Tactical Emergency Casualty Care Pediatric Guidelines

On a typical school day morning, school bus 17, carrying 42 elementary school students through suburban roads and main thoroughfares, suddenly strikes metal debris in the road blowing out the bus’s right tire and sending the bus careening off the road and into a tree.

The bus lands on its side and the passengers are trapped inside. After a frantic 9-1-1 call by a commuter, law enforcement arrives on scene, followed closely by the first fire and EMS units. They quickly establish incident command, declare a mass casualty incident (MCI), order additional resources and begin triaging the casualties. The responding medics find numerous school-age casualties in varying degrees of injury, criticality and distress.

Shifting the Paradigm of Treating Pediatric Trauma
The rise in Active Violence Incidents (AVIs) is a concerning trend facing EMS.1 While we shouldn’t let AVIs dominate discussions regarding trauma care, the increased awareness offers opportunities to drive a paradigm shift in the prehospital training and treatment of pediatric trauma casualties.2

Training that was once the domain of only specialized law enforcement teams and their medical components is slowly but steadily transitioning to street-level first responders.3,4 In the past five years, fire-based systems have driven much of this expansion.5,6 The traditional EMS community is now racing to catch up.

It’s important to recognize that threats don’t simply include active shooters or terrorists; threats can include a burning bus, structural collapse, gas leaks, etc. The case above highlights two distinct gaps in the prehospital care in the high threat environment. First, although the system-level training of the civilian Tactical Emergency Casualty Care (TECC) principles has begun to reach the ground level with the recent International Association of Fire Fighters and United States Fire Administration/Federal Emergency Management Agency position papers, traditional EMS trauma education (e.g., BTLS and PALS) falls short on the treatment of the pediatric casualty in today’s high-threat environment.

Although these protocols are helpful in most cases of blunt trauma or medical arrest, they aren’t sufficient in the setting of multiple, high acuity penetrating trauma patients.

Second, the teaching and use of triage protocols without guidance on intervention may be due to the previous lack of literature regarding the treatment of the critically injured child.7
For example, an EMS provider encountering a situation with multiple children suffering critical bleeding is currently being taught to respond via MCI declaration and triage protocol such as JumpSTART. However, in many cases this approach may subject the pediatric casualty to unnecessary delays in hemodynamic stabilization.8

Currently there are no critical care pediatric programs that deal with critically injured pediatrics within the austere environment of mass casualties involving predominantly pediatric patients. This differs markedly from the literature base and approach taken with adult MCI and poly-trauma casualties.9

Recognizing this gap in rescue operations, the Committee for TECC began an effort to develop a set of evidence-based pediatric casualty care guidelines.

Beginning in 2011, the committee formed a special populations subcommittee and pediatric working group to address the less represented demographics in our casualty population. These guidelines were developed using the same methodology employed for the development of the adult guidelines combining expert agreement, best evidence and current practices.10

Beginning with an extensive literature review, the pediatric working group analyzed the literature for current evidence regarding pediatric casualty treatment. Given the significant lack of prehospital pediatric trauma data, the literature review included ED, operating theater and pediatric critical care data as well as prehospital and international disaster response research. The findings were presented for consensus review and published as the initial pediatric appendix to the TECC guidelines in 2013.

How the Pediatric Guidelines Apply to EMS
While modern law enforcement and EMS training frequently focuses on the response to dynamic threats, there’s wide variability in the preparation for pediatric casualties. Additionally, multiple sources confirm that children are often overlooked in disaster response, which may be resultant from inadequacy of current pediatric training.8,11

Within the past two years, events involving public locations (e.g., schools, churches and theaters) have attracted the attention of the national media. Most, if not all, have involved pediatric casualties.12 The guidelines proposed by the TECC committee will greatly empower first responders of all types to improve familiarity and confidence with care for the pediatric trauma while in the high-threat scenario.

