COMPREHENSIVE REVIEW

Disaster Preparedness: Hospital

Decontamination and the Pediatric Patient-
Guidelines for Hospitals and Emergency
Planners
Christopher W. Freyberg, MD; 1 Bonnie ArquiUa, DO; 2 Baruch S. Fertel, MPA;3
Michael G. Tunik, MD; 3 Arthur Cooper, MD; 4 Dennis Heon, MD; 3
Stephan A. Kohlhoff, MD; 5 Katherine I. Uraneck, MD;6 George L. Foltin, MD 3
Abstract
1. Department of Emergency Medicine, In recent years, attention has been given to disaster preparedness for first
New York University School of Medicine, responders and first receivers (hospitals). One such focus involves the decon-
New York, New York USA tamination of individuals who have fallen victim to a chemical agent from an
2. Department of Emergency Medicine, attack or an accident involving hazardous materials. Children often are over-
State University of New York Health looked in disaster planning. Children are vulnerable and have specific medical
Science Center at Brooklyn, Brooklyn, and psychological requirements. There is a need to develop specific protocols
New York USA to address pediatric patients who require decontamination at the entrance of
3. Department of Pediatrics and Emergency hospital emergency departments. Currently, there are no published resources
Medicine, Division of Pediatric, that meet this need. An expert panel convened by the New York City
Emergency Medicine, New York Department of Health and Mental Hygiene developed policies and proce-
University School of Medicine and dures for the decontamination of pediatric patients. The panel was comprised
Bellevue Hospital, New York, New York of experts from a variety of medical and psychosocial areas. Using an iterative
USA process, the panel created guidelines that were approved by the stakeholders
4. Department of Surgery, Columbia and are presented in this paper. These guidelines must be utilized, studied, and mod-
University College of Physicians and ified to increase the likelihood that they will work during an emergency situation.
Surgeons. New York, New York USA
5. Department of Pediatrics, State University Freyberg CW, ArquiUa B, Fertel BS, Tunik MG, Cooper A, Heon D,
of New York Health Science Center at Kohlhoff SA, Uraneck KI, Foltin GL: Disaster preparedness: Hospital
Brooklyn, Brooklyn, New York USA decontamination and the pediatric patient—Guidelines for hospitals and
6. New York City Department of Health emergency planners. PrehospitalDisast Med 2008;23(2):16&-172.
and Mental Hygiene, New York, New
York USA
Introduction
The use of chemical weapons in wartime has been documented throughout
Correspondence:
history. During the Peloponnesian war in 429 BC, the Spartans and Thebans
Bonnie Arquilla, D O
attempted to destroy the city of Palatea by creating a hot fire and adding
State University of New York Health
brimstone and pitch. Finely pulverized lime, known for its caustic effects, was
Science Center at Brooklyn
used during the reign of Henry III when English sailors used it to blind
Box 1260
French sailors. During World War I, widespread use of chemical weapons
440 Lenox Road
such as mustard gas on the battlefield prompted the need for decontamina-
Brooklyn, New York 11203 USA
tion procedures and treatment of injuries arising from their use.1 Recently, the
E-mail: [email protected]
use of chemical weapons by Saddam Hussein against the Kurdish population2
brought chemical warfare and the need for emergency preparedness to the
This publication was supported in part by Grant forefront of the national psyche.3 In 1995, members of the religious cult Aum
Number U3RHSO5957-Ol-OOfrom the United Shinrikyo poisoned civilians riding the Tokyo subway using sarin gas.4
States Health Resources and Services Administration.
Its contents are solely the responsibility of the authors
Hospital Decontamination
and do not necessarily represent the official views of
Within the last few years, much emphasis has been placed on disaster pre-
HRSA.
paredness. In the aftermath of the attacks on 11 September 2001, the focus of
preparedness has expanded from coping with disasters due to natural hazards
Keywords: children; decontamination;
such as earthquakes and hurricanes, to coping with disasters caused by human
hospitals; preparedness
activity, such as terrorist attacks,5 and accidents involving hazardous materi-
als. Consequently, many hospitals have been developing systems and protocols
Abbreviations:
EMS = emergency medical services Received: 03 May 2007 Web publication: 18 April 2008
PAPR = powered air purifying respirators Accepted: 19 October 2007
PPE = personal protective equipment Revised: 06 November 2007

