| Challenges |
Adaptations to usual care |
Decisions |
| Pulmonary |
- Bronchospasm is common in those with and without histories of asthma.
- Children with bad/labile asthma present early due to stress, environmental triggers, lack of medication.
- Stable asthmatics start showing up as triggers increase or medication runs out.
- Children with bronchospasm due to respiratory infection start to present after the first 3-5 days.
- October storms correspond to high allergy season and a slight peak in RSV incidence.
- Winter storms may occur during RSV outbreaks.
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- Need adequate supplies to treat patients.
- Premixed beta agonists for nebulizers (infant and child dosing).
- Nebulizer capability with and without oxygen.
- Pediatric nebulizer masks and pipes.
- Oral and parenteral steroids.
- Peak flow monitoring helpful but not essential.
- Outpatient treatment:
- Allow use of facility's electricity for families giving their own nebulization.
- Using MDIs with spacer chambers more frequently.
- Be liberal with steroids.
- Counsel regarding allergen exposure.
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- Lower threshold for admission based on available resources and ongoing hazards.
- Consider recommendation to temporarily remove child from the area to healthier environment.
- Temper decisions with consideration of family's existing resources and demands on family members.
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| Gastrointestinal (GI) |
- Close living quarters may lead to transmission of GI viral illnesses,
- Limited water and facilities for washing; limited diaper/hygiene supplies.
- Inadequate sanitation in field kitchens/food distribution points.
- Norovirus precautions go beyond soap and water or alcohol.
- Erratic availability of potable water and oral rehydration solutions.
- MREs have high sodium/high calorie content.
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- Ask about sheltering situation. Give specific infection control instructions (written if possible).
- Health care sites can act as distribution points for hygiene items such as alcohol solution, diaper wipes, diapers, soap, garbage (biohazard?) bags/gloves, bleach.
- Maintain contact with public health officials.
- Ask about diet specifics, including origin of drinking water and food storage conditions.
- Warn families of need to increase fluid intake if eating MREs.
- Consider unusual electrolyte abnormalities in clinically dehydrated children.
- Distribute oral rehydration solutions.
- Focus on oral rehydration protocols unless staff and intravenous (IV) fluids are in adequate supply.
- Limit use of antiemetics and antidiarrheals in children.
- Minimize infant formula-switching.
- Use fecal volume replacement techniques in cases of diarrhea.
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- Admission decisions must include consideration of shelter status.
- Lower admission threshold if adequate outpatient management is doubtful.
- If in doubt, schedule patient rechecks.
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| Infectious diseases |
- Infections will mostly follow existing community patterns.
- "Third world" epidemics have not occurred in the U.S.
- Isolation/segregation of infected people is difficult in the post-storm environment.
- Children need different preparations of antibiotics, some requiring controlled environmental conditions.
- Pharmacies and drug supplies may be limited and may focus on adult medications.
- Skin infections are common; good hygiene is not.
- Penetrating injuries to the foot are common; Pseudomonas must be suspected.
- Community-acquired MRSA is an increasing problem.
- Animal control may be problematic; may need to vaccinate patients against rabies.
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- Contact local public health or hospital officials for intelligence regarding existing infection patterns and sensitivities.
- Cooperate with public health officials in monitoring efforts.
- Assist in informing shelter staffs of infection patterns seen and what to look for.
- Assist public health personnel with projects needed to protect exposed high-risk groups, such as giving VZIG to exposed immunocompromised victims or tetanus boosters to those who need them.
- Educate patients and families about infection control issues, especially if they are shelter residents.
- Prescribe antibiotics judiciously; use the simplest appropriate form for the shortest practical course.
- Use alternative medication formulations (chewable tabs, crushed tabs) and those that do not require refrigeration.
- Obtain and distribute information about pharmacies in operation.
- Inform local pharmacies about prescribing privileges for federal responders.
- Consider distribution of starter doses of medications.
- Distribute hygiene and wound care supplies, insect repellant, and topical or oral medications for itching/inflammation.
- Plan follow-up for penetrating and contaminated injuries (especially nails into feet).
- Consider using ciprofloxacin for children with penetrating wounds into feet.
- May use first-generation cephalosporins for most skin infections.
- Consider adding TMP-SMX or clindamycin if community-acquired MRSA is suspected.
- Communicate with local public health authorities about rabies exposure.
- Recognize that most children will not need a tetanus booster.
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- Consider family's environment and mobility when making decisions about admission vs. outpatient treatment with rechecks.
- May need to admit children with highly contagious diseases to avoid exposing others in a crowded environment.
- Consider sending infected children out of the area if more appropriate shelter is available.
- Maintain low admission thresholds for the very young with fever and for immunocompromised patients.
- Use antibiotics judiciously.
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| Trauma |
- The post-storm environment is hazardous!
- Children may not have adequate supervision or may be asked to perform inappropriate tasks.
- Children are risk-takers.
- Minor skin and musculoskeletal injuries are common.
- Penetrating injuries by contaminated objects are common.
- Skin foreign bodies are common.
- Major trauma is not common.
- Increased chance of:
- Carbon monoxide exposure
- Hydrocarbon and bleach ingestion/aspiration
- Ingestion of medications
- Drowning
- Traffic incidents due to unregulated intersections
- Intentional injury
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- Carefully document mechanisms of injury.
- Be prepared to stabilize a badly injured child while arranging for transfer.
- Identify local pediatric trauma and burn care resources.
- Have access to poison control resources.
- If lacking x-ray capabilities, splint the injured extremity on any child with bony tenderness, regardless of lack of deformity.
- Emphasize elevation and splinting of an injured extremity for control of pain and swelling; ice may not be a viable option.
- Provide the best possible initial wound care in an environment as comfortable for the patient as possible.
- Consider delayed/no closure for contaminated wounds or possible retained foreign bodies.
- Consider self-absorbing sutures for children with lip, finger or toe lacerations.
- Use skin glue only if wound is clean and can be kept dry.
- Don't forget pain management!
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- Follow-up care may be biggest issue; patients may need to go to another facility to initiate contact with follow-up caregivers.
- Make some allowances for unusual circumstances but be alert for potentially negligent or dangerous family situations.
- Depending on available medical resources, conscious sedation/analgesia should remain a consideration for painful or stressful procedures.
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| Psychosocial |
- Families may have difficulty coping with their child's illness or injury.
- Delays in seeking care may be more common than in ordinary circumstances.
- Families may not have had primary care resources before the disaster.
- Compliance with treatment recommendations may be difficult for many reasons.
- Stress may lead to higher risk for domestic and child abuse.
- Pediatric mental health goes beyond posttraumatic stress disorder (PTSD).
- Children with mental health issues may present with acute or prolonged nonspecific physical symptoms.
- Parents are often not well informed about children's reactions to catastrophic stress.
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- Assume family members do not get your message the first time.
- Write down instructions for the family.
- Always ask, "Is there anything else we can help you with?"
- Address children directly; let them know what they have to say is important and that they have a role in feeling better.
- Encourage children to express their feelings.
- Make the visit as pleasant as possible for the child.
- Explore alternatives with the family to help ensure compliance with treatment recommendations.
- Avoid judgmental attitudes.
- Identify local resources for family psychosocial support.
- Use available mental health resources.
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- Recognize risks for abuse or intentional neglect; know the local reporting mandates and procedures.
- Try to keep family members together.
- Remember that a child's reactions will reflect what's going on with the rest of the family. Ask!
- Be willing to accept reasonable therapeutic compromises that help increase family coping abilities without jeopardizing patient care.
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