The Impact of Terrorism on Children: A Two-Year Experience

Pediatric Casualties in Terrorist Attacks: A Semi-Quantitative Analysis of Global Events

BACKGROUND

Terrorism remains a major threat and concern in many countries around the world. Pediatric populations represent approximately 30% of the world population, and in the event of a terrorist attack, can either be primary targets, to include the possibility of abduction, or unintended victims. They are unique in their vulnerabilities and, therefore, require special consideration.

METHODS

This study is a semi-quantitative, epidemiological analysis of all terrorism-related pediatric fatalities and injuries sustained from 1970-2019. Data collection was performed using a retrospective database search through the Global Terrorism Database (GTD). Summaries of events including search terms associated with pediatric population were individually reviewed and those describing the deaths, injuries, or abductions were tallied.

RESULTS

Of the over 200,000 terror events, 2,302 events met inclusion criteria. This represented 1.14% of total events which involved death, injury, or abduction. Of 2,032 events, a total of 2,275 pediatric fatal injuries (FI) were recorded, as well as 2,280 pediatric non-fatal injuries (NFI). The most common weapons used in all attacks involving the pediatric population were explosives (1,539 [66.8%]), firearms (543 [23.5%]), other (169 [7.3%]), and melee (83 [3.6%]). A total of 275 of the 2,032 events were related to abductions, with 71 cases involving the abduction of 10 individuals or more.

CONCLUSION

Pediatric casualties in terrorist events represent a small proportion of overall victims. However, it should be understood that the pediatric population has unique vulnerabilities, and when directly impacted by terrorism, can have long-term physical and psychosocial sequelae, as well as a devastating emotional impact on the community.

Children's Health Care in Mass-Casualty Incidents: A Systematic Literature Review

OBJECTIVES

Considering the pediatric peculiarities and the difficulty of assisting this population in mass-casualty situations, this study aims to identify the main topics regarding children's health care in mass-casualty incidents (MCIs) that are discussed in the Emergency Medicine area.

METHODS

This systematic review was performed according to the recommendations of Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) and registered with the PROSPERO database of systematic reviews with the number CRD42021229552. The last update of the search in the databases was on May 27, 2021 and resulted in 45 documents to be analyzed. The inclusion criteria included the peer-reviewed academic papers in English, Portuguese, Spanish, and Italian languages; the databases used were PubMed, Scopus, MEDLINE/Bireme (Virtual Library of Health - VLH), and Web of Science, which execute the query on the topic, keywords, or abstracts. Also, to be included, documents that were available with full-text access through CAPES, Google, or Google Scholar. Books, non-academic research, and content in languages other than the presented ones were represented as exclusion criteria.

RESULTS

From the resulting papers, 21 articles served as the basis for this analysis. Revealed were the year of publication, the first author's institution nationality, topic, and disaster management phase for each study, which allow other researchers to understand the main topics regarding children's health care in MCIs.

CONCLUSIONS

The topics regarding child's health care in MCIs found in the primary studies of this review, in order of frequency, were: Disaster Response (including the following sub-topics: simulation, education, quality of care, use of technological tools, and damage analysis); Triage; and Disaster Planning. The Emergency Medicine operation was focused on harm reduction after the occurrence of an MCI. Further studies focusing on the pre-disaster and post-disaster phases are needed.

Blast injuries in children: a mixed-methods narrative review

BACKGROUND AND SIGNIFICANCE

Blast injuries arising from high explosive weaponry is common in conflict areas. While blast injury characteristics are well recognised in the adults, there is a lack of consensus as to whether these characteristics translate to the paediatric population. Understanding blast injury patterns in this cohort is essential for providing appropriate provision of services and care for this vulnerable cohort.

METHODS

In this mixed-methods review, original papers were screened for data pertaining to paediatric injuries following blasts. Information on demographics, morbidity and mortality, and service requirements were evaluated. The papers were written and published in English from a range of international specialists in the field.

RESULTS

Children affected by blast injuries are predominantly male and their injuries arise from explosive remnants of war, particularly unexploded ordinance. Blasts show increased morbidity and mortality in younger children, while older children have injury patterns similar to adults. Head and burn injuries represent a significant cause of mortality in young children, while lower limb morbidity is reduced compared with adults. Children have a disproportionate requirement for both operative and non-operative service resources, and provisions for this burden are essential.

CONCLUSIONS

Certain characteristics of paediatric injuries arising from blasts are distinct from that of the adult cohort, while the intensive demands on services highlight the importance of understanding the diverse injury patterns in order to optimise future service provisions in caring for this child blast survivor.