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 Freyberg, Arquilla, Fertel, eta/ 167

that direct decontamination of persons who present to the Columbine massacre,17 the attack at a Jewish community
hospital during a disaster.6 Hospital decontamination is center in Argentina, 18 and the bombing in Oklahoma
distinct from first responder or gross decontamination, City. 19 ' 20 In addition, a large number of daycare centers,
which ideally should be performed at the scene of the dis- schools, and other facilities with a high density of children
aster by fire, emergency medical services (EMS), police, or are potential targets for terrorists. 3 ' 21 Media quotes from
military personnel. Then the decontaminated victims are an Al Qaeda spokesperson have said,
transported to hospitals for medical treatment. Typically, these
protocols do not address the special needs of pediatric patients. We have not reachedparity with them. We have the right to
kill four million Americans—two million ofthem children—
Self-Presentation of Patients and to exile twice as many and wound and cripple hundreds
In past disaster planning scenarios, first responder decont- ofthousands. Furthermore, it is ourrighttofight them with
amination was the expected norm, and most hospitals chemical and biological weapons, so as to afflict them with the
expected to receive fully decontaminated patients. This fatal maladies that have afflicted [us] because of the
thinking changed after the 1995 sarin gas attack in the [Americans'] chemical and biological weapons?2
Tokyo. In Tokyo, 85% of the exposed patients "self-trans-
ported" to hospital facilities without any prehospital inter- Although chemical, radiological, and biological attacks
vention or notification.4 A similar phenomenon occurred have been infrequent, the threat is real. 23 The proposed
at the Alfred Murrah federal building bombing in protocols outlined also are appropriate for industrial or
Oklahoma City—only 33% of patients were transported to other accidents involving hazardous materials.
the hospitals by EMS. 7 The same pattern of self-referral
was reported at hospitals in New York City and Pediatric Decontamination
Washington, D C on 11 September 2001. Many of these The vulnerabilities of pediatric patients during decontami-
patients, including children, were coated with an unknown nation have been identified in US federally funded docu-
grey ash, and self-transported to hospitals in lower ments that call for the creation of decontamination protocols
Manhattan. These facilities were not prepared to deconta- that directly address the special needs of children. 24 ' 25
minate those exposed. Subsequently, hospitals received Recently, the American Academy of Pediatrics released a
funds to establish facilities so that decontamination could policy statement on the impact of chemical and biological
occur outside of the hospital. 8 With the support of hospi- terrorism on children 26 that advocates specific disaster
tal administration, staff members from various depart- planning for children, since children have their own set of
ments were recruited to train to provide decontamination, needs that are distinct from those of adults. 27 A literature
and teams were established to ensure continuous coverage. search revealed that written operating procedures address-
Many hospitals already have made significant alterations in ing the special needs of infants and children have not been
their physical plant by building permanent decontamina- published. The only identified resource to provide guidance
tion showers for contaminated patients in order to protect is a video that was produced by the Center for Biopreparedness
their healthcare providers and other patients from sec- at Children's Hospital in Boston, Massachusetts.28
ondary contamination. However, few have made spe-
cific arrangements to cope with one of the most vulnerable Development ofProtocol
populations, children. Under the auspices of the Hospital Bioterrorism Preparedness
Program of the New York City Department of Health and
Limited Resources for Hospital Mental Hygiene, an expert panel, led by the New York Center
In the US, and possibly worldwide, there are limited for Terrorism Preparedness and the Central Brooklyn Center
resources for hospitals to accomplish the goal of being for Bioterrorism Preparedness and Planning, was convened to
properly prepared to care for children during a disaster, develop policies and procedures for the decontamination of
despite a presidential directive12 that acknowledged that pediatric patients to be shared with the general pediatric and
emergency departments are first receivers, and thus, are eli- emergency medicine communities.
gible for first responder resources and funding. In 2005, the These guidelines, which are part of the Pediatric
US Occupational Safety and Health Administration Disaster Toolkit,29 easily can be incorporated into a hospital's
(OSHA) published a manual entitled, Hospital-Based First current decontamination plan or adopted as an addendum.
Receivers of Victims from Mass Casualty Incidents Involving One chapter is devoted to decontamination of children.
the Release of Hazardous Substances}^ as a guide to promote Minimal equipment adjustments are necessary to adopt
best practices of preparing and implementing such systems. these protocols, and any existing decontamination facility
Despite this, many hospitals still do not have any deconta- can implement these procedures.
mination plans. There are examples of protocols in mass-
casualty mass-decontamination guidance documents for Expert Panel Methods
first responders, as well as training programs, 14 ' but few The expert panel was comprised of people with expertise
for hospital-based first receivers. in: disaster preparedness, emergency medicine, nursing,
pediatric emergency medicine, pediatric surgery, public
Threats to Children health, social work, and toxicology. Child life personnel, pro-
Children also are targets for terrorists. Examples include fessionals who help reduce the stress and anxiety that many
the hostage situation at a school in Beslan, Russia,16 the children may experience in the hospital and healthcare set-

