Earthquakes rank among the most deadly natural disasters, and children are particularly affected due to their inherent vulnerability. Following an earthquake, there is a substantial increase in visits to emergency services. These visits stem not only from patients seeking care for physical traumas resulting from the earthquake and its subsequent complications, but also from individuals affected by the circumstances created by the disaster.

This study aims to determine the characteristics and outcomes of children who presented to the pediatric emergency department (PED) after the earthquake and to evaluate children who had crush injuries at a referral tertiary university hospital away from the earthquake area.

The medical records of children who presented to the PED from the earthquake area from February 6 through March 7, 2023 were retrospectively reviewed. Children rescued from under rubble were categorized as Group 1, those affected by earthquake conditions as Group 2, and patients seeking medical attention due to the follow-up of chronic illnesses were considered as Group 3. Patient data, including sociodemographic characteristics, time period under rubble (TPR), laboratory findings, and details of medical and surgical procedures, developing acute kidney injury (AKI), and the requirement for hemodialysis were recorded.

A total of 252 children were enrolled in the study, with 52 (20.6%) in Group 1, 180 (71.4%) in Group 2, and 16 (6.0%) in Group 3. The median age was six (IQR = 1.7-12.1) years. In the first group (n = 52), 46 (85.2%) children experienced crush injuries, 25 children (46.3%) developed crush syndrome, and 14 of them (14/25; 56.0%) required dialysis. In the second group, the most common diagnoses were upper respiratory tract infections (n = 69; 37.9%), acute gastroenteritis (n = 23; 12.6%), simple physical trauma (n = 16; 8.8%), and lower respiratory tract infections (n = 13; 7.1%). For children in the third group, pediatric neurology (n = 5; 33.3%), pediatric oncology (n = 4; 25.0%), and pediatric nephrology (n = 3; 18.8%) were the most frequently referred specialties.

Crush injuries, crush syndrome, and AKI were the most common problems in the early days following the earthquake. Along with these patients, children who were affected by the environmental conditions caused by the earthquake, as well as children with chronic illnesses, also accounted for a significant portion of visits to the PED, even if they were distant from the disaster area.

The majority of pediatric medications are dosed according to weight and therefore accurate weight assessment is essential. However, this can be difficult in the unpredictable and peripatetic prehospital care setting, and medication errors are common. The Handtevy method and the Broselow tape are two systems designed to guide Emergency Medical Services (EMS) providers in both pediatric patient weight estimation and medication dosing. The accuracy of the Handtevy method of weight estimation as practiced in the field by EMS has not been previously examined.

The primary objective of this study was to examine the field performance of the Handtevy method and the Broselow tape with respect to prehospital patient weight estimation.

This was a retrospective chart review of trauma and non-trauma patients transported by EMS to the emergency department (ED) of a quaternary care children’s hospital from January 1, 2021 through June 30, 2021. Demographic data, ED visit information, prehospital weight estimation, and medication dosing were collected and analyzed. Scale-based weight from the ED was used as the standard for comparison.

A total of 509 patients <13 years of age were included in this study. The EMS providers using the Broselow method estimated patient weight to within +/-10% of ED scale weight in 51.3% of patients. When using the Handtevy method, the EMS providers estimated patient weight to within +/-10% of ED scale weight in 43.7% of patients. When comparing the Handtevy versus Broselow method of prehospital weight estimation, there was no significant association between method and categorized weight discrepancy (over, under, or accurate estimates – defined as within 10% of ED scale weight; P = .25) or percent weight discrepancy (P = .75). On average, prehospital weight estimation was 6.33% lower than ED weight with use of the Handtevy method and 6.94% lower with use of the Broselow method.

This study demonstrated no statistically significant difference between the use of the Handtevy or Broselow methods with respect to prehospital weight estimation. While further research is necessary, these results suggest similar field performance of the Broselow and Handtevy methods.

To explore parents’ perspectives regarding end-of-life (EOL) decisions, factors and possible barriers that influence the EOL decision making process, and to understand parental preferences for communication about EOL care in an Asian population.

