Pediatric Disaster Life Pediatric Disaster Life Support (PDLSSupport (PDLS©)©)::Pediatric Disaster Medicine Pediatric Disaster Medicine

The Fundamentals: Anatomy, Physiology, The Fundamentals: Anatomy, Physiology, Disaster SpecificDisaster Specific

Patters of InjuryPatters of Injury

Body Size and CompositionBody Size and Composition

height and weight increase throughout height and weight increase throughout childhoodchildhood

less protective fat and muscleless protective fat and muscle

large surface area predisposes to large surface area predisposes to hypothermiahypothermia

Anatomic DifferencesAnatomic Differences

The youngest children have relatively larger and The youngest children have relatively larger and heavier headsheavier heads

Relatively larger and less protected abdomensRelatively larger and less protected abdomens- Penetrating injuriesPenetrating injuries

- Primary and secondary impact from objects or blast wavePrimary and secondary impact from objects or blast wave

Predisposition to Predisposition to more seriousmore serious traumatic traumatic damage during disasters compared to adult for damage during disasters compared to adult for the same injurythe same injury

Anatomic DifferencesAnatomic Differences

Smaller mass may cause children to be Smaller mass may cause children to be thrown further and faster, resulting in thrown further and faster, resulting in greater secondary injuries upon impactgreater secondary injuries upon impact

Surface to Body RatioSurface to Body Ratio

Higher surface area and thinner skinHigher surface area and thinner skin

Risk of exposure-related injuriesRisk of exposure-related injuries- BurnsBurns

- Hypothermia after decontaminationHypothermia after decontamination

- Toxic exposure to the skinToxic exposure to the skin

- DehydrationDehydration

Higher Baseline MetabolismHigher Baseline Metabolism

Faster Respiratory RateFaster Respiratory Rate- DehydrationDehydration- Ingestion of toxins, smoke, dustIngestion of toxins, smoke, dust

Lower Blood VolumeLower Blood Volume- Shock from bleedingShock from bleeding- Greater risk from dehydrationGreater risk from dehydration

Greater relative metabolic needsGreater relative metabolic needs- Higher risk for malnutrition sooner than adultsHigher risk for malnutrition sooner than adults- ↑ ↑ susceptibility to hypoglycemia? susceptibility to hypoglycemia?

SizeSize

Live Closer to the FloorLive Closer to the Floor- Risk of exposure to debris and waterRisk of exposure to debris and water

- Greater chance of exposure to chemical or Greater chance of exposure to chemical or radioactive residueradioactive residue

- ExampleExample: : Infant contracts cutaneous anthrax on Infant contracts cutaneous anthrax on arm after visiting ABC television studios targeted arm after visiting ABC television studios targeted during the 2001 attackduring the 2001 attack

SizeSize

Hand-to-Mouth ActivityHand-to-Mouth Activity- Children routinely place hands and objects in Children routinely place hands and objects in

mouth, increasing risk of exposure to chemicals, mouth, increasing risk of exposure to chemicals, toxinstoxins

- Increases risk of contracting vomiting and Increases risk of contracting vomiting and diarrheal illness during unsanitary conditions such diarrheal illness during unsanitary conditions such as in a shelter or with exposure to contaminated as in a shelter or with exposure to contaminated water supplywater supply

Immune SystemsImmune Systems

Young children do not have the same Young children do not have the same capacity as adults to respond to capacity as adults to respond to infectious diseaseinfectious disease- Biological agentsBiological agents

- Routine infections during shelteringRoutine infections during sheltering

How Children DecompensateHow Children Decompensate Differently than adultsDifferently than adults

Children rarely have primary cardiac eventChildren rarely have primary cardiac event

Pathway is predictablePathway is predictable- Focus is on respiratory problems and shockFocus is on respiratory problems and shock

- To know it is to prevent decompensationTo know it is to prevent decompensation

- Recognize early signs and symptoms of respiratory Recognize early signs and symptoms of respiratory distress and shockdistress and shock

Pathway to Decompensation

FULL ARREST

DEATH

RESPIRATORY FAILURE

Respiratory DistressDECOMPENSATED

Respiratory DistressCompensated

CIRCULATORY FAILURE

Circulatory DistressDECOMPENSATED

Circulatory DistressCompensated

Many CausesAsthma, ShockFB, Secretions

Toxins, etc.

