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Objective: ICU resources may be overwhelmed by a mass casualty event, triggering a conversion to Crisis Standards of Care in which critical care support is diverted away from patients least likely to benefit, with the goal of improving population survival. We aimed to devise a Crisis Standards of Care triage allocation scheme specifically for children. Design: A triage scheme is proposed in which patients would be divided into those requiring mechanical ventilation at PICU presentation and those not, and then each group would be evaluated for probability of death and for predicted duration of resource consumption, specifically, duration of PICU length of stay and mechanical ventilation. Children will be excluded from PICU admission if their mortality or resource utilization is predicted to exceed predetermined levels (���high risk���), or if they have a low likelihood of requiring ICU support (���low risk���). Children entered into the Virtual PICU Performance Systems database were employed to develop prediction equations to assign children to the exclusion categories using logistic and linear regression. Machine Learning provided an alternative strategy to develop a triage scheme independent from this process. Setting: One hundred ten American PICUs Subjects: One hundred fifty thousand records from the Virtual PICU database. Interventions: None. Measurements and Main Results: The prediction equations for probability of death had an area under the receiver operating characteristic curve more than 0.87. The prediction equation for belonging to the low-risk category had lower discrimination. R2 for the prediction equations for PICU length of stay and days of mechanical ventilation ranged from 0.10 to 0.18. Machine learning recommended initially dividing children into those mechanically ventilated versus those not and had strong predictive power for mortality, thus independently verifying the triage sequence and broadly verifying the algorithm. Conclusion: An evidence-based predictive tool for children is presented to guide resource allocation during Crisis Standards of Care, potentially improving population outcomes by selecting patients likely to benefit from short-duration ICU interventions. (Pediatr Crit Care Med 2015; XX:00���00) Key Words: intensive care unit length of stay; intensive care unit mortality; mass casualty; palliative care; pandemic preparedness; triage

To provide clinicians with practical considerations for care of children with Ebola virus disease in resource-rich settings.Review of the published medical literature, World Health Organization and government documents, and expert opinion.There are limited data regarding Ebola virus disease in children; however, reported case-fatality proportions in children are high. Ebola virus may affect immune regulation and endothelial function differently in children than adults. Considerations for care of children with Ebola virus disease are presented.Ebola virus disease is a severe multisystem disease with high mortality in children and adults. Hospitals and clinicians must prepare to provide care for patients with Ebola virus disease before such patients present for care, with particular attention to rigorous infection control to limit secondary cases. Although there is no proven specific treatment for Ebola virus disease, meticulous supportive care offers patients the best chance of survival.

BACKGROUND In a pandemic, needs for ventilators might overwhelm the limited supply. Outcome predictors have been proposed to guide ventilator triage allocation decisions. However, pandemic triage predictors have not been validated. This quantitative simulation study evaluated outcomes resulting from allocation strategies varying in their performance for selecting short-stay survivors as favorable candidates for ventilators. METHODS A quantitative simulation modeled a pandemic surge. Postulated numbers of potential daily admissions presented randomly from a specified population, with a limited number of available ventilators. Patients were triaged to ventilator care vs palliation or turned away to palliation if no ventilator was available. Simulated triage was conducted according to a set of hypothetical triage tools varying in sensitivity and specificity to select favorable ventilator candidates vs first-come, first-served allocation. Death was assumed for palliation. Survival or death was counted for patients who were ventilated according to the specified characteristic of each randomly selected patient. RESULTS Triage predictors with intermediate-quality performance resulted in a median daily mortality of 80%, similar to first-come, first-served allocation. A poor-quality predictor resulted in a worse mortality of 90%. Only a high-quality predictor (sensitivity 90%, specificity 90%) resulted in a substantially lower 60% mortality. CONCLUSIONS Performance of unvalidated pandemic ventilator triage predictors is unknown and possibly inferior to first-come, first-served allocation. Poor performance of unvalidated predictors proposed for triage would represent an inadequate plan for stewarding scarce resources and would deprive some patients of fair access to a ventilator, thus falling short of sound ethical foundations.

Background/ObjectiveTo qualitatively describe interventions by schools to meet children's needs after the May 2011 Joplin, Missouri tornado.MethodsQualitative exploratory study conducted six months after the tornado. Key informant interviews with school staff (teachers, psychologists, guidance counselor, nurse, principal), public health official, and physicians.ReportAfter the tornado, school staff immediately worked to contact every enrolled child to provide assistance and coordinate recovery services. Despite severe damage to half of the city's schools, the decision was made to reopen schools at the earliest possible time to provide a safe, reassuring environment and additional services. An expanded summer school session emphasized child safety and emotional wellbeing. The 2011-2012 school year began on time, less than three months after the disaster, using temporary facilities. Displaced children were bused to their usual schools regardless of their new temporary residence locations. In just-in-time training sessions, teachers developed strategies to support students and staff experiencing anxiety or depression. Certified counselors conducted school-based, small-group counseling for students. Selective referrals were made to community mental health providers for children with greatest needs.ConclusionsEvidence from Joplin adds to a small body of empirical experience demonstrating the important contribution of schools to postdisaster community recovery. Despite timely and proactive services, many families and children struggled after the tornado. Improvements in the effectiveness of postdisaster interventions at schools will follow from future scientific evidence on optimal approaches.KanterRK, AbramsonD. School interventions after the Joplin tornado. Prehosp Disaster Med. 2014;29(2):1-4.

ObjectiveNatural disasters exacerbate risks of hazardous environmental exposures and adverse health consequences. The present study determined the proportion of previously identified lead industrial sites in urban locations that are at high risk for dispersal of toxic chemicals by natural disasters.MethodsGeographic analysis from publicly available data identified former lead smelting plants that coincide with populated urban areas and with high-risk locations for natural disasters.ResultsFrom a total of 229 urban smelting sites, 66 (29%) were in relatively high-risk areas for natural disasters: flood (39), earthquake (29), tornado (3), and hurricane (2). States with urban sites at relatively high risk for natural disaster included California (15); Pennsylvania (14); New York (7); Missouri (6); Illinois (5); New Jersey (4); Kentucky (3); Florida, Oregon, and Ohio (2 each); and Indiana, Massachusetts, Rhode Island, Texas, Utah, and Washington (1 each). Incomplete historical records showed at least 10 smelting site locations were affected by natural disaster.ConclusionsForgotten environmental hazards may remain hazardous in any community. Uncertainty about risks in disasters causes disruptive public anxiety that increases difficulties in community responses and recovery. Our professional and public responsibility is to seek a better understanding of the risks of latent environmental hazards. (Disaster Med Public Health Preparedness. 2014;0:1–7)

Objectives To develop and validate an algorithm to guide selection of patients for pediatric critical care admission during a severe pandemic when Crisis Standards of Care are implemented. Design Retrospective observational study using secondary data. Patients Children admitted to VPS-participating PICUs between 2009-2012. Interventions A total of 111,174 randomly selected nonelective cases from the Virtual PICU Systems database were used to estimate each patient's probability of death and duration of ventilation employing previously derived predictive equations. Using real and projected statistics for the State of Ohio as an example, triage thresholds were established for casualty volumes ranging from 5,000 to 10,000 for a modeled pandemic with peak duration of 6 weeks and 280 pediatric intensive care beds. The goal was to simultaneously maximize casualty survival and bed occupancy. Discrete Event Simulation was used to determine triage thresholds for probability of death and duration of ventilation as a function of casualty volume and the total number of available beds. Simulation was employed to compare survival between the proposed triage algorithm and a first come first served distribution of scarce resources. Measurements and main results Population survival was greater using the triage thresholds compared with a first come first served strategy. In this model, for five, six, seven, eight, and 10 thousand casualties, the triage algorithm increased the number of lives saved by 284, 386, 547, 746, and 1,089, respectively, compared with first come first served (all p Conclusions Use of triage thresholds based on probability of death and duration of mechanical ventilation determined from actual critically ill children's data demonstrated superior population survival during a simulated overwhelming pandemic.