[Mass casualty incidents and attacks involving a multitude of children and adolescents-Overview of policy recommendations and challenges]

Fortunately, mass casualty incidents involving a large number of children and adolescents are rare and the experience in this field, both in terms of medical as well as psychosocial emergency care is comparatively low. Children represent a vulnerable group and have a particularly high risk of developing posttraumatic stress disorder in the aftermath of experiencing disasters. A selective literature search was carried out in Medline. The peculiarity of damaging events with a large number of children and adolescents affected is that in addition to emergency medical care, an early approach to psychosocial emergency care must be provided. Accordingly, it makes sense to integrate such structures into the respective deployment concepts. A specific screening algorithm for children could so far not prevail but due to the physiological and anatomical characteristics appropriate emergency medical care concepts should be provided. Furthermore, hospitals must adapt to this patient group in a suitable manner.

Pediatric Online Disaster Preparedness Training for Medical and Non-Medical Personnel: A Multi-Level Modeling Analysis

IntroductionTerrorism and natural catastrophes have made disaster preparedness a critical issue. Despite the documented vulnerabilities of children during and following disasters, gaps remain in health care systems regarding pediatric disaster preparedness. This research study examined changes in knowledge acquisition of pediatric disaster preparedness among medical and non-medical personnel at a children's hospital who completed an online training course of five modules: planning, triage, age-specific care, disaster management, and hospital emergency code response.

METHODS

A multi-disciplinary team within the Pediatric Disaster Resource and Training Center at Children's Hospital Los Angeles (Los Angeles, California USA) developed an online training course. Available archival course data from July 2009 to August 2012 were analyzed through linear growth curve multi-level modeling, with module total score as the outcome (0 to 100 points), attempt as the Level 1 variable (any module could be repeated), role in the hospital (medical or non-medical) as the Level 2 variable, and attempt by role as the cross-level effect.

RESULTS

A total of 44,115 module attempts by 5,773 course participants (3,686 medical personnel and 2,087 non-medical personnel) were analyzed. The average module total score upon first attempt across all participants ranged from 60.28 to 80.11 points, and participants significantly varied in how they initially scored. On average in the planning, triage, and age-specific care modules: total scores significantly increased per attempt across all participants (average rate of change ranged from 0.59 to 1.84 points) and medical personnel had higher total scores initially and through additional attempts (average difference ranged from 13.25 to 16.24 points). Cross-level effects were significant in the disaster management and hospital emergency code response modules: on average, total scores were initially lower among non-medical personnel compared to medical personnel, but non-medical personnel increased their total scores per attempt by 3.77 points in the disaster management module and 6.40 points in the hospital emergency code response module, while medical personnel did not improve their total scores through additional attempts.

CONCLUSION

Medical and non-medical hospital personnel alike can acquire knowledge of pediatric disaster preparedness. Key content can be reinforced or improved through successive training in an online course. PhamPK, BeharSM, BergBM, UppermanJS, NagerAL. Pediatric online disaster preparedness training for medical and non-medical personnel: a multi-level modeling analysis Prehosp Disaster Med. 2018;33(4):349-354.

Validity of the Pediatric Canadian Triage Acuity Scale in a tertiary children's hospital in Israel

OBJECTIVE

In 2015, the Israeli Ministry of Health issued national guidelines demanding the use of a five-level triage system in pediatric emergency departments (EDs). The present study aimed to evaluate the validity of the Pediatric Canadian Triage Acuity Scale (PedCTAS) in the ED of a tertiary children's hospital in Israel.

METHODS

A retrospective cohort study of all patients admitted between January 2011 and December 2015 was carried out. The proportion of hospitalization was the primary outcome measure. The secondary outcomes were proportion of admissions to the ICU, proportions of patients who left without being seen (LWBS), and length of stay (LOS) in the ED.

RESULTS

A total of 83 609 patients were included in our analysis. Triage levels 1-5 included 533 (0.6%), 4428 (5.3%), 46 461 (55.6%), 28 510 (34.1%), and 3677 (4.4%) patients, respectively. Hospitalization proportions were 70, 51, 28, 15, and 12% for triage levels 1, 2, 3, 4, and 5, respectively. Admission proportions to ICU were 24.2, 3.05, 0.24, 0.05, and 0.05% for PedCTAS levels 1, 2, 3, 4, and 5, respectively. The proportions of LWBS were 0.001, 0.002, and 0.005% for triage levels 3, 4, and 5, respectively. LOS was shorter as the triage level increased from 2 to 5.