Body ProportionsBody Proportions

body proportions account for unique injury body proportions account for unique injury patterns in childhoodpatterns in childhood

large head increases risk of head injury large head increases risk of head injury accompanying any other major traumatic accompanying any other major traumatic injury injury

large, “unprotected” intraabdominal organs large, “unprotected” intraabdominal organs increases risk of liver, spleen, bowel injury increases risk of liver, spleen, bowel injury following less severe trauma following less severe trauma

Etiologies of Cardiopulmonary FailureEtiologies of Cardiopulmonary Failure

Many EtiologiesMany Etiologies

Cardiopulmonary Cardiopulmonary FailureFailure

Respiratory Respiratory FailureFailure

Circulation Failure Circulation Failure (shock)(shock)

Respiratory Distress and FailureRespiratory Distress and Failure

respiratory distress: increased work of respiratory distress: increased work of breathingbreathing

respiratory failure: inadequate respiratory failure: inadequate oxygenation and/or ventilation to meet oxygenation and/or ventilation to meet metabolic needs metabolic needs

Signs of Respiratory Distress and Signs of Respiratory Distress and FailureFailure signs of respiratory distress:signs of respiratory distress:

- tachypnea, tachycardiatachypnea, tachycardia

- retractions (intercostal, supraclavicular, nasal flaring)retractions (intercostal, supraclavicular, nasal flaring)

- gruntinggrunting

signs of respiratory failuresigns of respiratory failure- altered mental statusaltered mental status

- poor colorpoor color

- hypotoniahypotonia

Infant with Increased Infant with Increased Respiratory EffortRespiratory Effort

Note use of intercostal and Note use of intercostal and accessory musclesaccessory muscles

Features of the Pediatric Upper Features of the Pediatric Upper AirwayAirway

large occiputlarge occiput

small mouthsmall mouth

large tonguelarge tongue

anterior and cephalad larynxanterior and cephalad larynx

angled cordsangled cords

large, floppy epiglottis overriding airwaylarge, floppy epiglottis overriding airway

narrow cricoid ringnarrow cricoid ring

Neonatal AirwayNeonatal Airway

Large headLarge head

Small naresSmall nares

Large tongueLarge tongue

High glottisHigh glottis

Overhanging Overhanging epiglottisepiglottis

Angled cordsAngled cords

Narrow cricoid regionNarrow cricoid region

Airway Equipment forAirway Equipment forthe Young Pediatric Patientthe Young Pediatric Patient

straight blade: compresses large straight blade: compresses large tongue and mandibular tissuetongue and mandibular tissue

uncuffed tube in children < 8 yearsuncuffed tube in children < 8 years

tube size = age yearstube size = age years+ 44

(for children over 2 years)

Features of the Pediatric Lower Features of the Pediatric Lower AirwayAirway

short trachea short trachea

narrow caliber of all airway structuresnarrow caliber of all airway structures

chest wall compliance chest wall compliance

lung compliance & elastic recoillung compliance & elastic recoil

diaphragm as a respiratory musclediaphragm as a respiratory muscle

Features ofFeatures ofthe Pediatric Cardiovascular Systemthe Pediatric Cardiovascular System

shock: defined as the clinical state of shock: defined as the clinical state of inadequate perfusion to meet metabolic needsinadequate perfusion to meet metabolic needs

Features ofFeatures ofthe Pediatric Cardiovascular Systemthe Pediatric Cardiovascular System

degree of shock is based on evaluation of the degree of shock is based on evaluation of the end organs of perfusion:end organs of perfusion:

- skin (color, temperature, cap refill)skin (color, temperature, cap refill)

- CNS (developmentally appropriate behavior, CNS (developmentally appropriate behavior, lethargy, anxiety)lethargy, anxiety)

- central central vs.vs. peripheral pulses peripheral pulses

- renal (urine output)renal (urine output)

- Lactate levelsLactate levels

- Central venous pressures & mixed venous satsCentral venous pressures & mixed venous sats

Simultaneous Palpation of Proximal Simultaneous Palpation of Proximal and Distal Pulsesand Distal Pulses