OBJECTIVES Previous simulation studies suggest that temporary pediatric mass critical care approaches would accommodate plausible hypothetical sudden-impact public health emergencies. However, the utility of sustained pediatric mass critical care responses in prolonged pandemics has not been evaluated. The objective of this study was to compare the ability of a typical region to serve pediatric intensive care unit needs in hypothetical pandemics, with and without mass critical care responses sufficient to triple usual pediatric intensive care unit capacity. DESIGN, SETTING, PATIENTS, AND INTERVENTIONS: The Monte Carlo simulation method was used to model responses to hypothetical pandemics on the basis of national historical evidence regarding pediatric intensive care unit admission and length of stay in pandemic and nonpandemic circumstances. Assuming all ages are affected equally, federal guidelines call for plans to serve moderate and severe pandemics requiring pediatric intensive care unit care for 457 and 5,277 infants and children per million of the population, respectively. MEASUREMENTS AND MAIN RESULTS A moderate pandemic would exceed ordinary surge capacity on 13% of pandemic season days but would always be accommodated by mass critical care approaches. In a severe pandemic, ordinary surge methods would accommodate all the patients on only 32% of pandemic season days and would accommodate 39% of needed patient days. Mass critical care approaches would accommodate all the patients on 82% of the days and would accommodate 64% of all patient days. CONCLUSION Mass critical care approaches would be essential to extend care to the majority of infants and children in a severe pandemic. However, some patients needing critical care still could not be accommodated, requiring consideration of rationing.

Introduction Improved health outcomes are associated with neonatal and pediatric critical care in well-organized, cohesive, regionalized systems that are prepared to support and rehabilitate critically ill victims of a mass casualty event. However, present systems lack adequate surge capacity for neonatal and pediatric mass critical care. In this document, we outline the present reality and suggest alternative approaches. Methods In May 2008, the Task Force for Mass Critical Care published guidance on provision of mass critical care to adults. Acknowledging that the critical care needs of children during disasters were unaddressed by this effort, a 17-member Steering Committee, assembled by the Oak Ridge Institute for Science and Education with guidance from members of the American Academy of Pediatrics, convened in April 2009 to determine priority topic areas for pediatric emergency mass critical care recommendations.Steering Committee members established subcommittees by topic area and performed literature reviews of MEDLINE and Ovid databases. The Steering Committee produced draft outlines through consensus-based study of the literature and convened October 6-7, 2009, in New York, NY, to review and revise each outline. Eight draft documents were subsequently developed from the revised outlines as well as through searches of MEDLINE updated through March 2010.The Pediatric Emergency Mass Critical Care Task Force, composed of 36 experts from diverse public health, medical, and disaster response fields, convened in Atlanta, GA, on March 29-30, 2010. Feedback on each manuscript was compiled and the Steering Committee revised each document to reflect expert input in addition to the most current medical literature. Task force recommendations States and regions (facilitated by federal partners) should review current emergency operations and devise appropriate plans to address the population-based needs of infants and children in large-scale disasters. Action at the state, regional, and federal levels should address legal, operational, and information systems to provide effective pediatric mass critical care through: 1) predisaster/mass casualty planning, management, and assessment with input from child health professionals; 2) close cooperation, agreements, public-private partnerships, and unique delivery systems; and 3) use of existing public health data to assess pediatric populations at risk and to model graded response plans based on increasing patient volume and acuity.

Background: Age-specific pediatric health consequences of community disruption after Hurricane Katrina have not been analyzed. Post-Katrina vital statistics are unavailable. The objectives of this study were to validate an alternative method to estimate child mortality rates in the greater New Orleans area and compare pre-Katrina and post-Katrina mortality rates.Methods: Pre-Katrina 2004 child mortality was estimated from death reports in the local daily newspaper and validated by comparison with pre-Katrina data from the Louisiana Department of Health. Post-Katrina child mortality rates were analyzed as a measure of health consequences.Results: Newspaper-derived estimates of mortality rates appear to be valid except for possible underreporting of neonatal rates. Pre-Katrina and post-Katrina mortality rates were similar for all age groups except infants. Post-Katrina, a 92% decline in mortality rate occurred for neonates (Conclusions: A declining infant mortality rate raises questions about persistent displacement of high-risk infants out of the region. Otherwise, there is no evidence of long-lasting post-Katrina excess child mortality. Further investigation of demographic changes would be of interest to local decision makers and planners for recovery after public health emergencies in other regions.(Disaster Med Public Health Preparedness. 2010;4:62-65)

Study objective National policy for emergency preparedness calls for hospitals to accommodate surges of 500 new patients per million population in a disaster, but published studies have not evaluated the ability of existing resources to meet these goals. We describe typical statewide and regional hospital occupancy and patterns of variation in occupancy and estimate the ability of hospitals to accommodate new inpatients. Methods Daily hospital occupancy for each hospital was calculated according to admission date and length of stay for each patient during the study period. Occupancy was expressed as the count of occupied beds. Peak hospital capacity was defined as the 95th percentile highest occupancy at each facility. Data obtained from the New York Statewide Planning and Research Cooperative System were analyzed for 1996 to 2002. Patients were classified as children (0 to 14 years, excluding newborns) or adults. Vacant hospital beds per million age-specific population were determined as the difference between peak capacity and average occupancy. Results In New York State, 242 hospitals cared for a peak capacity of 2,707 children and 46,613 adults. Occupancy averaged 60% of the peak for children and 82% for adults, allowing an average statewide capacity for a surge of 268 new pediatric and 555 adult patients for each million age-specific population. After the September 11, 2001, attacks, in the New York City region, a discretionary modification of admissions and discharges resulted in an 11% reduction from the expected occupancy for children and adults. Conclusion Typically, there are not enough vacant hospital beds available to serve 500 children per million population. Modified standards of hospital care to expand capacity may be necessary to serve children in a mass-casualty event.

BACKGROUND. Federal planners have suggested that one strategy to accommodate disaster surges of 500 inpatients per million population would involve altering standards of care. No data are available indicating the extent of alterations necessary to meet disaster surge targets. OBJECTIVE. Our goal was to, in a Monte Carlo simulation study, determine the probability that specified numbers of children could be accommodated for PICU and non-ICU hospital care in a disaster by a set of strategies involving altered standards of care. METHODS. Simulated daily vacancies at each hospital in New York City were generated as the difference between peak capacity and daily occupancy (generated randomly from a normal distribution on the basis of empirical data for each hospital). Simulations were repeated 1000 times. Capacity for new patients was explored for normal standards of care, for expansion of capacity by a discretionary 20% increase in vacancies by altering admission and discharge criteria, and for more strictly reduced standards of care to double or quadruple admissions for each vacancy. Resources were considered to reliably serve specified numbers of patients if that number could be accommodated with a probability of 90%. RESULTS. Providing normal standards of care, hospitals in New York City would reliably accommodate 250 children per million age-specific population. Hypothetical strict reductions in standards of care would reliably permit hospital care of 500 children per million, even if the disaster reduced hospital resources by 40%. On the basis of historical experience that as many as 30% of disaster casualties may be critically ill or injured, existing pediatric intensive care beds will typically be insufficient, even with modified standards of care. CONCLUSIONS. Extending resources by hypothetical alterations of standards of care would usually satisfy targets for hospital surge capacity, but ICU capacity would remain inadequate for large disasters.

