Đề ôn thi thử môn hóa (518)

e3

92. Robertson MA, Molyneux EM. Description of cause of serious illness and outcome in patients identified using ETAT guidelines in
urban Malawi. Arch Dis Child. 2001;85:214-217.
93. Tamburlini G, Di Mario S, Maggi RS, Vilarim JN, Gove S. Evaluation of guidelines for emergency triage assessment and treatment
in developing countries. Arch Dis Child. 1999;81:478-482.
94. Tchorz KM, Thomas N, Jesudassan S, et al. Teaching trauma care
in India: an educational pilot study from Bangalore. J Surg Res.
2007;142:373-377.
95. Bergman S, Deckelbaum D, Lett R, et al. Assessing the impact of
the trauma team training program in Tanzania. J Trauma.
2008;65:879-883.
96. Aboutanos MB, Rodas EB, Aboutanos SZ, et al. Trauma education
and care in the jungle of Ecuador, where there is no advanced
trauma life support. J Trauma. 2007;62:714-719.
97. Ali J, Adam RU, Gana TJ, Williams JI. Trauma patient outcome
after the Prehospital Trauma Life Support program. J Trauma.
1997;42:1018-1021; discussion 21-22.
98. Homaifar N, Mwesigye D, Tchwenko S, et al. Emergency obstetrics knowledge and practical skills retention among medical students in Rwanda following a short training course. Int J Gynaecol
Obstet. 2013;120:195-199.
99. Butler MW, Ozgediz D, Poenaru D, et al. The Global Paediatric
Surgery Network: a model of subspecialty collaboration within
global surgery. World J Surg. 2015;39:335-342.
100. MacLeod JB, Gravelin S, Jones T, et al. Assessment of acute trauma
care training in Kenya. Am Surg. 2009;75:1118-1123.
101. Opiyo N, English M. In-service training for health professionals to
improve care of seriously ill newborns and children in low-income
countries. Cochrane Database Syst Rev. 2015;5:CD007071.
102. Edgcombe H, Paton C, English M. Enhancing emergency care in
low-income countries using mobile technology-based training
tools. Arch Dis Child. 2016;101:1149-1152.

103. Organization WH. Telemedicine - Opportunities and Developments
in Member States. Report on the Second Global Survey on eHealth.
Geneva: WHO Press; 2010.
104. Alirol E, Getaz L, Stoll B, Chappuis F, Loutan L. Urbanisation and
infectious diseases in a globalised world. Lancet Infect Dis. 2011;
11:131-141.
105. Mould-Millman NK, Dixon JM, Sefa N, et al. The State of Emergency Medical Services (EMS) Systems in Africa. Prehosp Disaster
Med. 2017;32:273-283.
106. Leligdowicz A, Bhagwanjee S, Diaz JV, et al. Development of an
intensive care unit resource assessment survey for the care of critically ill patients in resource-limited settings. J Crit Care.
2017;38:172-176.
107. El-Khatib Z, Shah M, Zallappa SN, et al. SMS-based smartphone
application for disease surveillance has doubled completeness and
timeliness in a limited-resource setting - evaluation of a 15-week
pilot program in Central African Republic (CAR). Confl Health.
2018;12:42.
108. Geiling J, Burkle Jr FM, Amundson D, et al. Resource-poor settings: infrastructure and capacity building: care of the critically ill
and injured during pandemics and disasters: CHEST consensus
statement. Chest. 2014;146:e156S-e167S.
109. Marston BJ, Dokubo EK, van Steelandt A, et al. Ebola Response
Impact on Public Health Programs, West Africa, 2014-2017.
Emerg Infect Dis. 2017;23:S25-S32.

110. Rosenberg DI, Moss MM, American College of Critical Care
Medicine of the Society of Critical Care M. Guidelines and levels
of care for pediatric intensive care units. Crit Care Med. 2004;
32:2117-2127.
111. Rosenberg DI, Moss MM, American Academy of Pediatrics Section on Critical C, American Academy of Pediatrics Committee on
Hospital C. Guidelines and levels of care for pediatric intensive care
units. Pediatrics. 2004;114:1114-1125.