Features ofFeatures ofthe Pediatric Cardiovascular Systemthe Pediatric Cardiovascular System

cardiac output is rate dependent: infants cardiac output is rate dependent: infants cannot increase stroke volume to cannot increase stroke volume to compensate for shockcompensate for shock

smaller total blood volume: 80-100cc/kgsmaller total blood volume: 80-100cc/kg

increased parasympathetic output: increased parasympathetic output: increased vagal toneincreased vagal tone

Hemodynamic Changes with Blood Hemodynamic Changes with Blood LossLoss

Pediatric Vital SignsPediatric Vital Signs

mean heart rate decreases with agemean heart rate decreases with age

tachycardia is an early and nonspecific sign of shocktachycardia is an early and nonspecific sign of shock

mean blood pressure increases with agemean blood pressure increases with age

blood pressure is usually normal even in a child with blood pressure is usually normal even in a child with moderate-severe hypoperfusionmoderate-severe hypoperfusion

increased peripheral vascular tone allows for normal increased peripheral vascular tone allows for normal blood pressure until end-stage shock blood pressure until end-stage shock

vital signs not helpful in gauging degree of shock in vital signs not helpful in gauging degree of shock in childrenchildren

Pediatric Cervical SpinePediatric Cervical Spine

fulcrum is at C2-3fulcrum is at C2-3

growth plate of densgrowth plate of dens

weak neck musclesweak neck muscles

large head increases momentum large head increases momentum

SCIWORA because of ligamentous laxity SCIWORA because of ligamentous laxity

most fractures occur at C1-2 most fractures occur at C1-2

difficulty with immobilization: large head/small chest allow difficulty with immobilization: large head/small chest allow for excessive flexion in supine position for excessive flexion in supine position

Head Injury inHead Injury inthe Young Pediatric Patientthe Young Pediatric Patient

skull is more compliant offers less skull is more compliant offers less protection to the brainprotection to the brain

open sutures and fontanelopen sutures and fontanel

mobile middle meningeal arterymobile middle meningeal artery

intracranial bleeds occur without intracranial bleeds occur without accompanying fractureaccompanying fracture

intracranial bleed can cause shockintracranial bleed can cause shock

Localized Head TraumaLocalized Head Trauma AssessmentAssessment

- historyhistory- vital signsvital signs- local findingslocal findings

Treatment GoalsTreatment Goals- prevent secondary brain damageprevent secondary brain damage- maintain good cerebral perfusion pressuremaintain good cerebral perfusion pressure

TreatmentTreatment- control external bleedingcontrol external bleeding- oxygenate & hyperventilate as neededoxygenate & hyperventilate as needed- fluid resuscitate to maintain adequate perfusionfluid resuscitate to maintain adequate perfusion- keep head in midline position and HOB elevated 30 degreeskeep head in midline position and HOB elevated 30 degrees- control seizures if possiblecontrol seizures if possible

Isolated Spinal TraumaIsolated Spinal Trauma

AssessmentAssessment

- history (mechanism, amount of force)history (mechanism, amount of force)

- vital signsvital signs

- local findings (thorough neuro exam, palpation etc.)local findings (thorough neuro exam, palpation etc.)

Treatment GoalsTreatment Goals

- immobilization of the cervical spine and the childimmobilization of the cervical spine and the child

TreatmentTreatment

- appropriate size hard collar or rolls to immobilize the neckappropriate size hard collar or rolls to immobilize the neck

- back board or modified board with proper restraintsback board or modified board with proper restraints

Features of the Pediatric AbdomenFeatures of the Pediatric Abdomen

thinner abdominal wall with less fat and thinner abdominal wall with less fat and musclemuscle

decreased anterior-posterior diameterdecreased anterior-posterior diameter

large liver and spleen extend below ribslarge liver and spleen extend below ribs

kidney contains less perinephric fatkidney contains less perinephric fat

gastric distention (with ventilation or gastric distention (with ventilation or crying) can present as a tense abdomencrying) can present as a tense abdomen

Isolated Abdominal TraumaIsolated Abdominal Trauma

AssessmentAssessment

- historyhistory

- vital signsvital signs

- local findingslocal findings

Goal of TreatmentGoal of Treatment

- early assessment and prevention of complicationsearly assessment and prevention of complications

TreatmentTreatment

- monitor ventilatory status and assist when necessarymonitor ventilatory status and assist when necessary

