Download Pediatric Wilderness Medicine Concerns

Pediatric Wilderness Medicine
Concerns
Wendalyn K Little MD, MPH
Assistant Professor of Pediatrics and Emergency
Medicine
Emory University
Children’s Healthcare of Atlanta
Quick PSA
Why paperwork and quality
improvement is important….
What is wilderness medicine?
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Expeditions to remote and exotic locations?
Preparation for travel – foreign and domestic?
Family vacations/camping trips?
Response to disasters – natural and man-made?
Sporting events on mountains, oceans, remote
areas?
…….what do these have in common?
What is wilderness medicine?
“Practice of medicine in situations of
constrained resources…”
Paul S. Auerbach MD, MS
Auerbach: Wilderness Medicine, 5th ed
2007 Mosby
Wilderness Medicine Considerations
• Planning
• Packing
• When something goes wrong
– Minimizing damage/impact
• Avoid creating new victims
– Evacuation
• When
• How
• Who
Why worry about pediatric concerns?
• Millions of children annually venture into the
wilderness
– Family trips
– Sporting events
• Ever increasing frequencies of families
traveling and relocating
Why worry about pediatric concerns?
• Kids are not “Little Adults”
– Size and developmental factors affect all aspects
of care
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Injury patterns
Susceptibility to illness
Physiologic response to illness and injury
Psychological /behavioral response
Dependence on caregivers
Medication dosing
Kid Sizes
Age
Weight (Kg)
Weight (lb)
6mo
6k
13
1y
10
20
3y
15
33
6y
20
44
8y
25
55
9.5y
30
66
11y
37
77
13y
45
100
From U.S. Centers for Disease Control and Prevention National Center for Health Statistics
(www.cdc.gov/nchs/
Overview
• Injury and illness patterns
• Environmental exposure
– Heat
– Cold
– Altitude
• Developmental considerations
• Prevention and treatment
– Medical kits
Pediatric Trauma
• Head Injury
– Leading cause of trauma morbidity and mortality
– Cranium of young children more pliable/less
protective of underlying brain
• More prone to skull fractures
– Worrisome signs
• More than brief (seconds) LOC
• Persistent vomiting, lethargy, irritability
• Scalp hematoma in patients <2 yrs
Pediatric Trauma
Prominent occiput may lead to flexion of
neck and airway obstruction
May need padding under shoulders for
appropriate airway and cervical spine
alignment
Pediatric Trauma
• Chest wall more compliant
– Rib fractures rare
– Pulmonary contusion common
• Abdomen larger, less developed musculature
– Intra-abdominal organs relatively larger and less
protected
Pediatric Trauma
• Response to hemorrhage/volume loss
– Vasoconstrictive response
– Hypotension is a late sign of intravascular depletion
• May not see until 30% intravascular volume loss
– Close attention for signs of shock
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Tachycardia
Pallor
Mental status changes
Capillary refill
Urine output
Pediatric Trauma
• Musculoskeletal injuries
– Open growth plates common area of injury
• “Kids don’t sprain”
– Bones compliant with strong periosteum
• Buckle (torus) fractures
• Greenstick fractures
– Assume fracture if tenderness over joint
• Splint/immobilize
Pediatric Fracture Patterns
Salter Harris Classification
Torus or “buckle” fracture
Trauma Prevention
• Helmets, personal flotation devices when
appropriate
• Sturdy shoes
• Selection of campsites away from bodies of
water, drops/cliffs
Stings/ Envenomations
• Children more prone to being bitten /stung
and more susceptible to toxic effects
• Snakes
Snakes
– 20% of US snakebite deaths are in kids <5
– 2 species of poisonous snakes in US
• Crotalines (pit vipers): rattlesnake, cottonmouth,
copperhead
• Elapids: coral snake
– Often kids running/playing outdoors
– Treatment:
• Calm patient
• Clean wound and splint extremity
• If possible poisonous snake, evacuation for medical
evaluation and antivenom