Objective To identify comprehensive pediatric hospitals on the basis of publicly available data. Study design We developed identification criteria for comprehensive pediatric hospitals, then evaluated the number of hospitals meeting these selection criteria. Criteria for a comprehensive pediatric hospital included pediatric residency accreditation, pediatric inpatient volume, and diversity of pediatric disorders at each hospital. New York State hospital administrative discharge data were analyzed for patients 0 to 14 years of age, excluding neonatal diagnoses. Results Infants and children (n = 125,588) with 375 different diagnosis-related groups were discharged from 230 hospitals in 2000. Through the use of higher selective criteria (educational accreditation plus both high volume and diversity in the top decile), 11 comprehensive pediatric hospitals were identified. These hospitals serve populations of 1.7 ± 0.3 million (mean ± SD) each, with 8 referral regions throughout the state, collectively providing care for 29% of all pediatric statewide hospitalizations. Conclusions Comprehensive pediatric hospitals serve the population of New York widely and evenly. The ability to identify pediatric hospitals will permit evaluation of the relative quality of care and suggest appropriate regulatory interventions to improve pediatric hospital utilization.

In postdisaster settings, health care providers encounter secondary surges of unmet primary care and mental health needs that evolve throughout disaster recovery phases. Whatever a community’s predisaster adequacy of health care, postdisaster gaps are similar to those of any underserved region. We hypothesize that existing practice and evidence supporting medical homes and care coordination in primary care for the underserved provide a favorable model for improving health in disrupted communities. Elements of medical home services can be offered by local or temporary providers from outside the region, working out of mobile clinics early in disaster recovery. As repairs and reconstruction proceed, local services are restored over weeks or years. Throughout recovery, major tasks include identifying high-risk patients relative to the disaster and underlying health conditions, assisting displaced families as they transition through housing locations, and tracking their evolving access to health care and community services as they are restored. Postdisaster sources of financial assistance for the disaster-exposed population are often temporary and evolving, requiring up-to-date information to cover costs of care until stable services and insurance coverage are restored. Evidence to support disaster recovery health care improvement will require research funding and metrics on structures, processes, and outcomes of the disaster recovery medical home and care coordination, based on adaptation of standard validated methods to crisis environments. (Disaster Med Public Health Preparedness. 2015;9:337–343)

Children with disabilities and chronic conditions are more likely than their healthy peers to be admitted to emergency rooms, to be hospitalized, and to require pediatric intensive care. Although many of these admissions are attributable to disease burden, a significant percentage are unscheduled stays for an acute illness that is directly related to a known condition. Such admissions are foreseeable, and therefore may be avoidable. An understanding of typical patterns of events that lead to acute illness in children with chronic conditions might suggest strategies to prevent these illnesses or to minimize the severity of unpreventable illnesses when they occur. When viewed as a marker for avoidable morbidity, an "unanticipated" hospitalization of a child with a chronic condition or disability thus provides an important opportunity for health care quality improvement at the community level.

OBJECTIVE To investigate statewide variation in failure to utilize existing regional pediatric intensive care units (PICUs). METHODS Deaths of children in hospitals lacking specialized units (non-PICU hospitals) were postulated to represent possible PICU utilization failures. A survey study was performed on hospital inpatient discharges and deaths in 1997, using data obtained from the New York Statewide Planning and Research Cooperative System (SPARCS). Children 0-14 yrs old were studied, excluding neonatal Diagnosis-Related Groups and emergency department deaths. Hospitals were considered to have a PICU if they had a board-certified pediatric intensivist on staff, and either New York State designation as a PICU or a separate dedicated unit for children. Non-PICU hospital pediatric death rates were compared for health service areas to determine whether regional variation occurred. RESULTS Statewide, 157 of 584 (27%) pediatric hospital inpatient deaths occurred in non-PICU hospitals. Significant variation was seen among eight regions in pediatric death rates in non-PICU hospitals (p < .05). The 114 of 328 (35%) New York City inpatient deaths occurring in non-PICU hospitals significantly exceeded the 43 of 256 (17%) throughout the remainder of the state (p < .05). New York City non-PICU hospital death rates also were higher than in the rest of the state, when expressed per 100,000 pediatric population (8.04 vs. 2.00), and per 1,000 non-PICU hospital discharges (2.25 vs. 1.18), respectively (p < .05). Forty percent of New York City non-PICU hospitals experienced a pediatric inpatient death compared with only 13% in the rest of the state (p < .05). CONCLUSIONS Although the death of some children in hospitals lacking a PICU is expected, the significant regional variation in these deaths suggests that local obstacles, perhaps unique to metropolitan areas, may interfere with access to existing pediatric critical care resources.

System-level planning involves uniting hospitals and health systems, local/regional government agencies, emergency medical services, and other health-care entities involved in coordinating and enabling care in a major disaster. We reviewed the literature and sought expert opinions concerning system-level planning and engagement for mass critical care due to disasters or pandemics and offer suggestions for system-planning, coordination, communication, and response. The suggestions in this chapter are important for all of those involved in a pandemic or disaster with multiple critically ill or injured patients, including front-line clinicians, hospital administrators, and public health or government officials.The American College of Chest Physicians (CHEST) consensus statement development process was followed in developing suggestions. Task Force members met in person to develop nine key questions believed to be most relevant for system-planning, coordination, and communication. A systematic literature review was then performed for relevant articles and documents, reports, and other publications reported since 1993. No studies of sufficient quality were identified upon which to make evidence-based recommendations. Therefore, the panel developed expert opinion-based suggestions using a modified Delphi process.Suggestions were developed and grouped according to the following thematic elements: (1) national government support of health-care coalitions/regional health authorities (HC/RHAs), (2) teamwork within HC/RHAs, (3) system-level communication, (4) system-level surge capacity and capability, (5) pediatric patients and special populations, (6) HC/RHAs and networks, (7) models of advanced regional care systems, and (8) the use of simulation for preparedness and planning.System-level planning is essential to provide care for large numbers of critically ill patients because of disaster or pandemic. It also entails a departure from the routine, independent system and involves all levels from health-care institutions to regional health authorities. National government support is critical, as are robust communication systems and advanced planning supported by realistic exercises.