- decompress abdomendecompress abdomen

Soft Tissue InjuriesSoft Tissue Injuries

AssessmentAssessment- visual and palpation examvisual and palpation exam

- vital signsvital signs

Treatment GoalsTreatment Goals- prevention of complicationsprevention of complications

TreatmentTreatment- close monitoring of oxygenationclose monitoring of oxygenation

- maintenance of adequate ventilation with assist if neededmaintenance of adequate ventilation with assist if needed

- oxygen delivery as neededoxygen delivery as needed

- restore intravascular volume if needed for excessive blood restore intravascular volume if needed for excessive blood lossloss

Skeletal SystemSkeletal System

Fractures seen exclusively in children:Fractures seen exclusively in children:

- growth plate (Salter Harris) fracture growth plate (Salter Harris) fracture

- torus fracturestorus fractures

- bowing fracturesbowing fractures

- greenstick fracture greenstick fracture

Skeletal SystemSkeletal System

physis is site of growth physis is site of growth

physis is the weakest part of bonephysis is the weakest part of bone

physis is composed of cartilage and physis is composed of cartilage and separates epiphysis from metaphysisseparates epiphysis from metaphysis

fractures of the physis are described by fractures of the physis are described by the Salter Harris Classificationthe Salter Harris Classification

Musculoskeletal InjuriesMusculoskeletal Injuries

AssessmentAssessment- history (mechanism, force)history (mechanism, force)- vital signs (peripheral perfusion)vital signs (peripheral perfusion)- local findings (discoloration, deformity etc.)local findings (discoloration, deformity etc.)

Goal of TreatmentGoal of Treatment- prevention of complicationsprevention of complications- minimize discomfortminimize discomfort

TreatmentTreatment- ice, elevation, immobilizationice, elevation, immobilization- frequent evaluation of peripheral vascular perfusionfrequent evaluation of peripheral vascular perfusion- reassess neuromuscular functionreassess neuromuscular function

Environmental EmergenciesEnvironmental Emergencies

Burns and Thermal InjuriesBurns and Thermal Injuries

Smoke and Inhalation Injuries Smoke and Inhalation Injuries

HyperthermiaHyperthermia

HypothermiaHypothermia

Burns & Thermal InjuriesBurns & Thermal Injuries

Airway..Breathing..CirculationAirway..Breathing..Circulation

AssessmentAssessment

Fluid TherapyFluid Therapy

Care of the Burn WoundCare of the Burn Wound

Pain ManagementPain Management

Parkland FormulaParkland Formula

- 4 ml/kg/%BSA of crystalloid over the first 24 4 ml/kg/%BSA of crystalloid over the first 24 hours.hours.

- Half during the first 8 hours and half over the Half during the first 8 hours and half over the next 16 hoursnext 16 hours

Fluid Therapy for the Burn VictimFluid Therapy for the Burn Victim

Rule of ThumbRule of Thumb

Children should produce 1 ml/kg/hr of urineChildren should produce 1 ml/kg/hr of urine .. .. ..

Care of the Burn WoundCare of the Burn Wound

Goals Goals - promote rapid healing, prevent infectionpromote rapid healing, prevent infection

CleanseCleanse

- using large volumes of lukewarm sterile salineusing large volumes of lukewarm sterile saline

CoverCover- with loose, clean, preferably sterile dressings or with loose, clean, preferably sterile dressings or

sheetssheets

Pain Management for Burn VictimPain Management for Burn Victim

Covering burn from moving airCovering burn from moving air

Analgesic medicationsAnalgesic medications

Drug of ChoiceDrug of Choice

- Morphine 0.1-0.5 mg/kgMorphine 0.1-0.5 mg/kg

Smoke & Inhalation InjuriesSmoke & Inhalation Injuries

AssessmentAssessment

- Clinical ManifestationsClinical Manifestations

TreatmentTreatment

Hints of Smoke InhalationHints of Smoke Inhalation

Exam may show:Exam may show:- facial burnsfacial burns

- singed nasal hairssinged nasal hairs

- soot in pharynxsoot in pharynx

- mental confusionmental confusion

Tachypnea, cough or stridor may or may Tachypnea, cough or stridor may or may not be present.not be present.