112. Maitland K, Kiguli S, Opoka RO, et al. Mortality after fluid bolus
in African children with severe infection. N Engl J Med. 2011;364:
2483-2495.
113. Seydel KB, Kampondeni SD, Valim C, et al. Brain swelling and
death in children with cerebral malaria. N Engl J Med. 2015;372:
1126-1137.
114. Sarmin M, Ahmed T, Bardhan PK, Chisti MJ. Specialist hospital
study shows that septic shock and drowsiness predict mortality in
children under five with diarrhoea. Acta Paediatr. 2014;103:
e306-e311.
115. Ranjit S, Aram G, Kissoon N, et al. Multimodal monitoring for
hemodynamic categorization and management of pediatric septic
shock: a pilot observational study. Pediatr Crit Care Med. 2014;
15:e17-e26.
116. Ranjit S, Natraj R, Kandath SK, Kissoon N, Ramakrishnan B,
Marik PE. Early norepinephrine decreases fluid and ventilatory
requirements in pediatric vasodilatory septic shock. Indian J Crit
Care Med. 2016;20:561-569.
117. Sankar J, Ismail J, Sankar MJ, Meena RS. Fluid bolus over 15-20
versus 5-10 minutes each in the first hour of resuscitation in children with septic shock: a randomized controlled trial. Pediatr Crit
Care Med. 2017;18:e435-e445.
118. Sankar J, Dhochak N, Kumar K, Singh M, Sankar MJ, Lodha R.
Comparison of international pediatric sepsis consensus conference
versus sepsis-3 definitions for children presenting with septic shock
to a tertiary care center in India: a retrospective study. Pediatr Crit
Care Med. 2019;20:e122-e129.
119. von Saint Andre-von Arnim AO, Attebery J, Kortz TB, et al. Challenges and priorities for pediatric critical care clinician-researchers
in low- and middle-income countries. Front Pediatr. 2017;5:277.
120. English M, Gathara D, Mwinga S, et al. Adoption of recommended practices and basic technologies in a low-income setting.
Arch Dis Child. 2014;99:452-456.

121. Wiens MO, Kumbakumba E, Larson CP, et al. Postdischarge mortality in children with acute infectious diseases: derivation of postdischarge mortality prediction models. BMJ Open. 2015;5:e009449.
122. Chisti MJ, Graham SM, Duke T, et al. Post-discharge mortality in
children with severe malnutrition and pneumonia in Bangladesh.
PLoS One. 2014;9:e107663.
123. Richardson B, Dol J, Rutledge K, et al. Evaluation of mobile apps
targeted to parents of infants in the neonatal intensive care unit:
systematic app review. JMIR Mhealth Uhealth. 2019;7:e11620.
124. Metelmann B, Metelmann C, Schuffert L, Hahnenkamp K, Brinkrolf P. Medical Correctness and user friendliness of available apps
for cardiopulmonary resuscitation: systematic search combined
with guideline adherence and usability evaluation. JMIR Mhealth
Uhealth. 2018;6:e190.


e4

Abstract: Low- and middle-income countries continue to carry
the largest burden of critical illness and pediatric mortality yet
have the least critical care resources. Basic low-cost critical care
interventions can be successfully provided in resource-poor settings without an intensive care unit (ICU). However, publicly
funded ICU treatment remains limited in low-income countries,
and its introduction requires careful resource allocation. Healthcare systems improvements for the critically ill should involve a
graded approach of strengthening capacity to provide health

maintenance, basic critical care, and then publicly funded intensive care services as overall health indices improve. Critical care
research from low-income countries is sorely needed to guide effective and efficient care and advocate for resources.
Key words: Low-resource settings, low- and middle-income
countries, resource allocation, pediatric critical care training, costeffectiveness


9

Public Health Emergencies and
Emergency Mass Critical Care
KATHERINE L. KENNINGHAM AND MEGAN M. GRAY

“Keep your eye on the ball.”

Bob Kanter, Trailblazer for Children
in the World of Disaster Medicine



•



•

Emergency mass critical care (EMCC) is limited, essential critical care
during disasters when intensive care demands surpass resources.
Pediatric, neonatal, and cardiac intensivists must be engaged
with hospital and regional public health emergency (PHE) planning and preparedness efforts to ensure that they are familiar
with strategies and resources to rapidly increase care capacity.
Pediatric intensive care units (ICUs) should plan to care for three
times their usual census for 10 days without outside help during a severe PHE.

During a public health emergency (PHE) such as a natural disaster
or pandemic, a large number of infants, children, and young adults
may need critical care in order to survive. During such an event, the
incident command system (ICS) provides a framework to support
decision-making and coordinate efforts across affected sites. Because pediatric critical care is highly specialized and because few

nonpediatric providers are comfortable caring for severely ill or injured children, pediatric, neonatal, and cardiac intensive care units
(ICUs) represent an essential aspect of patient management during
a PHE and should be included within a structured response.
Planning and preparedness for PHEs can save lives. Unfortunately, critical care providers receive little training in disaster
medicine and response and are often underinvolved in hospital
disaster preparedness efforts. Recent public health emergencies
have exposed a lack of PHE awareness, training, and preparation
by critical care providers. The goal of this chapter is to educate the
pediatric or neonatal ICU provider in the principles and tools of
PHE preparedness and emergency mass critical care (EMCC).
Learning from smaller or more local PHEs and preparing for
critical care during anticipated PHEs may help intensivists better
prepare for future catastrophic events that require EMCC. Forward consideration of how to scale up response and conserve,
ration, and allocate critical care services can reduce dangerous
uncertainty and save time in the event of a larger-scale PHE.