A prospective questionnaire cohort study conducted in a university-based tertiary care hospital. 30 parents of children who had been admitted to general pediatric wards for acute ailments and/or were being followed up in general pediatric outpatient clinics after inpatient admissions or emergency department visits completed 30 interviewer-administered questionnaires. With the first 10 completed questionnaires, we sought feedback on the design of the four case vignettes and related questions. Responses to specific questions related to each case vignette were rated on a Likert scale.

The majority of parents were able to comprehend and identify with the issues in the case vignettes, which allowed them to respond appropriately. Parents tended to avoid active withdrawal or withholding of life-sustaining treatment. The top three priorities for parents making EOL decisions for their children were: the chance of improvement, the presence of pain or discomfort, and information provided by healthcare staff. Parents reported that they would prefer to know immediately if their child is at risk of dying; they also preferred to get as much information as possible from the healthcare team and thought that meeting with the healthcare team before making EOL decisions was pivotal.

Parents place highest priorities on their child's likelihood of improvement, perception of their child's pain, and information provided by healthcare professionals in making EOL decisions.

The goal of this study was to test the hypothesis that the prehospital time between injury and arrival at a trauma center for critically injured children is associated with patient injury severity and mode of transport.

Secondary analysis of prospectively collected data on children 0-17 years of age admitted with traumatic injuries to a designated Level I pediatric trauma center from January 1, 2006 through September 30, 2007 was conducted. Multivariate regression methods were used to assess for factors independently associated with prehospital time.

Of 1,175 admissions during the study period, only 355 (30%) had a prehospital time within 60 minutes of injury. Prehospital time within 60 minutes of injury was associated with higher frequency of coma, higher mean injury severity scores (ISS), and greater frequency of admission to the intensive care unit when compared with prehospital time beyond 60 minutes of injury. Children who arrived at the trauma center within 60 minutes versus beyond 60 minutes were 13-fold (odds ratio [OR]: 12.9; 95% Confidence Interval [CI], 7.6-22.0) more likely to be transported via air ambulance than a private vehicle, and had 4.8-fold greater odds (95% CI, 2.2-10.3) of transport via ground ambulance than private vehicle. For each kilometer of distance between the injury zip code and the trauma center, the odds of arrival within 60 minutes versus beyond 60 minutes decreased by 15% (OR: 0.85; 95% CI, 0.79-0.91).

Field triage and decision making appeared to correlate with severity of patient injury with expeditious transport of the most severely injured children to definitive trauma care. This finding serves as important groundwork that might enable further study into factors that influence triage and overall prehospital care for critically injured children.

OdetolaFO , MannNC , HansenKW , BrattonSL . Factors Associated with Time to Arrival at a Regional Pediatric Trauma Center. Prehosp Disaster Med. 2016;31(1):4–9.

Pediatric Intensive Care Unit (PICU) resources are overwhelmed in disaster as the need to accommodate influx of critically-ill children is increased. A full-scale chlorine overexposure exercise was conducted by the New York Institute for All Hazard Preparedness (NYIAHP) to assess the appropriateness of response of Kings County Hospital Center's (KCHC's) PICU surge plan to an influx of critically-ill children. The primary endpoint that was assessed was the ability of the institution to follow the PICU surge plan, while secondary endpoints include the ability to provide appropriate medical management.

Thirty-six actors/patients (medical students or emergency medicine residents) were educated on presentations and appropriate medical management of patients after a chlorine overexposure, as well as lectures on drill design and expected PICU surge response. Victims presented to the hospital after simulated accidental chlorine overexposure at a public pool. Twenty-two patients with 14 family members needed evaluation; nine of these patients would require PICU admission. Three of nine PICU patients were low-fidelity mannequins. In addition to the 36 actor/patient evaluators, each area had two to four expert evaluators (disaster preparedness experts) to assess appropriateness of global response. Patients were expected to receive standard of care. Appropriateness of medical decisions and treatment was assessed retrospectively with review of electronic medical record.