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 168 Hospital Decontamination and the Pediatric Patients

Hospital Decontamination and the Pediatric Patient

2-8 years old, and 0 to 2 years old. It often will be necessary
MODEL PROTOCOL ALGORITHM to estimate the child's age, since asking may be impractical
Victims arrive at the hospital requiring decontamination
due to the limitations inherent to the use of the personal
Children are present among the victims protective equipment (PPE) worn by decontamination team
Critical injuries are decontaminated first
Children and their families (parents or caregivers) should not be separated members or due to a large influx of patients.
unless critical medical issues take priority

Psychosocial Needs
\ One of the challenges in dealing with children is that they
Non-ambulatory Ambulatory |
respond to stress differently than adults and may act
j Estimate child's age by visual inspection
younger than their chronologic age. They may be incon-
• disrobe by child's
caregiver and 'hot
1
School Age
,1 1 solable or totally withdrawn, and often are unable to follow
zone'personnel (8-18 years old)
Preschool
(2-5 years old)
Infants andToddlers
(<2 years old)
commands. Children walking through the shower have the
place on a potential to frolic or panic and/or become immobile while
stretcher or
restraining device
' escort through the
1
disrobe without
1
• assist disrobing
1
- disrobe by child's
in the shower, thereby hindering a steady flow of patients
decon shower by
assistance respect (child's caregiver caregiver and "hot through the decontamination process. For those children
respect modesty or "hot zone" zone" personnel
"hot zone"
personnel and respect privacy personnel) • place on a strecher aware of their surroundings, the added stress of the poten-
caregiver
direct supevisfon
child decons him/
herself, but goes
• direct supervision
ofdecon
or restraining
device
tial for a terrorist attack is even more distressing34 and they
ofdecon through decon • monitor airway -escort through the
decon shower by
are at high risk for the development of anxiety reactions
shower in • escort through the
and/or post-traumatic stress disorder.27 Consequently, even
(of caregiver too)
monitor airway succession with shower by either "hot zone"
caregiver, parent, caregiver or"hot personnel and
or classmates zone'personnel caregiver
normally verbal children may be unable to provide a med-
-direct supervision
of decon(of
ical history or answer questions for a focused examination
caregiver, too) during pre-decontamination triage. Registration and track-
- monitor airway
ing often is more difficult, because the child may not be
(Caregiver should not
carry the child due to able to identify him/herself. Wristbands with whatever
the risk of accidental
trauma resulting from a information is provided should be put on the children in
fall or from dropping
the child while In the the cold zone. Polaroid or digital camera have been used for
shower)
documentation and identification in other countries. However,
- treat or prevent hypothermia (towels, gowns, warming blankets)
in the US, camera use is controversial due to privacy issues.
- immediately give a unique identification number of a wristband (or equivalent)
- triage to an appropriate area for further medical evaluation