CONCLUSION

Triage level was predictive of hospitalization, admission to the ICU, and proportions of LWBS and LOS in the ED. The findings suggest validity of the PedCTAS in this cohort. This is the first report of the performance of a triage tool in an Israeli ED.

[And if it happened to children? Adapting medical care during terrorist attacks with multiple pediatric victims]

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.

Are Pediatric Emergency Physicians More Knowledgeable and Confident to Respond to a Pediatric Disaster after an Experiential Learning Experience?

Objectives

Pediatric hospital disaster responders must be well-trained and prepared to manage children in a mass-casualty incident. Simulations of various types have been the traditional way of testing hospital disaster plans and training hospital staff in skills that are used in rare circumstances. The objective of this longitudinal, survey-based, observational study was to assess the effect of disaster response and management-based experiential learning on the knowledge and confidence of advanced learners.

Methods

A simulation-based workshop was created for practicing Pediatric Emergency Medicine (PEM) physicians, senior PEM physicians, and critical care and pediatric surgery residents to learn how to manage a disaster response. Given that this particular group of learners had never been exposed to such a disaster simulation, its educational value was assessed with the goal of improving the quality of the hospital pediatric medical response to a disaster by increasing the responders’ knowledge and confidence. Objective and subjective measures were analyzed using both a retrospective, pre-post survey, as well as case-based evaluation grids.

Results

The simulation workshop improved the learners’ perceived ability to manage patients in a disaster context and identified strengths and areas needing improvement for patient care within the disaster context.

Conclusion

Advanced learners exposed to an experiential learning activity believed that it improved their ability to manage patients in a disaster situation and felt that it was valuable to their learning. Their confidence was preserved six months later.

BankI, KhalilE. Are pediatric emergency physicians more knowledgeable and confident to respond to a pediatric disaster after an experiential learning experience?Prehosp Disaster Med. 2016;31(5):551–556.

Mass Casualty Triage: An Evaluation of the Science and Refinement of a National Guideline

Mass casualty triage is the process of prioritizing multiple victims when resources are not sufficient to treat everyone immediately. No national guideline for mass casualty triage exists in the United States. The lack of a national guideline has resulted in variability in triage processes, tags, and nomenclature. This variability has the potential to inject confusion and miscommunication into the disaster incident, particularly when multiple jurisdictions are involved. The Model Uniform Core Criteria for Mass Casualty Triage were developed to be a national guideline for mass casualty triage to ensure interoperability and standardization when responding to a mass casualty incident. The Core Criteria consist of 4 categories: general considerations, global sorting, lifesaving interventions, and individual assessment of triage category. The criteria within each of these categories were developed by a workgroup of experts representing national stakeholder organizations who used the best available science and, when necessary, consensus opinion. This article describes how the Model Uniform Core Criteria for Mass Casualty Triage were developed.

(Disaster Med Public Health Preparedness. 2011;5:129-137)

Model uniform core criteria for mass casualty triage

There is a need for model uniform core criteria for mass casualty triage because disasters frequently cross jurisdictional lines and involve responders from multiple agencies who may be using different triage tools. These criteria (Tables 1-4) reflect the available science, but it is acknowledged that there are significant research gaps. When no science was available, decisions were formed by expert consensus derived from the available triage systems. The intent is to ensure that providers at a mass-casualty incident use triage methodologies that incorporate these core principles in an effort to promote interoperability and standardization. At a minimum, each triage system must incorporate the criteria that are listed below. Mass casualty triage systems in use can be modified using these criteria to ensure interoperability. The criteria include general considerations, global sorting, lifesaving interventions, and assignment of triage categories. The criteria apply only to providers who are organizing multiple victims in a discrete geographic location or locations, regardless of the size of the incident. They are classified by whether they were derived through available direct scientific evidence, indirect scientific evidence, expert consensus, and/or are used in multiple existing triage systems. These criteria address only primary triage and do not consider secondary triage. For the purposes of this document the term triage refers to mass-casualty triage and provider refers to any person who assigns primary triage categories to victims of a mass-casualty incident.