•

•





•



PEARLS
The surge capacity continuum that spans conventional to contingency to crisis capacity should be employed during a PHE in

order to extend resources to meet needs.
All ICU disaster planning efforts should consider protocols for
triage teams to support the emergency department, patient
tracking and reunification, victim and staff mental health, and
the role of medical learners in EMCC efforts.

How Many Pediatric Patients Could Be
Affected in a Public Health Emergency?
If a PHE affected persons of all ages equally, children aged 0 to
14 years would account for 20% of all patients.1 However,
younger patients may be more vulnerable to infections, dehydration, toxins, and trauma. Therefore, they may be overrepresented
in the patient population during a PHE.2 Events involving a
child-specific location, such as school, may result in a patient
population predominantly made up of children.
Under usual circumstances, survival rates from high-risk pediatric conditions tend to be higher when children receive care at
pediatric hospitals.3–6 A national survey estimated a pediatric ICU
(PICU) peak capacity of 54 beds per million pediatric population.7 Typical PICU occupancy in excess of 50% leaves fewer than
30 vacant PICU beds per million age-specific population, with
even fewer cardiac ICU (CICU) beds generally available. The
younger the patient, the more age-specific and specialized the
treatment requirements become, culminating in the extremely
preterm neonate who requires equipment unavailable outside of a
regional neonatal ICU (NICU). There are approximately 4 million
newborns born in the United States annually and 5700 total
NICU beds per million age-specific population. In contrast to
PICU capacity, occupancy of NICU beds is higher at baseline,
59


60

S E C T I O N I   Pediatric Critical Care: The Discipline

with 6% of low-risk term infants and 97% of very-low-birthweight infants requiring NICU care.8 Because each region may be
served by only a few or even a single pediatric-capable hospital,
events that disable one hospital may disproportionately degrade
regional pediatric and neonatal care.
Quantitative models indicate that survival during a PHE
would improve if a pediatric patient surge is distributed to pediatric
beds throughout a larger geographic area rather than overwhelming
facilities near the epicenter of an emergency.9 Unfortunately, control of patient distribution may be limited in a severe PHE. As a
result, all hospitals must be prepared to care for some children for
an extended period of time.10–12 Whether or not patients are
distributed optimally, outcomes from a large PHE are likely to
improve with EMCC approaches.9,14 Additionally, using telemedicine to connect available pediatric critical care and subspecialty physicians to facilities unaccustomed to caring for pediatric
patients may significantly extend the reach of pediatric EMCC
during a PHE.

Incident
commander

Operations
chief
Medical
director

Public info
officer

Safety

officer

Planning
chief

Logistics
chief

Labor pool

Finance and
admin chief

Materials &
supplies

ICU leader

•  Fig. 9.1  ​Incident

command system diagram. admin, Administrative;
ICU, intensive care unit; info, information.

What Are the Most Likely Public Health
Emergencies?

What Is the Expected Timeline of a Public
Health Emergency?

Public health emergency risks vary depending on hospital location, population demographics, and local resources. Each

hospital is tasked with maintaining emergency plans for its
most likely PHEs. This list is usually generated via a hazards
vulnerability analysis (HVA), which leverages local expertise in
medical management and infrastructure risks, and combines
this with frequency and severity data on past and potential
events.15 Events such as information technology (IT) and electronic medical record (EMR) outages are experienced nearly
universally in healthcare settings and are included in HVAs.
Primary planning for IT/EMR outages should include protocols for downtime procedures, paper charting, and nonelectronic communication. Hospitals should engage in drills, tabletop exercises, and simulations targeted to address issues
identified by their HVA. Smaller and less severe events, such
as planned EMR downtimes and routine adverse weather
should be used as opportunities to clarify and test protocols
for larger PHEs.

When a sudden-impact PHE occurs, the hospital’s ICS is activated. The initial priority is to perform an assessment of the current state of the hospital; units rapidly assess their bed capacity,
including potential beds that could be mobilized. Patients potentially no longer requiring ICU care should be identified for rapid
transfer or discharge, and on-site staff able to be redirected to
patient care should be tallied. If the PHE directly affects the structure or function of the hospital building, the initial assessment
should also include numbers of newly injured staff, visitors, and
patients, as well as any damage to the unit. These initial assessment numbers are collected from each unit, and a rough estimate
of potential incoming patients is, in turn, shared with area leaders.
Based on initial assessment and estimates, the incident commander will direct the response to ensure adequate staff supplies,
equipment, and clinical space, and will communicate decisions
regarding whether to mobilize potential bed capacity identified
in the initial assessment. Information from the ICS should be
communicated to front-line staff early on to reduce uncertainty
and ensure a clear and united message to patients and families.
ICS-directed response may include assigning and sometimes reassigning current staff, calling in additional staff, ordering and
distributing additional supplies, and identifying when standards
of care should change. Area leaders should be called in as soon as
possible to aid in coordinating the response and offload clinical

staff of administrative duties. As information about the event
becomes available, ICU leaders and educators may need to provide
incident-specific just-in-time teaching to staff.