Please note: Children and their families (parents or caregivers) should not be separated
Communication
unless critical medical issues take priority Pre-school and most school-age children should be able to
Freybeng © 2008 Prehospital and Disaster Medicine
undress and decontaminate themselves when given clear,
Figure 1—Model protocol algorithm short, specific instructions. Communication is difficult for
those performing decontamination wearing powered air
tings, were included in the planning of the protocol. The purifying respirators (PAPR). Shouting instructions through
interventions by child life personnel help children cope a mask is tiring and only effective for brief instructions, and
during medical procedures or interventions.30"32 impractical in chaotic situations. The use of an amplified
Therefore, child life personnel should be included as mem- bullhorn was suggested, but was discarded due to difficulty
bers of the decontamination team. of lining up microphones with the vent on the hood of the
A working group identified issues that are unique to PAPR. Another option is the use of an electronic commu-
children during decontamination, and presented them to nication device attached to the protective suits.35 This may
the panel. The panel did not focus on other facets of decon- be impractical because some children may be scared by the
tamination that already have been outlined in prior docu- PAPR, and the distorted voices from these devices may
ments. Modifications were made based on input from the exacerbate existing fears. A short cartoon video or simple
expert panel. After several iterative reviews, no new poster with illustrations of actions that are required may
changes were made. From these, a draft set of decontami- work well and avoid language barriers, and, when necessary,
nation guidelines were produced. All controversial issues hand signals and gestures also should be employed.
were discussed by the entire panel during each review
meeting, and agreement was reached as to the best method Chaperones
to address each issue. Either there were no controversial During a disaster, children may present to the hospital with
issues that were not resolved through this methodology, or their parents, teachers, caregivers, or other familiar and
most controversial issues were resolved using this method- reassuring persons, who also will require decontamination.
ology, and those issues that could not be resolved are pre- Children also may present without a dedicated caregiver.
sented in this paper as "unresolved". During disasters, children may become more anxious about
leaving their parents or caregivers, and young children
Format of Protocol often show signs of separation anxiety.36 Thus, in the case
The protocol is provided in an outline form (Appendix) of accompanied children, all attempts should be made to
and also is summarized as aflowchart (Figure 1). Children keep families and familiar caregivers together during and
were categorized by ages into three groups: 9-18 years old, after decontamination. This will reduce anxiety among the

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 Freyberg, Arquilla, Fertel, etal 169