Psychosocial considerations about children and radiological events

Children are identified as a vulnerable population in the case of radiological events because of their increased physical sensitivity to radiation and its impact on critical development stages. Using a comprehensive integrated risk framework, psychosocial risk protective factors are discussed in a social ecology paradigm. Children have been shown to be both vulnerable and resilient; they are both easily impressionable and also quick to adapt and learn. Psychosocial interventions during, after and most efficiently before an event can improve outcome, especially if they involve parents and schools, media and work organisations. Public education through children should be encouraged to increase knowledge of radiation and strategies to minimise exposure and irradiation. Children can become vectors of prevention, preparedness and mitigation through information and behavioural rehearsal. Special consideration must therefore be given to education, school programmes, practice rehearsal and media exposure.

Operation Child-ID: reunifying children with their legal guardians after Hurricane Katrina

Children constitute a vulnerable population and special considerations are necessary in order to provide proper care for them during disasters. After disasters such as Hurricane Katrina, the rapid identification and protection of separated children and their reunification with legal guardians is necessary in order to minimise secondary injuries (i.e. physical and sexual abuse, neglect and abduction). At Camp Gruber, an Oklahoma shelter for Louisianans displaced by Hurricane Katrina, a survey tool was used to identify children separated from their guardians. Of the 254 children at the camp, 36 (14.2 per cent) were separated from their legal guardians. Answering 'no' to the question of whether the accompanying adult was the guardian of the child prior to Hurricane Katrina was a strong predictor (27.8 per cent versus 3.2 per cent) of being listed as 'missing' by the National Center for Missing and Exploited Children (NCMEC). All the children at Camp Gruber who were listed as 'missing' by the NCMEC were subsequently reunited with their guardians.

Suicide bombers form a new injury profile

BACKGROUND

Recent explosions of suicide bombers introduced new and unique profiles of injury. Explosives frequently included small metal parts, increasing severity of injuries, challenging both physicians and healthcare systems. Timely detonation in crowded and confined spaces further increased explosion effect.

METHODS

Israel National Trauma Registry data on hospitalized terror casualties between October 1, 2000 and December 31, 2004 were analyzed.

RESULTS

A total of 1155 patients injured by explosion were studied. Nearly 30% suffered severe to critical injuries (ISS > or = 16); severe injuries (AIS > or = 3) were more prevalent than in other trauma. Triage has changed as metal parts contained in bombs penetrate the human body with great force and may result in tiny entry wounds easily concealed by hair, clothes etc. A total of 36.6% had a computed tomography (CT), 26.8% had ultrasound scanning, and 53.2% had an x-ray in the emergency department. From the emergency department, 28.3% went directly to the operating room, 10.1% to the intensive care unit, and 58.4% directly to the ward. Injuries were mostly internal, open wounds, and burns, with an excess of injuries to nerves and to blood vessels compared with other trauma mechanisms. A high rate of surgical procedures was recorded, including thoracotomies, laparotomies, craniotomies, and vascular surgery. In certain cases, there were simultaneous multiple injuries that required competing forms of treatment, such as burns and blast lung.

CONCLUSIONS

Bombs containing metal fragments detonated by suicide bombers in crowded locations change patterns and severity of injury in a civil population. Specific injuries will require tailored approaches, an open mind, and close collaboration and cooperation between trauma surgeons to share experience, opinions, and ideas. Findings presented have implications for triage, diagnosis, treatment, hospital organization, and the definition of surge capacity.

Creating a Regional Pediatric Medical Disaster Preparedness Network: Imperative and Issues

Over the past few decades, the number of disasters, both natural and human initiated has increased. As a result, since the September 11, 2001 attacks on the World Trade Center and Pentagon, there has been a new emphasis on disaster preparedness. However, the preparedness emphasis has been primarily directed toward adults and little attention has been specifically given to the needs of children. One reason for the lack of attention to pediatric needs in disaster planning is that childhood is seldom viewed as a separate and special stage of growth, fundamentally different from adulthood. The expectation during emergencies is that the care provided for adults is appropriate for children. The purpose of this paper is to examine the types of and increase in disasters and discuss the importance of specifically addressing the special needs of children in disaster planning. Further the paper argues for a regional network approach to emergency pediatric care that would increase surge capacity for children during disasters and other emergencies.

The impact of terrorism on children: a two-year experience

Waismanet al1have once more highlighted the very real challenge of triaging children in mass-casualty events (MCE) in the pre-hospital setting. Difficulties encountered measuring vital signs and different patterns of injury, reflecting significant anatomical and physiological differences, necessitates a modified approach when applying traditional “adult” triage methods to paediatric trauma victims. When using physiological parameters to triage children, their faster respiratory rates and heart rates frequently result in younger children being triaged to a higher category than their injuries demand. These differences become less apparent during adolescence, as the young person matures into adulthood.