Understanding the current recommendations for an efficient and effective approach to the injured child incorporates not just mitigation of the physical injury but a holistic approach to minimize emotional distress in the casualty and improve understanding and thus compliance with direction given by responders.9 Integration of this approach into current protocols will go far to eliminate the confusion and uncertainty that often accompany these situations.

Approaching the Injured Child
The response to pediatric AVIs or MCIs is a poorly researched topic. As a result, we have incorporated data from several related fields including literature from experts in disaster/refuge care and child life specialists for general guidance on broad themes. Because of the difficulty writing guidance for a patient population ranging from infant to young adult, particular attention was paid to methods for improving communication with pediatric casualties and minimizing exposure to emotional distress.

Understanding that a child’s ability to respond to a stressful event is directly related to their development level and is critical to preparing providers to meet this challenge.

Because stress comes in many forms and is the summation of an emotional response to an event, it’s incumbent upon EMS and safety providers to minimize distress. Improper or ineffective management of the pediatric casualty’s distress will damage trust, complicate medical care and create difficulty in communication with the patient.

This perceived loss of control has operational consequences for the tactical response element. A child’s information processing ability is impaired under moderate stress. The extra time that’s required to engage a patient in a state of “frozen watchfulness” may have direct and severe consequences on the immediate operations of the response team.13 Moreover, the younger the child’s age, the more likely the child is to devolve into a state of undifferentiated threat and generalized distress.14

Not only might a child in this state be noncompliant with instruction or treatment, but this may limit information valuable to responders. As such, incorporating simple techniques can improve the chances of a cooperative patient and improve transition into post-event care. These techniques have been incorporated into the updated TECC pediatric appendix.

Pediatric vs. Adult TECC Guidelines
Pediatric care guidelines for the TECC phases of care as a whole mirror the adult guidelines with several important distinctions. As with adults, rapid hemorrhage control and tourniquet application is emphasized. The TECC pediatric guidelines are the first to specifically recommend pediatric tourniquet application. Supported by the only study to date,15 this recommendation is carried through the direct care, indirect care and evacuation phase guidelines.

Further recommendations put forth in the guidelines are important both for the provider and the management level oversight of response personnel. Based on physiologic differences in pediatric patients, changes in management and equipment are delineated.

Consistent with the adult guidelines, primary emphasis is again placed on achieving and maintaining hemostasis. Once achieved, controlling the pediatric airway is the next priority. Interventions, including positioning, manipulation and ventilation strategies, diverge from the adult guidelines.

Utilization of bag-valve mask ventilation is emphasized and shoulder elevation is recommended. Age criteria for invasive airway intervention is delineated and makes use of the “signs of puberty” method of age delineation familiar to most prehospital providers.

Other topics addressed in the pediatric appendix include recommendations for intraosseous line placement as primary access, vigilance in avoidance of hypothermia and resuscitation guidelines.

Again, because of the dramatic variance in size of the pediatric population, thoracostomy needle sizes in pediatric casualties have yet to be proven in the literature. As such, the TECC committee chose to recommend a minimum catheter gauge size thereby allowing for local medical direction and provider discretion.

Recommendations regarding the use of tranexamic acid, hypotensive resuscitation and whole blood transfusion were deferred pending establishment of supporting evidence. These topics were passed to the TECC research subcommittee to drive future pediatric trauma resuscitation studies.

Reducing Post-Event Emotional Distress
Understanding that minimizing additional emotional distress is critical to the post-traumatic management of pediatric casualties and their parents, the TECC pediatric guidelines incorporate strategies directly for this during the evacuation phase.

Information exchange in the post-event setting too often follows a unidirectional flow from provider to patient. This information, in the form of announcements or briefings, assumes the message can be clearly understood and easily processed by the recipient. However, a child’s ability to process the information is impaired under even moderate stress.14

Because the bidirectional information flow can be useful to both care providers and first responders alike, care must be taken to ensure that communications with casualties, witnesses and parents are presented in a manner that facilitates processing and retention.