Successful management of a pandemic or disaster requires implementation of preexisting plans to minimize loss of life and maintain control. Managing the expected surges in intensive care capacity requires strategic planning from a systems perspective and includes focused intensive care abilities and requirements as well as all individuals and organizations involved in hospital and regional planning. The suggestions in this article are important for all involved in a large-scale disaster or pandemic, including front-line clinicians, hospital administrators, and public health or government officials. Specifically, this article focuses on surge logistics-those elements that provide the capability to deliver mass critical care.The Surge Capacity topic panel developed 23 key questions focused on the following domains: systems issues; equipment, supplies, and pharmaceuticals; staffing; and informatics. Literature searches were conducted to identify studies upon which evidence-based recommendations could be made. The results were reviewed for relevance to the topic, and the articles were screened by two topic editors for placement within one of the surge domains noted previously. Most reports were small scale, were observational, or used flawed modeling; hence, the level of evidence on which to base recommendations was poor and did not permit the development of evidence-based recommendations. The Surge Capacity topic panel subsequently followed the American College of Chest Physicians (CHEST) Guidelines Oversight Committee's methodology to develop suggestion based on expert opinion using a modified Delphi process.This article presents 22 suggestions pertaining to surge capacity mass critical care, including requirements for equipment, supplies, and pharmaceuticals; staff preparation and organization; methods of mitigating overwhelming patient loads; the role of deployable critical care services; and the use of transportation assets to support the surge response.Critical care response to a disaster relies on careful planning for staff and resource augmentation and involves many agencies. Maximizing the use of regional resources, including staff, equipment, and supplies, extends critical care capabilities. Regional coalitions should be established to facilitate agreements, outline operational plans, and coordinate hospital efforts to achieve predetermined goals. Specialized physician oversight is necessary and if not available on site, may be provided through remote consultation. Triage by experienced providers, reverse triage, and service deescalation may be used to minimize ICU resource consumption. During a temporary loss of infrastructure or overwhelmed hospital resources, deployable critical care services should be considered.

Objective: For pediatric intensive care unit (ICU) survivors, to determine the proportion of hospital stay and estimated hospital costs accounted for by post-ICU care. Design: Prospective study. Setting: University teaching hospital. Patients: Pediatric patients who survive an ICU admission. Interventions: None. Measurements and Main Results: Estimated relative daily costs were assumed as follows: ICU, with ventilator/ICU, not on ventilator/intermediate care unit/general pediatric hospital day, at 2:1:0.7:0.3, respectively. Estimated costs were expressed in arbitrary units as (number of days at each level of care) × (relative cost per day). The ICU phase was defined as the patient's first ICU admission only, and the post-ICU phase included intermediate care unit and general pediatric hospital days, as well as ICU readmission during the same hospitalization. Pre-ICU hospital activity was excluded from analysis. For 341 ICU survivors, post-ICU days (median, 4 days per patient) accounted for 62% of the total hospital stay. Post-ICU care accounted for one third of the total estimated hospital costs for ICU survivors. Patients with longer post-ICU stays could not be reliably identified at the time of ICU discharge according to their ICU length of stay, duration of mechanical ventilation in the ICU, age, ICU day 1 mortality probability, or diagnostic group (p> .05). Conclusions: Post-ICU care accounts for a substantial proportion of hospital stay and estimated costs for ICU survivors. These observations suggest that developing strategies to optimize hospital utilization at the time of ICU discharge may be important for controlling costs of recovery from critical illness.

This chapter reviews the functional symptoms likely to be encountered in the pediatric critical care setting. Considering symptoms to be “functional” implies that a psychological or emotional state contributes to the symptom. Thus functional symptoms overlap with related terms such as “psychogenic,” “psychosomatic,” and “nonorganic” symptoms. Functional symptoms occur on a daily basis in the intensive care unit (ICU) when a child’s anxiety intensifies unpleasant symptoms. At the same time, unpleasant symptoms amplify anxiety. And if there is a vicious circle of anxiety and symptoms for the child, this is also exacerbated by a vicious circle of anxiety among the child, family, and staff. Symptoms during routine care, procedures, or crises in the ICU can be controlled by a combination of pharmacological and nonpharmacological strategies. Functional symptoms may mimic a life threatening condition, on rare occasions, requiring a timely diagnostic evaluation.

This chapter will review the typical symptoms occurring in children after stressful traumatic exposures. Unlike other chapters in this book, no specific organ system is the most likely focus of functional symptoms in this setting. Psychological distress may exacerbate symptoms of physical illness and injury associated with the traumatic events, may be expressed as almost any seemingly unrelated symptom, may intensify the age appropriate fears typical of any child, or may predominantly be exhibited behaviorally. In most nonsevere cases, the impact is self-limited and the individual’s functioning will be back to normal within days or weeks. We will suggest simple behavioral and environmental interventions intended to help relieve children’s distress. However, when large populations are affected and individuals suffer severe loss such as in a mass casualty disaster, the scale of events requires community-wide efforts to meet the needs of children and their families. The fact that some children are more psychosocially vulnerable than others will be discussed. The chapter will conclude by highlighting warning signs warranting professional mental health care.

Objective. The Pediatric Risk of Mortality (PRISM) score is a measure of illness severity based on abnormalities observed in the bedside examination and laboratory assessment. PRISM scores obtained after pediatric intensive care unit (PICU) admission predict mortality probability, but no previous efforts to evaluate mortality risk before PICU admission have been reported. Our study was performed on patients admitted to PICUs at four pediatric tertiary care centers to derive a quantitative estimate of hospital mortality probability as a function of PRISM scores obtained at referring hospitals before PICU transfer. Performance of the model was tested by evaluating accuracy of mortality predictions obtained from pre-ICU PRISM scores in a separate validation set of patients. Methods. Patients were randomized to the derivation or validation sets. Data were recorded prospectively from observations made at hospitals referring to the study PICUs. Patients included 780 infants and children with medical and surgical emergencies and trauma. Electively admitted patients were excluded from analysis. Results. The relationship between mortality probability (P) and the pre-ICU PRISM score is expressed by the equation: P =er/(1 + er). In this equation, r is an empirical function of the pre-ICU PRISM score: r = .197 × PRISM − 4.705. The mortality probability rises from near 0 at low scores, approaching 1 (certainty) above a PRISM score of 40. Mortality probability exceeds 10% at a score of 13 and exceeds 50% at a score of 24. Performance of predictions in the validation set of patients was evaluated for five categories of mortality probability. The observed number of deaths corresponded to predicted mortality across the range of illness severity. When compared for each tertiary institution, observed mortality rates were similar to predictions for three of four institutions. For data obtained at institution D, the observed mortality of 17% significantly exceeded the 7% predicted rate. In infants younger than 1 year, as well as children 1 year and older, observed mortality rates were similar to predicted. Conclusions. The pre-ICU PRISM score as a measure of illness severity provides an estimate of hospital mortality probability. Further investigation is required to determine the use of pre-ICU mortality estimates in making clinical decisions.

Neurons in rat medulla oblongata with Fos immunoreactivity as a marker of synaptic excitation evoked by pentylenetetrazole-induced seizures were compared with cell populations activated by the stimulation of chemoreceptor and baroreceptor afferent pathways. Chemoreceptors were stimulated by placing rats in a hypoxic gas mixture (7% oxygen) for 2 h. Baroreceptors were activated by phenylephrine-induced hypertension. Seizures and hypoxia induced Fos immunoreactivity in neurons with similar anatomical distributions in the nucleus tractus solitarius, dorsal motor nucleus of the vagus, and ventrolateral medulla. Hypertension was associated with Fos immunoreactivity in an overlapping anatomical distribution compared to seizures and hypoxia, but in a more restricted pattern. A similar proportion of catecholaminergic cells of medulla oblongata (cells immunoreactive for catecholamine synthetic enzymes, tyrosine hydroxylase or phenylethanolamine-N-methyltransferase) had Fos immunostaining after seizures and hypoxia (P > 0.05), while significantly fewer were activated by hypertension (P < 0.05). The majority of tyrosine hydroxylase-immunoreactive cells in caudal ventrolateral medulla were activated by both seizures and hypoxia (mean per cents, 79 and 67%, respectively). Since cell populations activated by seizures and hypoxia are indistinguishable, and a majority of tyrosine hydroxylase-reactive cells in caudal ventrolateral medulla are independently activated by each stimulus, it may be inferred that some impulses originating from seizures and chemoreceptor afferent pathways converge to a common set of neurons. These observations identify neurons in rat medulla oblongata which may mediate the impact of seizures on central processing of chemoreceptor afferent activity.