Treatment of Smoke Treatment of Smoke InhalationInhalation

Remove from contaminated environmentRemove from contaminated environment

CPR as neededCPR as needed

Provide 100% supplemental oxygenProvide 100% supplemental oxygen

Ensure patent airway…..ABC’sEnsure patent airway…..ABC’s

Intubate earlyIntubate early

HyperthermiaHyperthermia

Assessment & ExamAssessment & Exam

Heat exhaustionHeat exhaustion- T <41C, dry or wet skin, lethargy, thirst, T <41C, dry or wet skin, lethargy, thirst,

headache, increased heart rateheadache, increased heart rate

Heat stroke Heat stroke - T > 41C, hot skin, severe CNS dysfunction, T > 41C, hot skin, severe CNS dysfunction,

circulatory collapsecirculatory collapse

Treatment of HyperthermiaTreatment of Hyperthermia

Remove clothingRemove clothing

Begin active coolingBegin active cooling

Transport to cool environmentTransport to cool environment

Cardiovascular supportCardiovascular support

Fluid Resuscitation: 20 mg/kg Fluid Resuscitation: 20 mg/kg lactated Ringers or 0.9% sodium lactated Ringers or 0.9% sodium chloridechloride

HypothermiaHypothermia

Assessment & ExamAssessment & Exam

Internal vs. External EtiologiesInternal vs. External Etiologies

Pale or cyanoticPale or cyanotic

Shivering mechanismShivering mechanism

CNS function progressively impaired with CNS function progressively impaired with falling temp. Comatose at approx 27 C.falling temp. Comatose at approx 27 C.

Decreased BP, heart rate, or bothDecreased BP, heart rate, or both

Treatment for HypothermiaTreatment for Hypothermia

Mild [32-35C/89.6-95F]Mild [32-35C/89.6-95F] Passive External Rewarming Passive External Rewarming

• Warm environment, dry clothesWarm environment, dry clothes

Moderate [28-32C/82.4-89.6F]Moderate [28-32C/82.4-89.6F] Active External RewarmingActive External Rewarming

• Bair Hugger, radiant sources, warm water bottlesBair Hugger, radiant sources, warm water bottles

Severe [<28C/<82.4F]Severe [<28C/<82.4F] Active Core RewarmingActive Core Rewarming

• Warm peritoneal lavage, nasogastric lavage, IV fluids, thoracotomiesWarm peritoneal lavage, nasogastric lavage, IV fluids, thoracotomies• Extracorporeal Blood Rewarming – Cardiopulmonary bypassExtracorporeal Blood Rewarming – Cardiopulmonary bypass

Hazardous Materials ExposureHazardous Materials Exposure

Goal:Goal:

to provide guidelines for scene to provide guidelines for scene management , care and management , care and transportation of patients transportation of patients contaminated by radiation or contaminated by radiation or hazardous chemicalshazardous chemicals

General InstructionsGeneral Instructions

Upon discovery of Hazmat scene, notify Upon discovery of Hazmat scene, notify communication center to dispatch Hazmat expertcommunication center to dispatch Hazmat expert

Delay entry until appropriate team and protective Delay entry until appropriate team and protective equipment is availableequipment is available

Expect the Hazmat team to initially remove any Expect the Hazmat team to initially remove any patientspatients

Follow advice of Hazmat team regarding personal Follow advice of Hazmat team regarding personal protection or patient decontaminationprotection or patient decontamination

Additional RulesAdditional Rules

Don’t be a hero...Don’t be a hero...

Always maintain a high index of suspicionAlways maintain a high index of suspicion- Secondary devicesSecondary devices

General Signs and Symptoms of General Signs and Symptoms of Hazmat ExposureHazmat Exposure

Local EffectsLocal Effects-complaints of burning skin, teary eyes, complaints of burning skin, teary eyes,

dry or sore throat, a cough or sneezing.dry or sore throat, a cough or sneezing.

Systemic EffectsSystemic Effects-complaints of difficulty breathing, bizarre complaints of difficulty breathing, bizarre

behavior, stupor, seizures, coma.behavior, stupor, seizures, coma.

Psychological & Social EmergenciesPsychological & Social Emergencies

Separation AnxietySeparation Anxiety

Child SafetyChild Safety

Lack of Communication and Lack of Communication and Comprehension SkillsComprehension Skills