children. For unaccompanied children, a dedicated chaper- is unfeasible, using a traditional stretcher with the sides
one, possibly from child life or social work, should be raised be the most practical way to provide total access to
assigned to each child for comfort and reassurance in the the child. Due to the risk of aspiration of the water from
cold zone. However, this may be difficult due to the the high flow rates of the shower, the child should be placed
unavailability of staff. A good source of personnel would be on a side and not face up. Care should be taken to ensure
to train volunteers prior to an event from the community- adequate drainage from the stretcher to avoid water pooling.
at-large.
Exposure to Toxins
Removal of Clothing An infant's skin is more permeable and possesses less ker-
The undressing of children and their subsequent decontam- atin than does an adult's. 9 Children also have a large sur-
ination may take longer than for an adult. Any parent of a face area relative to their body weight, and more toxins may
recalcitrant toddler appreciates the effort necessary in be absorbed.26 Children differ from adults in their capacity
undressing a child. Sensitivity and modesty should be main- to excrete toxic substances. Additionally, because children's
tained, as children often are hesitant to disrobe in the pres- organs are in various stages of growth and differentiation,
ence of strangers especially of the opposite sex. Therefore, it their immune system may be immature, and thus, suscepti-
is preferred that when indicated, someone of the same sex bility to toxins also varies.40 Studies also have shown an
be assigned to assist with undressing.37 Removal of clothing increased susceptibility of children to more severe facial
may account for more than 85% of topical decontamination and ophthalmical injury than adults. This may be due to
of each victim.26 their failure to recognize danger and the fact that they do
not instinctively cover their faces during the event.41 Thus,
Holding Infants it is important that a careful and thorough decontamination
Although it is preferred that families decontaminate be performed to remove any toxin.
together, they still will require assistance. It will be difficult
for a parent to undress themselves and their children at the Process ofDecontamination
same time, especially if they are injured. Experience with Water pressure should be reduced to approximately 60
newborns has shown that" they are difficult to hold when psi26 (413.7 kPa), by using "kid-friendly" adapters such as
wet. This problem is exacerbated further by the reduced hand-held sprayers that are designed for adjustable pres-
dexterity of hospital personnel wearing chemically resistant sure, can be adjusted by hospital personnel. The water tem-
gloves and suits. Thus, when indicated, it is recommended perature must be no less than 98°F26 (36.7°C) to prevent
that two people handle any transfer of children in the the development of hypothermia, which also can be exac-
shower, and that the child be held tightly and securely, close erbated by the presence of large cutaneous injuries or pre-
to the body of the chaperone. Infant handling positions and vious exposure.40 The use of alcohol- or bleach-based
procedures where the head is supported in the palm and cleansers is not recommended due to the potential for
the body straddles the arm of the provider while tucked development of systemic intoxication. Only water, the old-
under the opposite arm can be employed. This is contro- est known and most effective decontaminant,1 possibly
versial, and many find it difficult to perform. Thus, the rec- combined with a low-Alkaline mild soap, but the utility of
ommendation was made that infants can be placed on a stretch- soap is questionable.26 At the conclusion of the shower,
er and decontaminated to decrease the risk of being dropped. children immediately should be dried and wrapped in a
towel or foil-type "space" blanket to avoid the development
Maintaining Airway of hypothermia. At this time, new, dry, sterile bandages and
During the decontamination process, maintaining a patent dressings should be applied as required. Special caution
airway is important. Infants have proportionally larger should be used in showers exposed to the outdoors to
occiputs and lack muscle tone to control their head move- maintain the ambient temperature by using space heaters
ment. Thus, proper airway positioning must be maintained or lamps and ensuring rapid entry into the triage area.
manually. It may be useful to move non-ambulatory infants Thus, the distance from the shower to the triage area
through the shower in a car seat made of plastic or other should be kept to a minimum.
waterproof material (without the cushion) to maintain the
airway in a neutral position, as well as maintaining spinal Physiological Concerns
immobilization, should that be necessary. However, this Children have underdeveloped self-preservation skills that
procedure is difficult due to the inaccessibility of the pos- make them less able to flee danger, and they may flee into
terior and sides of the patient to the decontamination harm's way during the chaotic situation, further increasing
shower. For school-age children, a scoop-style stretcher their exposure.26 Simple responses such as vomiting, saliva-
also may be used, which will keep children lateral recum- tion, lacrimation, or sweating as a consequence of their
bent. The added weight of the scoop will make decontam- exposure to a toxin may cause more rapid dehydration in
ination more difficult, and require additional personnel to children who lack the fluid reserve of adults and have a
carry the child. To alleviate this problem, there are com- greater surface area to volume ratio. Hypovolemic shock
mercially available conveyor-like roller systems that can be can be more difficult to ascertain in children who initially
used to slide a patient on a backboard or scoop stretcher compensate, then decompensate with very little warning or
through a decontamination process.38 When such a setup change in their vital signs until they are near collapse.40

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 170 Hospital Decontamination and the Pediatric Patients