Objectives: To determine the ability of five New York statewide regions to accommodate 30 children needing critical care after a hypothetical mass casualty incident (MCI) and the duration to complete an evacuation to facilities in other regions if the surge exceeded local capacity.Methods: A quantitative model evaluated pediatric intensive care unit (PICU) vacancies for MCI patients, based on data on existing resources, historical average occupancy, and evidence on early discharges and transfers in a public health emergency. Evacuation of patients exceeding local capacity to the nearest PICU center with vacancies was modeled in discrete event chronological simulations for three scenarios in each region: pediatric critical care transport teams were considered to originate from other PICU hospitals statewide, using (1) ground ambulances or (2) helicopters, and (3) noncritical care teams were considered to originate from the local MCI region using ground ambulances. Chronology of key events was modeled.Results: Across five regions, the number of children needing evacuation would vary from 0 to 23. The New York City (NYC) metropolitan area could accommodate all patients. The region closest to NYC could evacuate all excess patients to PICU hospitals in NYC within 12 hours using statewide critical care teams traveling by ground ambulance. Helicopters and local noncritical care teams would not shorten the evacuation. For other statewide regions, evacuation of excess patients by statewide critical care teams traveling by ground ambulance would require up to nearly 26 hours. Helicopter transport would reduce evacuation time by 40%-44%, while local noncritical care teams traveling by ground would reduce evacuation time by 16%-34%.Conclusions: The present study provides a quantitative, evidence-based approach to estimate regional pediatric critical care evacuation needs after an MCI. Large metropolitan areas with many PICU beds would be better able to accommodate patients in a local MCI, and would serve as a crucial resource if an MCI occurred in a smaller community. Regions near a metropolitan area could be rapidly served by critical care transport teams traveling by ground ambulance. Regions distant from a metropolitan area might benefit from helicopter transport. Using local noncritical care transport teams would involve shorter delays and less expert care during evacuation.(Disaster Med Public Health Preparedness. 2012;6:146–149)

Epidemics of acute respiratory disease, such as severe acute respiratory syndrome in 2003, and natural disasters, such as Hurricane Katrina in 2005, have prompted planning in hospitals that offer adult critical care to increase their capacity and equipment inventory for responding to a major demand surge. However, planning at a national, state, or local level to address the particular medical resource needs of children for mass critical care has yet to occur in any coordinated way. This paper presents the consensus opinion of the Task Force regarding supplies and equipment that would be required during a pediatric mass critical care crisis.In May 2008, the Task Force for Mass Critical Care published guidance on provision of mass critical care to adults. Acknowledging that the critical care needs of children during disasters were unaddressed by this effort, a 17-member Steering Committee, assembled by the Oak Ridge Institute for Science and Education with guidance from members of the American Academy of Pediatrics, convened in April 2009 to determine priority topic areas for pediatric emergency mass critical care recommendations.Steering Committee members established subcommittees by topic area and performed literature reviews of MEDLINE and Ovid databases. The Steering Committee produced draft outlines through consensus-based study of the literature and convened October 6-7, 2009, in New York, NY, to review and revise each outline. Eight draft documents were subsequently developed from the revised outlines as well as through searches of MEDLINE updated through March 2010.The Pediatric Emergency Mass Critical Care Task Force, composed of 36 experts from diverse public health, medical, and disaster response fields, convened in Atlanta, GA, on March 29-30, 2010. Feedback on each manuscript was compiled and the Steering Committee revised each document to reflect expert input in addition to the most current medical literature.The Task Force endorsed the view that supplies and equipment must be available for a tripling of capacity above the usual peak pediatric intensive care unit capacity for at least 10 days. The recommended size-specific pediatric mass critical care equipment stockpile for two types of patients is presented in terms of equipment needs per ten mass critical care beds, which would serve 26 patients over a 10-day period. Specific recommendations are made regarding ventilator capacity, including the potential use of high-frequency oscillatory ventilation and extracorporeal membrane oxygenation. Other recommendations include inventories for disposable medical equipment, medications, and staffing levels.

This paper will outline the Task Force recommendations regarding treatment during pediatric emergency mass critical care, issues related to the allocation of scarce resources, and current challenges in the development of pediatric triage guidelines.In May 2008, the Task Force for Mass Critical Care published guidance on provision of mass critical care to adults. Acknowledging that the critical care needs of children during disasters were unaddressed by this effort, a 17-member Steering Committee, assembled by the Oak Ridge Institute for Science and Education with guidance from members of the American Academy of Pediatrics, convened in April 2009 to determine priority topic areas for pediatric emergency mass critical care recommendations.Steering Committee members established subcommittees by topic area and performed literature reviews of MEDLINE and Ovid databases. The Steering Committee produced draft outlines through consensus-based study of the literature and convened October 6-7, 2009, in New York, NY, to review and revise each outline. Eight draft documents were subsequently developed from the revised outlines as well as through searches of MEDLINE updated through March 2010.The Pediatric Emergency Mass Critical Care Task Force, composed of 36 experts from diverse public health, medical, and disaster response fields, convened in Atlanta, GA, on March 29-30, 2010. Feedback on each manuscript was compiled and the Steering Committee revised each document to reflect expert input in addition to the most current medical literature.Recommendations are divided into three operational sections. The first section provides pediatric emergency mass critical care recommendations for hospitals that normally provide care to pediatric patients. The second section provides recommendations for pediatric emergency mass critical care at hospitals that do not routinely provide care to pediatric patients. The final section provides a discussion of issues related to developing triage algorithms and protocols and the allocation of scarce resources during pediatric emergency mass critical care.

A group of 205 patients (115 children and 90 adults) with a total of 212 intracranial pressure (ICP) monitors were retrospectively studied with attention to daily cerebrospinal fluid cultures, duration of monitoring, associated cranial injuries, and hospital site of the ICP monitor (intensive care unit or operating room). Only closed ICP monitoring systems without irrigation or compliance testing were used, and all patients received antibiotics as prophylaxis throughout the monitoring period. There were no complications associated with monitor placement. Incidence histograms and regression analysis were used to determine the daily risk of subsequent infections, in addition to evaluating the cumulative risk of infection, as has been previously described in the literature. No relation between the duration of ICP monitoring and the rate of daily infection through the period of maximal monitoring (1-2 weeks) was found in this series. The overall incidence of infection was 7.1% with a median duration of monitoring of 7.2 days. The age of the patient (adult vs. child), site of ICP monitor placement, and nature of the underlying disease (trauma vs. nontrauma) had no significant effect on the development of monitor-related infections in our study. These data indicate that the decision to continue ICP monitoring can be based solely on the clinical necessity for further monitoring rather than on concerns for monitor removal to prevent infection.

