • Respect modesty
    • Gender separation preferred
    • Gender-matched assistance preferred
    • Can decon themselves with supervision
wet decon nonambulatory
Wet decon: Nonambulatory
  • Assistance by caregivers when available
  • Caregivers must also decon
  • Decon on stretcher or other restraining device
  • Consider roller or slide system
wet decon special needs
Wet decon: Special needs
  • Allow caregiver to remain with child if at all possible
  • Maintain communication with child
  • Increased risk for hypothermia and medical deterioration
  • Be aware of need to decon stomas and possibly remove stomal appliances
  • Trachs and other appliances may need to be replaced in cold zone
wet decon equipment
Wet decon: Equipment
  • Equipment-dependent patients:
    • Non-waterproof equipment remains in hot zone if pt is symptomatic and/or equipment is grossly contaminated
    • Decon water-resistant equipment, preferably keeping it with the patient
wet decon other issues
Wet decon: Other issues
  • Mild soap may be used with water
  • Do not use bleach or other chemicals
  • Genitals must be deconned as well
  • Depending on contaminant, eye/nose/ear and mouth lavage may be necessary
wet decon other issues1
Wet decon: Other issues
  • Remove dressings to decon wounds
  • Ideally, there should be a protected pediatric care-capable clinician in the decon area at all times.
post decon
Post-decon
  • Immediately dry patient
  • Assure layer of clothing or other covering closest to skin is dry. Remember to cover head and feet to help prevent heat loss.
  • Use appropriate garb or coverings to assure warmth and comfort and protect modesty
post decon1
Post-decon
  • Assure patient is appropriately identified and tracked
  • Re-triage and commence further care
  • Will all those deconned be considered patients for further medical evaluation or is screening sufficient? Is this policy for prospective patients of all ages?
post decon2
Post-decon
  • Provide a child-friendly environment
  • Further assessment should include evaluation for psychological trauma due to the incident and the decon process
  • Ideally, provide families with information about psychological consequences and warning signs requiring further evaluation
key points1
Key Points
  • All hospitals should be prepared to decon patients of all ages
  • Decon procedures must be determined in advance. Training and retraining is crucial. Training should include pediatric considerations.
  • The “big one” may never come but the “small ones” may hurt you if you’re not prepared
key points2
Key Points
  • If children become contaminated they may be at increased risk of morbidity and mortality compared to adults
  • Deconning kids is personnel-intensive
  • Utilize caregivers but be prepared to assist them. Keep children with their caregivers.
key points3
Key Points
  • Children’s natural behavior can prolong the decon process
  • Keep children warm at all times using coverings, 98-100°F water and a warm decon facility
  • Identification and tracking through the entire decon process is critical to reunification efforts
key points4
Key Points
  • Ideally, genders should be separated for patients over early school age. Same gender personnel are also preferred.
  • Patient age can influence decon procedures
  • Never carry a wet slippery child through decon
key points5
Key Points
  • Details are important. A contaminated pacifier or field dressing can cause trouble.
  • Keep at least one pediatric-capable clinician available in protective gear in decon at all times to recognize and intervene in case a child rapidly deteriorates
references
References
  • The Decontamination of Children, DVD, AHRQ, Children’s Hospital Boston
  • “Principles of Pediatric Decontamination”, Heon and Foltin, Clinical Pediatric Emergency Medicine, Sept 2009
  • “Disaster Preparedness: Hospital Decontamination and the Pediatric Patient”, Freyberg, et al, Prehospital and Disaster Medicine, March-April 2008
  • Nebraska Alliance for Drug Endangered Children, http://www.nebraskadec.org/protocols.html
references1
References
  • OSHA Best Practices for Hospital First Receivers of Victims from Mass Casualty Incidents Involving the Release of Hazardous Substances, Jan 2005, http://www.osha.gov/dts/osta/bestpractices/html/hospital_firstreceivers.html#appj
  • Decontamination Guidance for Hospitals, Victorian Government, Emergency Management Branch, Department of Human Services, Melbourne, Australia, 2007, http://www.dhs.vic.gov.au/__data/assets/pdf_file/0004/613777/decon_guidance_for_hospitals.pdf
  • Pediatric and Obstetric Emergency Preparedness Toolkit, New York State Dept of Health, June 2010, http://www.health.ny.gov/facilities/hospital/emergency_preparedness/guideline_for_hospitals/index.htm
thank you
Thank you!

Lecture available for download at

www.jumpstarttriage.com

louromig@bellsouth.net