Children, like adults, obtain information from their surroundings, incorporating visual and other types of nonverbal clues with the actual message. Preferably, this information can be provided by the parent. However, in times of disaster, separation from their parents is likely. Unfortunately, parental absence or anxiousness on the part of the providers can be interpreted as a loss of control and is likely to increase emotional distress.

Accordingly, the TECC guidelines have suggested that first responders or care providers plan operationally, not only for a “child friendly space,” but for an individual or group of individuals dedicated specifically to interaction with pediatric casualties.

This shouldn’t be interpreted as a requirement for a pediatric specialist, but for at least one care provider who’s “frequently and readily available” to provide consistency and help offset the perceived loss of control by the children affected.

The final aim of the pediatric guidelines is to ensure that providers recognize the necessity for ensuring integrity of the family unit. This will fulfill two goals. First, it improves communication between those affected and the providers caring for them and, second, it’s essential to mitigating post-event emotional distress. By emphasizing family-centered care we can return a sense of autonomy to the family unit.

Too often, mission objectives are prioritized over patient care. Simple steps such as reuniting parents with children and keeping siblings and extended family groups together will improve operational flow, medical care and pediatric victim recovery. Improving familiarity will also improve both the victims’ and families’ understanding of a dynamic situation.

Providing prospective guidance to parents and families will increase predictability in these situations. This improved familiarity and predictability has a demonstrable effect on mitigating emotional distress.14 In this case, reducing distress can actually help reach mission objectives. Considering that information obtained by both law enforcement and EMS is obtained through witness testimonial, reduction of distress is paramount operationally. Community resilience is paramount culturally.

Conclusions
There’s no greater challenge to an EMS system or a society than an MCI involving children. As these events become a greater concern, systems and communities must evolve in their preparation.16

Our hope is that family-centered care and mitigation of emotional distress improves community and first responder resiliency. The mission of the Committee for TECC is to improve the civilian prehospital medical and law enforcement response to atypical disasters.

With the publication of the pediatric appendix to the TECC guidelines, we seek to continue the expansion of these principles of response to a broader demographic. We hope this article will empower local jurisdictions to tailor their response protocols to meet the needs of their civilian populations. ✚

Strategies for Communicating with Children During Trauma
“¢ Approach from eye level.
“¢ Use “minimally threatening” or “soft” language.
      —Use direct phrases (i.e., an incision should be described as “making a small opening” rather than a “cut” or “hole”).
      —Avoid using the word “hurt” because it has nonspecific connotations, and doesn’t convey helpful information. Try “sting” or “prick” when preparing children for an IV.
“¢ Give analogy for medical terms (e.g., shot, pressure dressing, stretcher or butterfly). When using a tourniquet describe it like a “big rubber band” (something familiar to most children).
“¢ Don’t provide explicit detail.
      —Only provide children with the information that they will directly experience.
      —Too much information may confuse or
frighten children.
“¢ Have child repeat back what they’ve heard.
“¢ Allow child to make choices.
      —”Some kids say it feels like a pinch and others say a sting. What do you think?”
“¢ Restore sense of control.
“¢ Give child autonomy over his or her body.
“¢ Enable children to play an active role.
      —”Your job is to hold his hand” or “sing the Air Force Song.”

Strategies for Post-Trauma Management of Children
“¢ Assign a single information provider for
pediatric victims.
      —The absence of a trusting relationship is a cause of emotional distress.14
      —Provide at least one care provider who is frequently and readily available.
      —Be mindful of nonverbal communications.
“¢ Allow for “play therapy” during evacuation phase and after the event.
      —Facilitate the transmission of complex or abstract concepts
“¢ Use drawings, medical tools, etc.
“¢ May provide more information post-event than verbal interviews.
“¢ Allow for family reunification.
      —Emphasizing “family-centered care” fosters return of family unit autonomy.
“¢ Keep parents with children.
“¢ Keep siblings together.
      —Increases familiarity for children affected by events (parental signaling).
      —Provide anticipatory guidance.
“¢ Increase familiarity and predictability
      —Need to work closely with families to assess their understanding of the situation.
      —Anticipatory guidance will reduce
emotional distress.