A prospective study was performed to determine whether excess morbidity occurred in critically ill and injured pediatric patients during interhospital transport compared with morbidity in a control group. Control observations were made during the first 2 hours of pediatric intensive care unit (PICU) care of patients emergently admitted from within the same institution and not requiring interhospital transport. The first 2 PICU hours of control patients corresponded to the interval of transport in those who required interhospital transfer. Transport care was provided by nonspecialized teams from referring hospitals. Morbidity occurred in 20.9% of 177 transported patients, exceeding the morbidity rate of 11.3% in 195 control patients (P < .05). The difference in morbidity was due to intensive care-related adverse events (eg, plugged or dislodged endotracheal tubes, loss of intravenous access) in 15.3% and 3.6% of transported and control patients, respectively (P < .05). Physiologic deterioration occurred at similar rates of 7.9% and 8.7% in transported and control patients, respectively (P > .05). Slightly greater pre-ICU severity of illness in transported than control patients (median Pediatric Risk of Mortality Score = 10 and 7, respectively, P < .05) and greater pre-ICU therapy relative to severity (P < .05) in control patients are potential confounding sources of the morbidity differences. If patients are stratified into subgroups of similar pre-ICU severity, an excess of intensive care-related adverse events in transported patients remains evident in the severe subgroup (P < .05). Further investigation is warranted to determine whether specialized transport teams can reduce the excess morbidity associated with interhospital transport of critically ill and injured pediatric patients.

This article applies developing concepts of mass critical care (MCC) to children. In public health emergencies (PHEs), MCC would improve population outcomes by providing lifesaving interventions while delaying less urgent care. If needs exceed resources despite MCC, then rationing would allocate interventions to those most likely to survive with care. Gaps between estimated needs and actual hospital resources are worse for children than adults. Clear identification of pediatric hospitals would facilitate distribution of children according to PHE needs, but all hospitals must prepare to treat some children. Keeping children with a family member and identifying unaccompanied children complicate PHE regional triage. Pediatric critical care experts would teach and supervise supplemental providers. Adapting nearly equivalent equipment compensates for shortages, but there is no substitute for age-appropriate resuscitation masks, IV/suction catheters, endotracheal/gastric/chest tubes. Limitations will be encountered using adult ventilators for infants. Temporary manual bag valve ventilation and development of shared ventilators may prolong survival until the arrival of ventilator stockpiles. To ration MCC to children most likely to survive, the Pediatric Index of Mortality 2 score meets the criteria for validated pediatric mortality predictions. Policymakers must define population outcome goals in regard to lives saved versus life-years saved. (Disaster Med Public Health Preparedness. 2009;3(Suppl 2):S166–S171)

Background: Neither professional consensus nor evidence exists to guide the choice of essential hospital disaster interventions. The objective of our study was to demonstrate a method for developing consensus on hospital disaster interventions that should be regarded as essential, quantitatively balancing needs and resources.Methods: A panel of pediatric acute care practitioners developed consensus using a modified Delphi process. Interventions were chosen such that workload per staff member would not exceed the previously validated maximum according to the Therapeutic Intervention Scoring System. Based on published models, it was assumed that the usual numbers of staff would care for a disaster surge of 4 times the usual number of intensive care and non–intensive care hospital patients.Results: Using a single set of assumptions on constrained resources and overwhelming needs, the panel ranked and agreed on essential interventions. A number of standard interventions would exceed crisis workload constraints, including detailed recording of vital signs and fluid balance, administration of vasoactive agents, invasive monitoring of pressures (central venous, intraarterial, intracranial), dialysis, and tube feedings.Conclusions: The quantitative methodology and consensus development process described in the present report may have utility in future planning. Groups with appropriate expertise must develop action plans according to authority within each jurisdiction, addressing likely disaster scenarios, according to the needs in each medical service region, using available regional resources, and accounting for the capabilities of each institution. (Disaster Med Public Health Preparedness. 2009;3:27–32)

Objective To describe changing rates of disorders associated with child hospitalization. Study design Trends for the 100 diagnosis related groups (DRGs) with the largest number of hospitalizations (0-14 years) were analyzed. Results Children were hospitalized at an average annual rate of 35 per 1000 age-specific population during 1996 to 2002. The hospitalization rate decreased by 2.3% per year. The top 100 DRGs accounted for 90% of all 949,376 child hospitalizations. Hospitalization for mental illness increased by 5.5% per year, accounting for more than 4% of all child hospitalizations in 2002. Ambulatory care-sensitive medical conditions (asthma, gastrointestinal disorders, pneumonia, seizures) continue to be leading causes of hospitalization, and they are declining no faster than the overall rate. DRGs with a significantly faster rate of decline than the overall trend included surgical procedures for which inpatient care is often unnecessary (–12.3%/year, accounting for 11% of the overall decline) trauma-related diagnoses (–4.4%/year, accounting for 7% of the overall decline), and HIV-related conditions (–31.7%/year, accounting for 3% of the overall decline). Conclusions The rising rate of hospitalization associated with child mental illness may represent a clinically important trend. Rates of hospitalization for ambulatory care-sensitive conditions have not declined substantially despite the availability of evidence-based strategies to avoid serious illness.

Background.Little published information is available regarding the proportion of hospitals that offer pediatric services at specified levels, or the actual utilization of such services.Objective.To determine if an existing national accreditation process created for educational purposes identifies hospitals with a distinct utilization pattern, in a sample of pediatric inpatient activity from one state.Methods.Hospitals in New York State were classified as “pediatric” hospitals according to their sponsorship or major participation with an accredited pediatric residence program. Institutions not affiliated with pediatric residencies were considered to be the “other” hospitals. Data on hospital discharges and interhospital transfers were studied for children from 0 to 14 years old, excluding neonatal Diagnosis-Related Groups. Data were obtained from the New York Statewide Planning and Research Cooperative System for 1996, 1997, and 2000.Results.Sixteen percent of hospitals were considered to be “pediatric” facilities (42 of 257) by study criteria. Annual pediatric inpatient activity per “pediatric” hospital significantly exceeded that in “other” institutions, including hospitalizations (2249 ± 1284 vs 258 ± 348), number of interhospital transfers received (153 ± 88 vs 18 ± 26), and number of hospitals referring interhospital transfers to each receiving hospital (36 ± 17 vs 5 ± 7; mean ± standard deviation; for each comparison). Statewide, “pediatric” hospitals served two thirds of all hospitalized children and 70% of all children’s hospital days. “Pediatric” hospitals cared for 26.5 patients per hospital day, compared with only 2.2 per day at “other” institutions. Although statewide hospitalizations of children fell by 14.3% the proportion of all pediatric hospitalizations served by “pediatric” hospitals increased by 3.8% from 1996 to 2000.Conclusions.Although intended for educational purposes, hospital affiliation with an accredited pediatric residency program identifies a subgroup of facilities with a distinct utilization pattern, which provides care for the majority of pediatric inpatients, and serves as a resource to other hospitals.

BACKGROUND System-level planning involves uniting hospitals and health systems, local/regional government agencies, emergency medical services, and other health-care entities involved in coordinating and enabling care in a major disaster. We reviewed the literature and sought expert opinions concerning system-level planning and engagement for mass critical care due to disasters or pandemics and offer suggestions for system-planning, coordination, communication, and response. The suggestions in this chapter are important for all of those involved in a pandemic or disaster with multiple critically ill or injured patients, including front-line clinicians, hospital administrators, and public health or government officials. METHODS The American College of Chest Physicians (CHEST) consensus statement development process was followed in developing suggestions. Task Force members met in person to develop nine key questions believed to be most relevant for system-planning, coordination, and communication. A systematic literature review was then performed for relevant articles and documents, reports, and other publications reported since 1993. No studies of sufficient quality were identified upon which to make evidence-based recommendations. Therefore, the panel developed expert opinion-based suggestions using a modified Delphi process. RESULTS Suggestions were developed and grouped according to the following thematic elements: (1) national government support of health-care coalitions/regional health authorities (HC/RHAs), (2) teamwork within HC/RHAs, (3) system-level communication, (4) system-level surge capacity and capability, (5) pediatric patients and special populations, (6) HC/RHAs and networks, (7) models of advanced regional care systems, and (8) the use of simulation for preparedness and planning. CONCLUSIONS System-level planning is essential to provide care for large numbers of critically ill patients because of disaster or pandemic. It also entails a departure from the routine, independent system and involves all levels from health-care institutions to regional health authorities. National government support is critical, as are robust communication systems and advanced planning supported by realistic exercises.

