Caleb Ward MB BChir, Children’s National Medical Center

The Case:
EMS calls 15 minutes ahead of time as they are en route with 4 children pulled from a house fire.

• 15 year old girl who is “unresponsive” on the ground but breathing on her own
• 13 year old boy who seems to be having a panic attack
• 2 year old girl who received chest compressions but is now breathing on her own
• 9 month old baby who has labored breathing

Here’s How You Answered Our Questions:

Discussion:

This day in age, a mass casualty is most providers nightmares. Sadly, it is becoming a reality day by day. However, this case highlights the importance of knowing your resources and limitations as a center as well as the possible variations given time of day. We were lucky enough to be able to create several teams with a wide variety of experiences and specialties so that a code orange did not need to be called. Dr. Root brought up the point that ensuring a mix of experiences and specialties for each team would allow for better patient care. Dr. Chapman, however, brought up a great point that activating a mass casualty would allocate a resource that typically is not there otherwise, which is a point person at triage to help assess possible severities and thus distribute to appropriate resuscitation areas and teams.

Cyanide poisoning should be suspected in any house fire and serum levels are not reflective of toxicity so not surprisingly, most of the group chose to administer the cyanokit and not worry about obtaining levels. For most of the group, the more difficult decision was the intubation thought process rather than giving cyanokits. If this child were a simply a board question, the answer is a no brainer. Intubate! However, as we all have come to know and love, the boards are NOT real life. Making the decision to intubate a child who is sitting there talking and conversing with you makes you always double think the decision, but the mild respiratory distress and tachypnea with soot stained nares made us much more confident.

Denouement:

A Mass Casualty was not activated, but Trauma Activations for all four were announced. As a result, in the ED at the time of arrival there was a team that included: PEM Attending, PEM Fellow, Anesthesia Attending, Anesthesia Fellow, PICU Fellow, Surgery Fellow, Surgery Resident. In addition a number of nurses, pharmacists and other resources were mobilized by the Nursing Administrator on call.

With respect to patient management:

1. A cyanokit was administered to the 13 year old boy. Over the next hour he became much more calm and lucid. The remainder of his trauma workup was unremarkable. He was admitted to the trauma service for observation and discharged home the next day.
2. A cyanokit was also administered to the 15 year old girl with respiratory distress and soot staining around her nares. She was intubated and admitted to the ICU.
3. The two younger children did not have cyanokits administered. The 2 year old had some mild signs of respiratory distress. The 9 month old had soot staining in the nares but no respiratory distress and a carbon monoxide level of 22. Both were admitted to the PICU for observation and able to be discharged home within 48 hrs.

Yoshida, M. A study on house fire victims: age, carboxyhemoglobin, hydrogen cyanide and hemolysis. Forensic Sci Int. 1991 Dec;52(1):13-20.

https://www.ncbi.nlm.nih.gov/pubmed/1664408

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