Who Will Make Decisions During
an Emergency?
Responses to major public health emergencies are organized
within a National Response Framework, as outlined by the
federal US Department of Homeland Security.16 Emergency
responses are coordinated at the most local jurisdiction possible, usually at the city or county level, until those resources are
outpaced. The hospital ICS further provides a leadership framework within and among organizations responding to an emergency, representing a simplified and clear chain of command in
order to speed decision-making. A hospital ICS includes clinical and nonclinical representation, provides flexible logistical
support, and helps to prioritize key functions. Disaster plans at
every hospital should incorporate ICS principles, regardless of
the size of the hospital; ICS planning guides are widely available to aid in plan development. Identifying the ICU role
within the local ICS framework is an essential part of PHE
preparedness (Fig. 9.1).

What Is a Surge and What Can Be Done to
Meet Surge Needs?
Critical care responses to PHEs are scaled according to the size
and severity of the emergency (Fig. 9.2).17,18 Emergency surges are
categorized as minor, moderate, or major. A minor event would
require up to 20% increase above usual peak hospital capacity;
conventional surge methods would likely suffice to provide normal standards of critical care to all who need it in this scenario.23
Conventional critical care surge needs can be met by canceling


CHAPTER 9  Public Health Emergencies and Emergency Mass Critical Care

61

Maximum ICU capacity

Level of care available

Crisis
standards of
Major surge: crisis response
care
Functionally
equivalent Moderate surge: contingency response
care

Minor surge: conventional response

Expanding ICU
capacity

Usual care
Usual volume

Usual ICU capacity

# of patients

•  Fig. 9.2  ​Surge volume, expansion of intensive care unit (ICU) capacity, and the effect on standards
of care.

Conventional strategies

Conserve resources
Utilize on-call staff
Substitute for
equivalent items
Utilize supply caches

Contingency strategies
Adapt other ICUs and
similar care areas

Crisis strategies

Extend usual staff

Adapt non-ICU and
noncare areas

Reuse select supplies

Utilize non-ICU staff

Substitute where
reasonable

Reallocate resources

• Fig. 9.3  ​Conventional, contingency, and crisis strategies to extend critical care resources. ICU, intensive
care unit.

elective admissions, quickly discharging all patients who can safely

leave the ICU, mobilizing staff, and adding bed space (Fig. 9.3).
Moderate emergency surges result in an increased patient
population of between 20% and 100% of usual capacity, necessitating a contingency response to most effectively use limited
resources. Contingency surge methods include all elements of the
conventional response with additional strategies to expand coverage. Non-ICU patient care areas may be repurposed for ICU-level
care. Staff are leveraged by changing provider-to-patient ratios or
by using non-ICU staff in a tiered approach whereby non-ICU
providers provide care and are, in turn, supervised by ICU providers. Supplies and equipment are conserved when possible; some
substitutions, adaptations, and reuse may be necessary when safe.
The goal of the contingency surge response is to significantly increase capacity while minimally affecting patient care practices.
EMCC and crisis standards of care (CSC) are required when a
large PHE threatens to overwhelm critical care resources despite
fully deployed conventional and contingency surge responses.
Following a sudden-impact PHE, there may be an initial emergency department (ED) surge lasting a few hours and a subsequent
ICU phase of weeks, while prolonged events such as pandemics

could require both EDs and ICUs to sustain contingency or crisis
strategies for months. It is recommended that hospitals with
PICUs be able to care for up to three times the usual number of
critically ill pediatric patients for up to 10 days without outside
help.19 In these circumstances, population-based goals will attempt to maximize the number of survivors by reallocating lifesaving interventions to persons who are more likely to benefit
from them. This represents an escalation from usual standards of
care to CSC. PHE powers are defined on a state-by-state basis;
thus, ICU leaders must be familiar with their own state and hospital incident command process for determining when CSC
should be activated.20
Sudden-impact events that stress the resources of a community
may require the implementation of temporary reactive mass critical care. However, no historical precedents exist for sustained
mass critical care such as might occur with major regional damage
or severe pandemic.21 During the initial wave of COVID-19 in
New York City, temporary mass critical care via rapid expansion

of COVID-19 units and staff was utilized as a means to address
the overwhelming care needs of patients. EMCC, whether temporary or sustained, should attempt to provide these five priority