Don’t forget children’s needs in your disaster plan

If an unconscious man was rushed to your ED after a terrorist attack with possible exposure to biological or chemical agents, would you know exactly how to decontaminate and treat this patient? What if your patient was a 3-year-old?

Pediatric patients have special needs during disasters, emphasizes Anne Jacob, MD, a consultant in emergency management for Alachua County Fire & Rescue, based in Gainesville, FL, and former ED attending physician at the University of Florida. "It’s one of those things that seems simple, but there is a lot to it," she says. "Kids have increased needs and are very susceptible to injury."

To dramatically improve care of children during a disaster, consider these suggestions:

  • Understand anatomical and physiological differences.

A child’s physiological response from exposure to nuclear, biological, and chemical agents is much different from an adult’s, says Lisa Kosits, RN, MSN, CCRN, CEN, clinical inservice instructor for the ED at Montefiore Medical Center in The Bronx, NY.

Children are closer to the ground and have higher metabolic rates, increased relative minute ventilation, thinner and more pliable skin, increased body surface area to mass ratio, immature immune systems, and a more a permeable blood-brain barrier, she says. "All of this results in increased absorption and distribution," says Kosits.

For that reason, time is an even bigger factor in treatment than it is with adults, she says. "Many chemical agents have a rapid onset, which is accelerated by these anatomical and physiological differences."

The upside is that children are very resilient, says Jacob. "An acutely injured child can bounce back with less intervention than an adult," she says. "Sometimes just a little oxygen and fluid resuscitation can turn things around."

  • Be aware of current recommendations for drug dosing in children.

AtroPen, an atropine autoinjector manufactured by Columbia, MD-based Meridian Medical Technologies, was approved by the Food and Drug Administration in late 2003 as a replacement for atropine. However, the product is not approved for use in children weighing less than 15 lbs. "It is not a replacement nor a substitute for the Mark I Nerve Agent Antidote Kit [also manufactured by Meridian Medical Technologies], which contains pralidoxime and atropine used to treat nerve agent exposure," notes Kosits, adding that the recommendations for the Mark I kit are ages 3 and older.

"However, the benefits would clearly be outweighed by the risks in a bona-fide exposure to a nerve agent, and these drugs should be seriously considered if no other treatment is available," says Kosits.

  • Include pediatric-specific information during disaster planning.

At Montefiore, information on pediatric patients is included in the Weapons of Mass Destruction training program that all ED staff members are mandated to attend. "We also have pediatric clinical resource material available to the staff on our ED web page and in a resource manual on emergency preparedness," says Kosits.

  • Keep the family together.

Although the facility has adult and pediatric EDs, an effort would be made to share resources during a disaster, says Kosits. "The goal is for the family to stay together and be treated in the same ED," she says.

  • Watch what you say.

Children will take your cue in how they respond to a disaster, says Jacob. "Kids pick up on our tone of voice and how frightened we are," she says. "Never make statements that indicate hopelessness or lack of caring, or say things like, "The parents are probably dead.’"

  • Take photos of children.

Since children don’t carry identification and may be nonverbal, taking photos can help you identify them and locate family members, suggests Jacob. "During a disaster, frantic parents are looking for their child," she says. With a digital camera, you could have a web site set up within an hour and post pictures of all the unidentified children at your ED, she explains.

  • Participate in community-based disaster planning.

Team with local school administrators to prepare for incidents involving large numbers of children, recommends Jacob. "School-based incidents, such as a bus crash or school shooting, generate both seriously injured children and an even greater number of worried well and their parents," she says.

Designate a site, such as an unaffected school gymnasium, as a safe location for parents to be reunited with their uninjured children, suggests Jacob. "Teaming has the added benefit of promoting compliance with 2004 Joint Commission requirements for hospital involvement in community disaster plans, as well as lessening the crowds at the ED."

  • Have age-appropriate equipment.

Check your ED’s equipment against the Emergency Medical Services for Children (EMS-C) recommendations for pediatric supplies, recommends Jacob. "A lot of the supplies on that list are items you would use for a mass-casualty incident," she says. (To order the complete guidelines, see resource box, below.

In addition, you should have age-appropriate toys on hand, says Jacob. "After disasters, there are often periods of time where people are sitting around waiting," she says. "Even something simple like crayons and paper can occupy and distract a child."

Sources and Resources

For more information on caring for children during a disaster, contact:

  • Anne Jacob, MD, Community Response Consulting, 4300 N.W. 23rd Ave., Suite 483, Gainesville, FL 32606. E-mail:
  • Lisa Kosits, RN, Clinical Inservice Instructor, Division of Education and Organizational Development, Montefiore Medical Center, 111 E. 210th St., Bronx, NY 10467. Telephone: (718) 920-5241. Fax: (718) 324-4246. E-mail:

"Pediatric Disaster Life Support: Caring for Children During Disasters" is a two-day training course for medical, emergency medical services, and disaster professionals. For training dates, contact the University of Massachusetts Medical School, Continuing Education Office, 55 Lake Ave., Worcester, MA 01655. Telephone: (508) 856-4101. E-mail:

A pamphlet describing symptoms of traumatic stress and strategies to help children cope in disaster situations can be downloaded at no charge on the Emergency Medical Services for Children (EMS-C) web site ( Click on "Products & Resources." Under "Issues of Interest," click on "Disasters," "When Disaster Strikes: Helping Young Children Cope." Guidelines for pediatric equipment in the ED also can be accessed at no charge by clicking on "Products & Resources," "EMSC Pediatric Emergency Care Resource Kit," "Equipment Guidelines," and "Guidelines for Pediatric Equipment and Supplies for Emergency Departments."