Although difficult and often impractical, hemodynamic mon- atric disaster preparedness and can help any facility pre-
itoring and aggressivefluidresuscitation should be considered. pare. Due to the recommendation that families not be sep-
arated, it is important that children's hospitals be prepared
Conclusions to treat the caregivers of these children.3'42'43 Protocols also
Planning for decontamination is important to all hospitals. should be developed to arrange for the transfer of patients
On 9/11, the first patient to present to the New York when feasible.
Veterans Administration Medical Center, which does not These recommendations and protocols are a work in
have pediatric facilities, was a five-month old child who progress. The inherent emotional and logistical difficulties
was in the World Trade Center at the time of the attack that these situations present are recognized. To meet the
and was covered in grey ash. Although circumstances dic- unique needs of all infants, children, adolescents, and young
tated that transfer to a facility with pediatric capabilities adults, it is critical that the community preparedness efforts
was unfeasible, fortunately there were staff well-trained in involve pediatric healthcare experts and key facilities, insti-
pediatric emergencies available to care for this infant (and tutions, and agencies that care for children. A carefully
his breast-feeding mother), and the outcome was excellent. planned drill with a mock disaster is required in order to
This emphasizes the importance that adult-only facilities test these protocols under simulated, real-world conditions.
should have pediatric equipment available and should train Further dialogue and revision will be necessary as experi-
for pediatric patients. The pediatric toolkit facilitates pedi- ence is gained.

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36. Gurwitch RH, Kees M, Becker SM, Schreiber M, Pfefferbaum B, Diamond we prepared? Pediatr Emerg Care 20Q4;20:198-208.
D. When disaster strikes: Responding to the needs of children. Prebospital 41. Momeni AZ, Aminjavaheri M: Skin manifestations of mustard gas in a group
Disaster Med 2004;19:21-28. of 14 children and teenagers: A clinical study, /n//Derma/a/1994;33:184-187.
37. Chur-Hansen A: Preferences for female and male nurses: The role of age, 42. Committee on Pediatric Equipment and Supplies for Emergency Departments,
gender and previous experience—Year 2000 compared with 1984. JAdv Nurs National Emergency Medical Services for Children Resource Alliance:
2002;37:192-198. Guidelines for pediatric equipment and supplies for emergency departments.
38. Andax Industries: Portable De-Con Roller System. Available at Pediatr Emerg Care 1998;14:62-64.
http://store.andax.com/index.asp?PageAction=VIEWPROD&ProdID=287. 43. AtheyJ, Dean JM, Ball J, etal: Ability of hospitals to care for pediatric emer-
Accessed 18 December 2006. gency patients. Pediatr Emerg Care 2001;17:170-174.

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 172 Hospital Decontamination and the Pediatric Patients

