Handling Pediatric Mass Casualty

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Mass casualty incidents are defined as events that “[overwhelm] the local healthcare system, where the number of casualties vastly exceeds the local resources and capabilities in a short period of time.”[1] Prevalence is unfortunately rising, and historically, pediatric populations have not been at the forefront of disaster preparedness.

MDCalc spoke with Dr. Ilene Claudius, an expert clinician-researcher who has studied pediatric mass casualty and potential evidence-based solutions, in 2017 for improving management. The following interview has been edited for clarity and length.


Can you tell us about your research in pediatric mass casualty incidents (MCI)? How did you develop an interest in pediatric mass casualty?

I haven’t had a personal experience with it, necessarily—we’ve certainly had some overwhelming car accidents, but nothing to the level that I would call a true pediatric mass casualty incident. These are always tragic events, and especially after Sandy Hook, it became clear that children could make up a sizable portion if not the entirety of the victim population of an MCI.

We’ve done a lot of work in the PEM community on general community hospitals being ready to see a lot of children in general. I work with an organization called COPEM [Committee on Pediatric Emergency Medicine] that looks at our pediatric receiving hospitals and makes sure they’re up to standard in terms of delivering pediatric care and having the appropriate supplies. And that’s just for a single routine pediatric patient. So the thought of how a group of very traumatized pediatric patients simultaneously is going to be handled is something we discuss a lot.


I also work with a research consortium of pediatric emergency medicine physicians in Los Angeles who have an interest in EMS, and we’re talking about the different tools for taking care of these children, even just for triaging. They’re not uniformly standardized or well-studied and validated, and we figured that this would be a great first step: to look at some of these tools and see which triage tools would be useful in the clutch — when you can hardly even remember your own name because it’s such a nerve-wracking situation — which tools are easy to remember, and easy to apply to a pediatric population with good validity. That’s how we started looking into MCI: how we could take those triage tools and make them usable for EMS providers and general emergency medicine providers.

Are any of these tools built into local policies yet, or are you still in the early phases of identifying them?

There are about five or six different tools for pediatric triage, and a lot of international groups have a difficult time because different tools are accepted in different countries. So if you have a group like Doctors Without Borders, that works with providers from very different areas, and you’re responding to a mass casualty incident with other volunteer providers from other countries, you may be using completely different triage tools. Some of them are arduous and take a long time to use, and some of them have relatively poor validity when looking at whether we’re sending the right people to the hospital at the right rate.

In America, we tend to use JumpSTART, which is a permutation of the START [Simple Triage and Rapid Treatment] system that we use for adult MCI. JumpSTART was designed specifically for triaging children in disaster settings and sorts patients into four triage categories: “Minor (Green)”, “Delayed (Yellow)”, “Immediate (Red)”, or “Deceased or Expectant (Black)”.[2] The JumpSTART tool assesses patients’ ability to walk, breathing, respiratory rate, pulse and AVPU (awake, verbal, pain, unresponsive). More work still needs to be done in refining these and making sure that they are picking out the children that we need to be picking out for immediate care.


How do these events affect patients over time, in terms of post-traumatic stress? Does this tie into your research into pediatric mental health?

I’m not doing specific PTSD research, but we do see PTSD from the trauma of everyday life, especially where I work in Los Angeles in Boyle Heights. We see a large Department of Child and Family Services population, and those children clearly have undergone a fair amount of trauma throughout the course of their lives. So we definitely see the effects of PTSD, or, as it may be more appropriately described, an ongoing trauma situation. It’s hard to say post-traumatic stress for a lot of these children, because they’re still undergoing more daily trauma than many of us can relate to.

But in terms of following a MCI, absolutely — even a single incident like that is going to cause a fair amount of trauma. And when you look at children who have sustained even a concussion, without being part of a mass casualty incident, one of the reasons for prolonged symptoms, mostly headaches, is the anxiety from post-traumatic stress disorder. So it’s something to consider with any trauma. And then when you throw on top of that that they might have seen friends and family traumatized, they might have seen friends and family die, that is a huge issue that needs to be dealt with for children who have been in that type of a situation.

Acutely, in the emergency department, we are focused more on stabilizing the medical conditions than treating the post-traumatic stress disorder, but sometimes that’s difficult as well. If a child is on the younger side, is a little bit injured, and has been separated from their family and witnessed something traumatic, sometimes it’s difficult to find out exactly how injured they are and where their injuries are if they’re quite hysterical. Just the other day, we had a routine trauma come in, and her dad was with her, but she was crying and crying so much that when I called for her to go to the floor and they asked what her Glasgow Coma Scale was, and I had to tell them, “It’s either 14 or 15—she looks fine, but she’s crying so much that I don’t know if she’s confused or not!” Can you imagine if her father hadn’t been there, or if she’d witnessed a great deal of trauma? That could have been something even more profound and persistent.

About the expert

Ilene Claudius, MD, is the chief of pediatric emergency medicine at the Keck School of Medicine of the University of Southern California. She is editor-in-chief of Pediatric Emergency Medicine Practice, and her clinical research interests include pediatric mass casualty, non-accidental trauma (child abuse), and pediatric mental health.


[1] https://www.ncbi.nlm.nih.gov/books/NBK482373/

2 https://www.ncbi.nlm.nih.gov/pubmed/12141119

[3] https://www.ncbi.nlm.nih.gov/books/NBK482373/

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