24.2 Pediatric Disaster Preparedness, Mass-Casualty Triage (JumpSTART) & Environmental Emergencies

Pediatric Disaster Preparedness, Mass-Casualty Triage and Environmental Emergencies

Quick Answer: Activate the incident plan and use the field triage protocol adopted by the responding agency. In JumpSTART, open the airway of an apneic child, then give five breaths if apnea persists and a pulse is present. Reassess as resources and clinical findings change. In individual drowning arrest, provide breaths and compressions. In severe hypothermic arrest, resuscitate during rewarming and consult an extracorporeal team. In heatstroke, start rapid cooling during resuscitation.

Prepare the pediatric disaster response

The hospital emergency operations plan identifies who activates incident command and how to coordinate with EMS, other hospitals and public health. In the Incident Command System, command sets incident objectives, operations carries out care and movement, planning tracks needs and prepares the action plan, logistics obtains supplies and staff support, and finance/administration tracks costs and records. Report through the assigned chain, communicate resource needs and rehearse pediatric mass-casualty response.

Plan for children with age-specific airway equipment, kilogram-based medication aids, warming supplies, transport capability and backup power, oxygen and suction for technology-dependent children. Keep children with caregivers when safe. Assign an identifier to an unaccompanied child, track location and transfers, provide a supervised area and verify the receiving caregiver before reunification. Young children may have difficulty describing symptoms or leaving danger and can cool quickly during wet decontamination. Plan for accessible communication and pediatric behavioral health support. FEMA incident command · HHS pediatric hospital preparedness · 2026 ED pediatric readiness policy

Apply JumpSTART when the field protocol calls for it

The HHS CHEMM description uses JumpSTART for casualties who appear younger than eight years. Use the local age or appearance rule. Pubertal signs are unnecessary. Triage labels guide priority under mass-casualty conditions. Reassess after movement, intervention or clinical change, and communicate the current category at handoff.

1. Walking: Send children who can walk to the designated minor (green) area for secondary triage. A child who cannot walk at baseline needs individual assessment. A carried infant in the green area still needs early assessment with the full algorithm.
2. Apnea: Open and reposition the airway. If spontaneous breathing resumes, assign immediate (red). If apnea persists, check for a palpable pulse. With no pulse, assign black. With a pulse, give five rescue breaths. If spontaneous breathing resumes, assign red. If apnea persists, assign black under the field protocol.
3. Spontaneous breathing: A respiratory rate below 15 or above 45 breaths/min, or absence of a palpable pulse, is red. With 15–45 breaths/min and a palpable pulse, assess alertness and responses to voice and pain. Inappropriate response to pain or unresponsiveness is red. Alertness, response to voice or appropriate response to pain is delayed (yellow) in the standard branch. Some local protocols allow green for a developmentally nonambulatory child with no significant injury after a full assessment.

Adult START uses different respiratory and perfusion criteria, simple commands and no five-breath trial. SALT is an all-age system that includes a two-breath option for children during airway opening and distinguishes expectant from deceased. Follow the named algorithm, including its local tag terminology. Neither mass-casualty approach substitutes for individual pediatric resuscitation when routine resources are available. HHS JumpSTART · Romig algorithm in pediatric surge guide · Kentucky EMS JumpSTART example · HHS adult START · HHS SALT

Respond to hazardous exposures and blast injury

Protect responders and prevent secondary contamination. Coordinate agent-specific clothing removal and decontamination with hazardous materials staff while providing lifesaving care in the appropriate protected zone. With wet decontamination, protect children from cold and dry and warm them promptly.

HHS decontamination · HHS nerve-agent guidance · CDC CO guidance · AHA cyanide guidance · Pediatric hydroxocobalamin regimen · U.S. label · CDC KI · CDC anthrax guidance · CDC plague guidance · CDC tularemia guidance · JTS burn care

Drowning, hypothermia and heatstroke

Drowning. Respiratory impairment from immersion or submersion can progress to hypoxic arrest. Provide prompt breaths for respiratory arrest with a pulse. After removal from the water, give CPR with breaths and compressions for cardiac arrest. Under 2025 AHA guidance, a trained rescuer may start with breaths if this does not delay resuscitation. If a rescuer is unable or unwilling to give breaths, start compressions. Start CPR before applying the AED. Use spinal motion restriction selectively for suspected trauma without delaying ventilation. Describe the outcome as fatal or nonfatal drowning.