We sought to determine whether institution of respiratory syncytial virus (RSV) practice guidelines decreased resource utilization for a heterogeneous population of children hospitalized with RSV bronchiolitis. Patients less than 24 months old with RSV bronchiolitis at a pediatric referral center were identified by retrospective chart review for consecutive RSV seasons. Before the guidelines were instituted patients were less likely to have a documented physician's assessment of response to albuterol, were more likely to have received supplemental oxygen and cardiorespiratory monitoring, and to be discharged on an albuterol regimen. Patients received more albuterol treatments. After the guidelines were in place fewer resources were utilized in the care of patients with RSV bronchiolitis. RSV practice guidelines may simplify and streamline the care of a heterogeneous population of children with bronchiolitis.

We estimated the relative risk (RR) of an unscheduled pediatric intensive care unit (ICU) admission as a marker for severe acute illness in children with chronic health conditions, compared with previously healthy children. Potentially preventable events that lead to acute illness were identified to develop preventive strategies. Methods. Children with chronic conditions were defined as those who have a chronic physical, developmental, behavioral, or emotional condition and who also require health and related services of a type or amount beyond that required by children generally. RR was estimated from admissions and regional population data. Potentially preventable events that lead to ICU admission of chronically ill children were identified retrospectively from hospital records. Results. Children with chronic health conditions had an RR of 3.3 for an unscheduled ICU admission related to their chronic condition, compared with previously healthy individuals (95% confidence interval [CI] = 2.5–4.2). The risk of severe acute illness in the small subgroup that received technology-assisted care was much greater (RR = 373; 95% CI = 330–422) than for the large group of chronically ill patients who did not require technology-assisted care (RR = 2.3; 95% CI = 1.7–3.0), each expressed relative to previously healthy children. Acute illness related to chronic health conditions accounted for 45% of 251 unscheduled ICU admissions during the 1-year study. Thirty-two percent of admissions that were related to chronic conditions were judged to have been potentially preventable. Preventable events were more common for those who did not require technology-assisted care, occurring in 38% of admissions, compared with those who received technology-assisted care, for whom 19% of admissions involved a preventable event. Fifty-six percent of potentially preventable events involved the physical or social environment and decisions made by the family, whereas 64% could be attributed to health care system factors. Conclusions. Children with chronic health conditions account for a substantial share of severe acute illness in a region. Because their underlying conditions have already been identified, problems may be anticipated. The small number of children who receive technology-assisted care each have such a high risk of severe and unavoidable acute illness that individualized emergency care plans are justified. For the remainder of children with chronic conditions, investigation of health system strategies to improve families' ability to anticipate, minimize, or prevent related acute illness is warranted.

We studied the early infectious complications of all children admitted for intensive care over a six-year period who were at high risk of having severe aspiration of gastric or pharyngeal secretions. Patients were only analyzed if they required mechanical ventilation for acute respiratory failure, had a blood culture obtained in the first 48 hours, and survived at least 24 hours. Infections were identified by positive blood cultures. Possible infections were defined as fever (over 38.5 degrees C), abnormal leukocyte count (greater than 10,000 or less than 5000), and a potential pathogen in tracheal secretions. Patients' diagnoses included near-drowning (13), aspirated foreign body (5), observed aspiration of gastric contents in a hospitalized patient (2), and hydrocarbon aspiration (1). Of 21 high-risk patients, five (23.8%) had infections and two (9.5%) had possible infections in the first 48 hours. In contrast, no late infections were seen. Infected patients tended to be older (P less than 0.05). No diagnostic features in the first two days of hospitalization reliably identified those who would develop early infections (P greater than 0.05). Since early life-threatening infection is common and cannot be reliably predicted by clinical signs, we recommend aggressive bacteriologic surveillance and the administration of IV antibiotics on admission to all patients in respiratory failure requiring mechanical ventilation after presumed aspiration of gastric or pharyngeal secretions.

Commercial interests in health care have begun to affect the contents of some medical research reports in a way that could interfere with the essential function of medical journals. Recently I was asked to review a manuscript submitted for publication to Pediatrics , investigating the application of a proprietary clinical scoring system in a pediatric population. Basic information was withheld because of its proprietary nature, such as the identification of clinical variables, values of normal age-related ranges, as well as the equations relating patient characteristics to outcome. The missing information made a potentially useful contribution uninterpretable. The difficulties encountered in evaluating this incomplete report typify a problem that journals increasingly will face as they deal with articles having commercial importance. Many journal editors have not yet stated a position on the practice of withholding proprietary information from articles submitted for publication. The fact that commercial interests arise in an article on health services research indicates the economic importance of this growing field. Health services research deals with effectiveness, costs, and efficiency of health care. In order to interpret observations of health outcomes, objective methods are needed to characterize the patient population involved. For example, a clinical scoring system measuring severity of illness might assist in the interpretation of differences in clinical outcomes between two health care organizations. Using clinical scoring systems, the investigator may be able to attribute differing outcomes … Address correspondence to: Robert K. Kanter, MD, Department of Pediatrics, SUNY Health Science Center, 750 East Adams St, Syracuse, NY 13210.

This study was performed to determine whether c-fos immunoreactivity (IR) induced in medulla oblongata by pentylenetetrazole seizures is a consequence of seizure-associated blood pressure elevation and activation of baroreceptor afferent pathways, or occurs independently of hypertension. Immunohistochemical study of sections of medulla oblongata revealed that seizures are followed by induction of c-fos IR in nucleus tractus solitarius (NTS), dorsal motor nucleus of the vagus (DMN 10), and ventrolateral medulla (VLM), while there is negligible c-fos IR after saline sham injections. Seizures were associated with blood pressure elevation peaking at 31 ± 17% (±SD) above baseline. Experimental hypertension at a similar level induced by i.p. phenylephrine also resulted in induction of c-fos IR in NTS. When seizures were preceded by antihypertensive treatment with the α-adrenergic antagonist, phentolamine, peak blood pressure tended to remain near the baseline level and lower than sham-injected controls. Normotensive seizures were associated with c-fos IR in NTS, DMN 10, and VLM similar to the pattern following hypertensive seizures. Seizure-induced activation of c-fos IR occurred despite normal blood pressure, and thus can be attributed to a direct effect of the seizure, and not to an indirect effect mediated by hypertension.