References
1. Blair JP, Martaindale MH, Nichols T. (Jan. 7, 2014.) Active shooter events from 2000 to 2012. FBI Law Enforcement Bulletin. Retrieved July 15, 2014, from http://leb.fbi.gov/2014/january/active-shooter-events-from-2000-to-2012.
2. Thompson T, Lyle K, Mullins SH, et al. A state survey of emergency department preparedness for the care of children in a mass casualty event. Am J Disaster Med. 2009;4(4):227—232.
3. Callaway DW, Smith ER, Cain J, et al. Tactical Emergency Casualty Care (TECC): Guidelines for the provision of prehospital trauma care in high threat environment. J Spec Oper Med. 2011;11(3);104—122.
4. Smith ER, Iselin B, McKay WS. Toward the sound of shooting: Arlington county, Va., rescue task force represents a new medical response model to active shooter incidents. JEMS. 2009; 34(12):48—55.
5. Fire/emergency medical services department operational considerations and guide for active shooter and mass casualty incidents. (September 2013.) U.S. Fire Administration. Retrieved July 15, 2014, from www.usfa.fema.gov/downloads/pdf/publications/active_shooter_guide.pdf.
6. IAFF position statement: Active shooter events. (n.d.) International Association of Fire Fighters. Retrieved July 15, 2014, from www.iaff.org/Comm/PDFs/IAFF_Active_Shooter_Position_
Statement.pdf.
7. Seid T, Ramaiah R, Grabinsky A. Pre-hospital care of pediatric patients with trauma. Int J Crit Illn Inj Sci. 2012;2(3):114—120.
8. Seidel JS. Emergency medical services and the pediatric patient: Are the needs being met? II. Training and equipping emergency medical services providers for pediatric emergencies. Pediatrics. 1986;78(5):808—812.
9. Bankole S, Asuncion A, Ross S, et al. First responder performance in pediatric trauma: A comparison with an adult cohort. Pediatr Crit Care Med. 2011;12(4):e166—e170.
10. Bobko J. Tactical emergency casualty care—pediatric appendix: Novel guidelines for the care of the pediatric casualty in the high threat, prehospital environment. J Spec Oper Med. 2013;13(4):94—107.
11. Johnson L, Bugge J. (2007) Child-led disaster risk reduction. International Save the Children Alliance. Retrieved July 15, 2014, from http://resourcecentre.savethechildren.se/library/child-led-disaster-risk-reduction-practical-guide-part-1.
12. Theater shooting victims are 4 months old to adults. (July 20, 2012.) KMGH-TV/TheDenverChannel.com. Retrieved July 15, 2014, from www.thedenverchannel.com/news/theater-shooting-victims-are-4-months-old-to-adults.
13. Kempe R, Kempe CH: Child abuse. Harvard University Press: Cambridge, Mass., 1978.
14. Gaynard L, Wolfer J, Foldberger J, et al: Psychosocial care of children in hospitals: A clinical practice manual from the ACCH Child Life Research Project. Child Life Council: Rockville, Md., pp. 15—65, 1998.
15. Kragh JF Jr, Cooper A, Aden JK, et al. Survey of trauma registry data on tourniquet use in pediatric war casualties. Pediatr Emerg Care. 2012;28(12):1361—1365.
16. Blair JP, Martaindale MH, Nichols T. (Jan. 7, 2014.) Active shooter events from 2000 to 2012. FBI Law Enforcement Bulletin. Retrieved July 31, 2014, from http://leb.fbi.gov/2014/january.

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