The initial PICU census was three of seven; two of these patients were transferred to the general ward. Of the nine patients that required Intensive Care Unit (ICU) admission, six actor/patients were admitted to the PICU, one was admitted to the Surgical Intensive Care Unit (SICU), one went to the Operating Room (OR), and one was admitted to a monitored-surge general pediatric bed. The remaining 13 actor/patients were treated and released. Medical, nursing, and respiratory staffing in the PICU and the general ward were increased by two main mechanisms (extension of work hours and in-house recruitment of additional staff). Emergency Department (ED) staffing was artificially increased prior to the drill. With the exception of ocular fluid pH testing in patients with ocular pruritus, all necessary treatments were given; however, an unneeded albuterol treatment was administered to one patient. Chart review showed adequate discharge instructions in four of 13 patients. Nine patients without respiratory complaints in the ED were not instructed to observe for dyspnea. All patients were in the PICU or alternate locations within 90 minutes.

The staff was well versed in the major details of KCHC's PICU surge plan, which allowed smooth transition of patient care from the ED to the PICU. The plan provided for a roadmap to achieve adequate medical, nursing, and respiratory therapists. Medical therapy was appropriate in the PICU; however, in the ED, patients with ocular complaints did not receive optimal care. In addition, written discharge instruction and educational material regarding chlorine overexposure to all patients were not consistently provided. The PICU surge plan was immediately accessible through the KCHC intranet; however, not all participants were cognizant of this fact; this decreased the efficiency with which the roadmap was followed. An exaggerated ED staff facilitated evaluation and transfer of patients.

During disasters, the ability to surge is paramount and each hospital addresses it differently. Hospitals and departments have written surge plans, but there is no literature available which assesses the validity of said plans through a rigorous, structured, simulated disaster drill. This study is the first to assess validity and effectiveness of a hospital's PICU surge plan. Overall, the KCHC PICU surge plan was effective; however, several deficiencies (mainly in communication and patient education in the ED) were identified, and this will improve future response.

ShahVS, PierceLC, RoblinP, WalkerS, SergioMN, ArquillaB. Waterworks, a Full-Scale Chemical Exposure Exercise: Interrogating Pediatric Critical Care Surge Capacity in an Inner-City Tertiary Care Medical Center. Prehosp Disaster Med. 2014;29(1):1-7.

The 2005 Gulf Coast hurricane season was one of the most costly and deadly in US history. Hurricane Rita stressed hospitals and led to multiple, simultaneous evacuations. This study systematically identified community factors associated with patient movement out of seven hospitals evacuated during Hurricane Rita.

This study represents the second of two systematic, observational, and retrospective investigations of seven acute care hospitals that reported off-site evacuations due to Hurricane Rita. Participants from each hospital included decision makers that comprised the Incident Management Team (IMT). Investigators applied a standardized interview process designed to assess evacuation factors related to external situational awareness of community activities during facility evacuation due to hurricanes. The measured outcomes were responses to 95 questions within six sections of the survey instrument.

Investigators identified two factors that significantly impacted hospital IMT decision making: (1) incident characteristics affecting a facility's internal resources and challenges; and (2) incident characteristics affecting a facility's external evacuation activities. This article summarizes the latter and reports the following critical decision making points: (1) Emergency Operations Plans (EOP) were activated an average of 85 hours (3 days, 13 hours) prior to Hurricane Rita's landfall; (2) the decision to evacuate the hospital was made an average of 30 hours (1 day, 6 hours) from activation of the EOP; and (3) the implementation of the evacuation process took an average of 22 hours. Coordination of patient evacuations was most complicated by transportation deficits (the most significant of the 11 identified problem areas) and a lack of situational awareness of community response activities. All evacuation activities and subsequent evacuation times were negatively impacted by an overall lack of understanding on the part of hospital staff and the IMT regarding how to identify and coordinate with community resources.

Hospital evacuation requires coordinated processes and resources, including situational awareness that reflects the condition of the community as a result of the incident. Successful hospital evacuation decision making is influenced by community-wide situational awareness and transportation deficits. Planning with the community to create realistic EOPs that accurately reflect available resources and protocols is critical to informing hospital decision making during a crisis. Knowledge of these factors could improve decision making and evacuation practices, potentially reducing evacuation times in future hurricanes.

DowneyEL, AndressK, SchultzCH. External Factors Impacting Hospital Evacuations Caused by Hurricane Rita: The Role of Situational Awareness. Prehosp Disaster Med. 2013;28(3):1-8.