Objective To empirically describe the integration of pediatric disaster services into regional systems of care after the April 27, 2011, tornado in Tuscaloosa, Alabama, a community with no pediatric emergency department or pediatric intensive care unit and few pediatric subspecialists. Study design Data were obtained in interviews with key informants including professional staff and managers from public health and emergency management agencies, prehospital emergency medical services, fire departments, hospital nurses, physicians, and the trauma program coordinator. Results A single hospital in Tuscaloosa served 800 patients on the night of the tornado. More than 100 of these patients were children, including more than 20 with critical injuries. Many children were unaccompanied and unidentified on arrival. Resuscitation and stabilization were performed by nonpediatric prehospital and emergency department staff. More than 20 children were secondarily transported to the nearest children's hospital an hour's drive away under the care of nonpediatric local emergency medical services providers. No preventable adverse events were identified in the resuscitation and secondary transport phases of care. Stockpiled supplies and equipment were adequate to serve the needs of the disaster victims, including the children. Conclusion Essential aspects of preparation include pediatric-specific clinical skills, supplies and equipment, operational disaster plans, and interagency practice embedded in everyday work. Opportunities for improvement identified include more timely response to warnings, improved practices for identifying unaccompanied children, and enhanced child safety in shelters. Successful responses depended on integration of pediatric services into regional systems of care.

We performed studies to determine the anatomical regions and chemical phenotypes of neurons within the rat medulla oblongata activated by pentylenetetrazole-induced seizures. Activated cells were identified by their expression of the c-fos gene, detected by in situ hybridization for c-fos mRNA and immunocytochemistry for Fos protein. Activated cells were located predominantly in nucleus tractus solitarius (NTS), with c-fos mRNA appearing within 20 min after seizures (peak at 1-2 h), followed by Fos immunoreactivity visible at 1 h (peak at 2-4 h). Neither nonspecific noxious stimulation by intraperitoneal injection of saline nor brief exposure to hypoxic or hypercapnic gas mixtures to stimulate chemoreceptors reproduced this pattern of labeling. Prodynorphin or proenkephalin mRNA, detected by in situ hybridization, was colocalized with Fos immunoreactivity in many NTS cells. Thus, seizures activate neuronal pathways in the medulla oblongata which express genes for endogenous opioids. Potential long-term effects of seizures are suggested by the in situ hybridization finding that NTS prodynorphin mRNA increased 24 h after seizures compared to control levels.

OBJECTIVE We prospectively compared the occurrence of morbidity during high-risk interhospital transport in two types of transport systems: specialized tertiary center-based vs. nonspecialized, referring hospital-based. DESIGN Concurrent, prospective comparison of morbidity at two pediatric centers that use different types of transport team. SETTING Two tertiary care pediatric intensive care units (ICU). The specialized team consisted of a pediatric resident, pediatric intensive care nurse, and a pediatric respiratory therapist. Comparison was made with referring institution transports by nonspecialized personnel to a second center. The two centers were similar in size and patient mix, with referral areas of similar population and rural/urban ratio. PATIENTS One hundred forty-one patients transported to two tertiary pediatric ICUs. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Two types of events were assessed: vital signs and other observable clinical events were described as "physiologic deteriorations." Events such as loss of intravenous access, endotracheal tube mishaps, and exhaustion of oxygen supply were described as "intensive care-related adverse events." Pretransport severity of illness and therapy were described by Pediatric Risk of Mortality (PRISM) and Therapeutic Intervention Scoring System (TISS) scores. Only high-risk patients with PRISM scores of > or = 10 were analyzed. Intensive care-related adverse events occurred in one (2%) of 49 transports by the specialized team and 18 (20%) of 92 transports by nonspecialized personnel. The difference is statistically significant (p < .05). Physiologic deterioration was similar in the two groups occurring in five (11%) of 47 specialized team transports and 11 (12%) of 92 transports by the nonspecialized team. CONCLUSION We conclude that specialized pediatric teams can reduce transport morbidity. This is the first published study to compare two models of pediatric transport using identical definitions of severity and morbidity.

Study objective: Ventilation frequently is impaired during prolonged clinical seizures and their treatment. In a pilot study, respiratory, metabolic, and hemodynamic variables were studied during induced seizures in a lightly anesthetized, spontaneously breathing piglet model. Participants: Weanling, mixed-breed domestic piglets. Interventions: Piglets were instrumented with a tracheostomy, arterial catheter, and epidural electrodes. Conditions included hyperoxia, normothermia, and ketamine maintenance infusion throughout recordings. After baseline recordings, 2 mg/kg IV bicuculline was administered. For further model validation, piglets were randomized to infusions of diazepam (three), lorazepam (two), or saline (control; five) groups after ten minutes of untreated seizures. Measurements and main results: Integrated tidal volume, respiratory rate, Paco 2 , pH, arterial pressure, rectal temperature, heart rate, and bipolar EEG waveforms were recorded and compared at intervals for 60 minutes. Vigorous tonic-clonic seizures occurred in all piglets, confirmed by sudden synchronization and large-amplitude EEG waveforms. Increases in heart rate, arterial pressure, tidal volume, respiratory rate, Paco 2 , minute ventilation, and base deficit occurred in all piglets during seizures as compared with baseline. Five minutes after bicuculline was administered, increases in minute ventilation (4.5 ± 0.4 L/min at baseline to 13 ± 2.1 L/min) were accounted for by increases in both tidal volume and respiratory rate. More abrupt decreases in respiratory rate were observed in anticonvulsant-treated piglets as compared with controls. The duration of continuous seizure activity (12 ± 1.0 minutes versus 21 ± 3.3 minutes; P Conclusion: Significant increases in ventilation occur during generalized seizures in tracheostomized piglets given bicuculline. Diazepam and lorazepam infusions ameliorate seizure activity and suppress increases in respiratory rate but not minute ventilation as compared with controls. Problems with this model included baseline variability, temperature instability, and that direct respiratory stimulation from the convulsant agent may have occurred.

We describe a model for evaluating techniques of infant ventilation during resuscitation. The utility of the model is illustrated by testing performance of emergency medical technicians in mouth to mouth ventilation of a model 4 kg infant. Ventilation was generally adequate with mean (+/- S.D.) frequency 22 +/- 9 breaths per minute and tidal volume 40 +/- 13 ml. Gas delivered to the model consisted of PICO2 7 +/- 6 mmHg and FIO2 0.20 +/- 0.007. Assuming normal metabolic rate and respiratory dead space, alveolar gas composition resulting from the simulated resuscitations would be PACO2 = 31 +/- 20 and PAO2 = 110 +/- 19 mmHg. Nine of ten rescuers would have achieved satisfactory PACO2 less than or equal to 50 and PAO2 greater than or equal to 100. However, the rescuers' exhaled oxygen concentration is not adequate to correct hypoxemia if associated with hypoventilation or a wide alveolar to arterial oxygen gradient.

To study the impact of trauma patients on Pediatric Intensive Care Units (PICUs), 164 trauma patients' data from 1,075 consecutive admissions to five PICUs were reviewed. Resource use (Therapeutic Intervention Scoring System [TISS] points) and mortality risks (Physiologic Stability Index [PSI] and Pediatric Risk of Mortality [PRISM] scores) were obtained daily for all patients. Trauma patients constituted 15.2% of all PICU patients, and used 14.9% of patient care days and 14.5% of TISS points. Efficiency of trauma patient care was 75% overall compared to 79% overall for nontrauma patients (p less than 0.001). Trauma patient mortality was 9.8%. Tests for goodness of fit showed the PSI and PRISM scores to be accurate outcome predictors for trauma patients (PSI: chi 2 (4) = 2.852, p greater than 0.50; PRISM: chi 2 (4) = 1.216, p greater than 0.50). Trauma patients are a minority of PICU patients and deaths. Their resource use is proportional to their numbers, although less efficient than for nontrauma patients. PSI and PRISM are accurate mortality risk predictors for trauma patients.