Pediatric Decontamination: More Than Just A Bath

1. Pediatric Decontamination: More Than Just A Bath Lou Romig MD, FAAP, FACEP Pediatric Emergency Medicine West Kendall Baptist Hospital Miami, FL

2. Disclosure The speaker has declared no conflict of interest.

3. Topics • Why worry about deconning kids? • What makes deconning kids different? • Behavior • Logistics • Pediatric decon in the field • Pediatric decon at the hospital

4. Why worry about contaminated kids?

5. Why worry about contaminated kids?

6. Nebraska Alliance for Drug-Endangered Childrenhttp://www.nebraskadec.org/protocols.html

7. 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

8. Risk factors once exposed • Close to the ground • More permeable skin • Larger body surface area • Higher minute ventilation

9. Risk factors once exposed • Susceptibility to fluid losses • Underdeveloped immune system • Rapidly dividing cells

10. Deconning a radioactive school yard in Fukushima

11. Risk factors once exposed • Medical providers inexperienced in pediatric care • Inadequate preparation by rescuers and responders, including hospitals • Inadequate forms and stocks of antidotes

12. What makes deconning kids different?

13. Behavior: Personnel • Need for adult supervision • Must deal with caregivers • Emotional involvement of responders • Crowd management

14. Behavior: The kids • Difficulty communicating • Difficulty following directions • Hesitancy to disrobe • Fear!

18. 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

19. Logistics • Prevent injury from water spray • 60 psi • Avoid using chemicals • Prevent slips and falls

20. Logistics • Unaccompanied children • Identification • Supervision • Prioritization • All children first? • Based on medical triage? • Maintain privacy/security

21. Decon of children in the field

22. Decon of victims vs responders

23. 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?

24. Pediatric decon at the hospital

25. 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

26. Arrival When notified of an event involving potentially contaminated victims, activate your decon plan early. Protect your facility!

28. 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

29. 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

30. 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?

31. 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

32. Pre-decon garb Courtesy UMHealth Systems

33. 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.

34. 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

35. 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.

36. Safety for young children

37. 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

38. Wet decon: Age issues • 8-18 years (“guestimate” age) • Respect modesty • Gender separation preferred • Gender-matched assistance preferred • Can decon themselves with supervision

39. Wet decon: Nonambulatory • Assistance by caregivers when available • Caregivers must also decon • Decon on stretcher or other restraining device • Consider roller or slide system

40. 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

41. 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

42. 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

43. 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.

44. 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

45. Post-decon garb

46. Decon Kits

47. 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?

48. 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

49. Key Points

50. 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