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[And if it happened to children? Adapting medical care during terrorist attacks with multiple pediatric victims]
L Alix-Séguin1, N Lodé2, G Orliaguet3
1SMUR pédiatrique Robert-Debré (SAMU 75), hôpital Robert-Debré, AP-HP, 48, boulevard Sérurier, 75019 Paris, France; Service d'urgence pédiatrique, CHU Sainte-Justine, 3175, chemin de la Côte-Sainte-Catherine, H3T 1C5 Montréal, Canada.
Insights
Pediatric mass casualty incidents require adapting prehospital damage control principles, focusing on hemorrhage control and preventing the lethal triad. Training for mass pediatric casualties is crucial for effective emergency medical management.
Area of Science:
- Emergency Medicine
- Pediatric Critical Care
- Disaster Medicine
Background:
- Recent terrorist attacks highlight the need for improved mass casualty incident (MCI) preparedness, particularly for pediatric victims.
- Children present unique anatomical and physiological challenges in mass casualty events, including increased risk of brain injury and complex airway management needs.
- Civilian medical teams utilize the MARCHE algorithm (Massive hemorrhage, Airway, Respiration, Circulation, Head/Hypothermia, Evacuation) principles adapted from military medicine.
Purpose of the Study:
- To adapt prehospital damage control principles for the unique needs of pediatric patients in mass casualty incidents.
- To outline critical interventions for managing hemorrhagic shock and the lethal triad (coagulopathy, hypothermia, acidosis) in pediatric victims.
- To emphasize the importance of training and preparedness for prehospital teams managing multiple pediatric casualties.
Main Methods:
- Review and adaptation of military-medicine principles (MARCHE algorithm) for pediatric mass casualty scenarios.
- Focus on prehospital damage control strategies including hemorrhage control and management of the lethal triad.
- Application of specific resuscitation guidelines for pediatric hemorrhagic shock, including fluid resuscitation, vasopressors, and tranexamic acid.
Main Results:
- Effective management of pediatric mass casualty incidents requires prioritizing hemorrhage control and preventing the lethal triad.
- Prehospital management strategies include rapid external bleeding control, judicious fluid resuscitation (10-20ml/kg), early vasopressor use (noradrenaline), and tranexamic acid administration.
- The study underscores the vulnerability of children and the need for specialized training and resources for pediatric mass casualty events.
Conclusions:
- Prehospital damage control principles must be tailored for pediatric mass casualty incidents, emphasizing hemorrhage control and the lethal triad.
- Swift and orderly evacuation, alongside adapted medical interventions, is critical for improving outcomes in pediatric mass casualty events.
- Enhanced training and resource allocation for prehospital providers are essential to effectively manage scenes with multiple pediatric victims.
Abstract:
In light of the recent terrorist attacks in Europe, we need to reconsider the organization of rescue and medical management and plan for an attack involving multiple pediatric victims. To ensure quick surgical management, but also to minimize risk for on-site teams (direct threats from secondary terrorist attacks targeting deployed emergency services), it is crucial to evacuate patients in a swift but orderly fashion. Children are vulnerable targets in terrorist attacks. Their anatomical and physiological characteristics make it likely that pediatric victims will suffer more brain injuries and require more, often advanced, airway management. Care of multiple pediatric victims would also prove to be a difficult emotional challenge. Civilian medical teams have adapted the military-medicine principles of damage control in their medical practice using the MARCHE algorithm (Massive hemorrhage, Airway, Respiration [breathing], Circulation, Head/Hypothermia, Evacuation). They have also learned to adapt the level of care to the level of safety at the scene. Prehospital damage control principles should now be tailored to the treatment of pediatric patients in extraordinary circumstances. Priorities are given to hemorrhage control and preventing the lethal triad (coagulopathy, hypothermia, and acidosis). Managing hemorrhagic shock involves quickly controlling external bleeding (tourniquets, hemostatic dressing), using small volumes for fluid resuscitation (10-20ml/kg of normal saline), quickly introducing a vasopressor (noradrenaline 0.1μg/kg/min then titrate) after one or two fluid boluses, and using tranexamic acid (15mg/kg over 10min for loading dose, maximum 1g over 10min). Prehospital resources specifically dedicated to children are limited, and it is therefore important that everyone be trained and prepared for a scene with multiple pediatric patients.
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