After initial stabilization, assess work of breathing, room-air oxygenation, auscultation and mental status serially. Persistent hypoxemia, respiratory distress, altered consciousness or need for support warrants hospital care. Low-risk discharge criteria and observation duration depend on the pathway. For example, the Children's Healthcare of Atlanta pathway reassesses after six hours and checks for room-air saturation at least 94% and a normal respiratory exam. Consider the cause, associated trauma, safe supervision and return precautions. If invasive ventilation is needed for pediatric ARDS, use a lung-protective strategy and titrate tidal volume, pressures and PEEP to physiology. Routine prophylactic antibiotics and steroids are unnecessary. Evaluate and treat suspected infection, considering the water exposure and cultures. Teach close supervision and age-appropriate water safety. AHA drowning resuscitation · Pediatric submersion pathway · PALICC-2 pediatric ARDS guidance · WMS drowning guideline · AAP drowning prevention

Accidental hypothermia. A core temperature below 35°C is hypothermia. Prevent further heat loss, remove wet clothing when protected, handle gently and monitor core temperature and rhythm. Use insulation and active trunk warming when indicated. Warmed IV fluid can avoid further cooling when fluid is needed. In a child in hypothermic cardiac arrest without obvious lethal injury, resuscitate immediately and continue during rewarming. Early consultation for extracorporeal life support (ECLS) is appropriate. The 2025 AHA pediatric guidance says it may be reasonable to shock once for a shockable rhythm and, if unsuccessful, defer further shocks until at least 30°C. It also allows deferring epinephrine to that temperature. The ERC pediatric pathway differs, with up to three shocks and a conditional single epinephrine dose below 30°C. Follow the applicable protocol. Base ongoing decisions on the clinical circumstances and the resuscitation and ECLS teams. AHA pediatric hypothermia recommendations · WMS hypothermia guidance · ERC pediatric guidance

Heatstroke. Suspect it with central nervous system dysfunction and marked heat exposure or exertion. Core temperature is often above 40°C, but prior cooling can lower the measured value. Activate emergency response, support airway and circulation and start active cooling concurrently. Use cold-water immersion when safe and feasible, with airway access and core temperature monitoring. Use other active methods if immersion is unavailable or interferes with resuscitation. For life-threatening pediatric hyperthermia, AHA considers it reasonable to cool by at least 0.15°C/min and stop active cooling at a core temperature of 38.6°C. The broader SCCM guideline aims for below 39°C within 30 minutes from recognition. Avoid antipyretics for heatstroke. Assess perfusion and volume needs and monitor for rhabdomyolysis, renal and hepatic injury, electrolyte or glucose abnormalities and coagulopathy. AHA pediatric hyperthermia recommendations · SCCM heatstroke guidance · Exertional heat illness position statement

Electrical injury and lightning

Ensure the electrical source is isolated before touching the patient. High-voltage injury can cause deep muscle and vascular injury beneath a small burn. Obtain ECG and monitor high-risk patients, assess for trauma and compartment syndrome, and check for rhabdomyolysis, electrolyte abnormalities and kidney injury. Individualize isotonic fluids and urine output goals with the burn and nephrology teams. The American Burn Association recommends immediate consultation with consideration for transfer for at least 1,000 V or lightning.

For multiple lightning casualties, the Wilderness Medical Society recommends reverse triage, with initial priority to those without vital signs or spontaneous breathing. Cardiac activity may recover before breathing. Provide ventilation promptly and use standard life support as indicated. Assess for transient keraunoparalysis, hearing and eye injury, and arrange follow-up based on exposure and findings. ABA referral guidance · Pediatric electrical injury guideline · WMS lightning guidance