Appendix—Decontamination of the Pediatric Patient Administrative Policy and Procedure (Sample Draft Protocol)29
continued on page 173
Purpose: This policy and procedure is intended to ensure that all children presenting to any hospital (during an MCI or terrorist
attack requiring decontamination) are properly decontaminated in a timely manner. Children require special considerations that
may not be addressed in the general Hospital Decontamination Plan.
Policy: It is the policy of the Hospital Decontamination Plan to:
1. Decontaminate all patients presenting to the facility who potentially have been exposed to any toxic or harmful substances
before they enter the facility; and
2. Ensure the safe working environment within the hospital grounds and physical plant for all hospital personnel.
Background: Infants and children have unique needs that require special considerations during the process of hospital-
based decontamination.
1. Separation of families should be avoided especially under conditions of large number of patients in a chaotic situation
but medical issues take priority (go through the shower together unless one patient is critical);
2. Do not be assume that the parents or caregivers will be able to decontaminate both themselves and their children at the
same time ("hot zone" personnel should recognize the need to assist them);
3. Older children may resist or be difficult to handle out of fear, peer pressure, and modesty (even in front of their parents
or caregivers);
4. If the water temperature is below 98°F (36.7°C), the risk of inducing hypothermia increases proportionately with the
smaller, younger child and thus, temperatures should be maintained slightly above this level;
5. Airway management through the shower is a priority; and
6. Large volume, low pressure water delivery systems (e.g., handheld hose sprayers) that are "child-friendly" need to be
incorporated into the hospital decontamination showers. This is the same for non-ambulatory stretcher adult patients.
Children <2 years of age
Infants and toddlers represent the most challenging group in which these special needs considerations are the most important.
1. All infants and toddlers should be placed on a stretcher and disrobed by either the child's caregiver or "hot zone" personnel.
All clothes and items that cannot be decontaminated should be placed in appropriate containers or bags as provided by the
hospital and appropriately labeled;
2. Ambulatory children should be accompanied through the decontamination shower by either the child's caregiver or "hot
zone" personnel to ensure the entire patient is properly decontaminated. It is not recommended that the child be
separated from family members or adult caregiver. It is not recommended that the caregiver carry the child due to the
possibility of injury resulting from a fall, or from dropping a slippery and squirming child. Special attention must be
given to presurring the child's airway while in the shower;
3. Non-ambulatory children will be placed on a stretcher by "hot zone" personnel and disrobed (using trauma shears if
necessary). All clothes and items that cannot be decontaminated should be placed in appropriate containers or bags as
provided by the hospital and labeled;
4. Each non-ambulatory child should be escorted through the decontamination shower by either the child's caregiver or
"hot zone" personnel to ensure the entire patient is properly decontaminated. Special attention must be paid to the
pressuring the integrity of the child's airway while in the shower;
5. Once through the shower, the child's caregiver or "cold zone" personnel will be given a towel and sheets to dry the
child, and a hospital gown. Immediately, the child should be given a unique identification number on a wristband and
then triaged to an appropriate area for medical evaluation; and
6. Children and their families (parents or caregivers) should not be separated unless critical medical issues take priority.
Children 2 to 8 years of age
From age 2 to 8 years, children should be able to walk and speak, yet still will look like a child with considerable variations
in physiology and anatomy.
1. Ambulatory children should be assisted in disrobing by either the child's caregiver or "hot zone" personnel. All clothes
and items that cannot be decontaminated should be placed in appropriate containers or bags as provided by the hospital
and labeled;
2. Ambulatory children should be directly accompanied through the shower by either the child's caregiver or "hot zone" personnel
to ensure the entire patient is properly decontaminated. It is recommended that the child not be separated from family member(s)
or the adult caregiver;
3. Non-ambulatory children should be placed on a stretcher by "hot zone" personnel and disrobed (using trauma shears if
necessary). All clothes and items that cannot be decontaminated should be placed in appropriate containers or bags as
provided by the hospital and labeled;
4. Each non-ambulatory child on a stretcher is escorted through the decontamination shower and assisted with decontamination
to ensure the entire patient is properly decontaminated;
5. Once through the shower, each child should be given a towel and sheets to dry, and a hospital gown. Immediately, the
child should be given a unique identification number on a wristband and then, triaged to an appropriate area for medical
evaluation; and
6. Children and their families (parents or caregivers) should not be separated unless critical medical issues take priority.

Freyberg © 2008 Prehospital and Disaster Medicine

Prehospital and Disaster Medicine http://pdm.medicine.wisc.edu Vol. 23, No. 2

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 Freyberg, Arquilla, Fertel, etal 173

Appendix—Decontamination of the Pediatric Patient Administrative Policy and Procedure (Sample Draft Protocol)29
continued from page 172
Children 8 to 18 years of age (school age)
At the age of 8 years and upward, the airway anatomy approximates that of an adult. Although it is tempting to regard this
age group as "small adults", there are special needs unique to this age group.
1. Ambulatory children should disrobe when instructed to do so by "hot zone" personnel. All clothes and items that cannot
be decontaminated should be placed in appropriate containers or bags as provided by the hospital and labeled;
2. Ambulatory children should then walk through the decontamination shower, preferably accompanied by their parent or
caregiver, and should decontaminate him/herself. Guidance should be provided to the child (and parent/caregiver) during
the decontamination process;
3. Non-ambulatory children should be placed on a stretcher by "hot zone" personnel and disrobed (using trauma shears if
necessary). All clothes and items that cannot be decontaminated should be placed in appropriate containers or bags as
provided by the hospital and labeled;
4. Then each non-ambulatory child is escorted through the decontamination shower and assisted with decontamination to
ensure the entire patient is properly decontaminated;
5. Once through the shower, each child will be given a towel and sheets to dry, and a hospital gown. Immediately, the child
should be given a unique identification number on a wristband and then Waged to an appropriate area for medical evaluation.
6. Children and their families (parents or caregivers) should not be separated unless critical medical issues take priority.
Freyberg © 2008 Prehospital and Disaster Medicine

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