• Avoid tourniquets, extraction kits, incisions over bite, electric
shock
Prevention of Snakebites
• Long pants, sturdy shoes/boots
• Teach children not to reach into crevasses,
overturn rocks or logs
“Hands and feed do not go where eyes cannot see”
• Do not locate campsites near wood or rock
piles
Hymenoptera
• Bees, wasps, hornets, ants
• Usually local pain, swelling, erythema
– Gently remove stinger if present by scraping
– Cool compresses
– Oral antihistamine
• May cause anaphylaxis
– Epinephrine
• 0.01mg/kg of 1:1000 IM
• Epipen Jr 0.15mg (kids up to 15kg)
• Epipen 0.3mg (kids/adults >15kg)
Other
• Mosquitoes…….and other flying things
– Bites are nuisance
– Disease vectors
• Ticks
– Length of time attached increases risk of transmission
of infectious agents
– Check daily
– Remove by grasping close to head with tweezers,
gentle traction
– Watch for signs of illness days to weeks later
Insect Prevention
• Deet
– Most effective
– Associated with toxic encephalopathy at high doses and ingestion can
be fatal
– Use max 35% DEET preparations
• Permethrins
– Little human toxicity
– Apply to clothing, tents, mosquito nets
• Mosquito nets/hats
– Consider in disease endemic areas
• Protective clothing
• Others: lavender, citronella, etc
– Not really effective for wilderness use
Illnesses
• Less-developed immune systems
– More respiratory and GI infections
– Fever in young infants (<3mo) should be
considered emergency
Respiratory Illness
• Young infants are obligate nose breathers
– Tolerate secretions poorly
• Saline drops, bulb syringe should be part of travel kit
• Many children wheeze with upper respiratory
infections
• Use of cough and cold meds discouraged in
infants and young children
Gastrointestinal Illness
• Higher incidence in infants/children
– Immune system
– Oral exploration
– Hygeine
• “Traveler’s Diarrhea” very common
– 25-50% travelers
– >50% children by some reports
• Antibiotic prophylaxis not recommended in children
• Treatment if bloody diarrhea, diarrhea with fever
– TMP-SMX
– Azithromycin
• Loperamide probably ok in >2y if no bloody diarrhea, fever,
abdominal distention
• Probiotics probably ok, efficacy unproven
Gastrointestinal illness
• Dehydration occurs much more quickly
– Appropriate oral rehydration solution (ORS)
• Sports drinks NOT acceptable substitute – too much glucose, not
enough sodium
• Commercially available preparations or home-made solution
• In moderately to severely dehydrated child
– Give 100ml/kg over 4 hour period
– Give small, frequent amounts if vomiting
• Need lower sodium maintenance /prevention fluids
– Breast milk, water, juice, sports beverage
– May alternate with ORS after initial rehydration stage
Source: CDC MMWR
Source: CDC MMWR
Environmental Exposures
• Heat
• Cold
• Altitude
Pediatric Heat Illness
• Heat illness spectrum from heat rash
(inconvenience) to heat stroke (life threatening
emergency)
• Children increased susceptibility:
– Increased body surface area to mass
• Increased head absorption
• More prone to dehydration
– Increased heat generation per unit mass
– Fewer sweat glands and less sweat production/gland
– Inability to independently change environmental
exposure
Milia
Heat Rash or “Prickly Heat”
Pediatric Heat Illness
• Heat Exhaustion
– Signs/symptoms
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Weakness, syncope, pallor
Sweating maintained
Children often have nausea/vomiting
Temp <40
– Treatment
• Rest in shaded area
• Loosen/remove cooling to aid evaporation
• Oral rehydration
– Often able to resume activity after period of
rest/cooling
Pediatric Heat Illness
• Heat stroke
– Signs/symptoms
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Altered mental status (ataxia, confusion, coma)
Shock
Multi-organ system dysfunction
Temp >40.6
– TRUE EMERGENCY
• Immediate cooling
– Remove clothing
– Immersion or spraying/fanning with water
• Evacuation to medical care
• Aggressive management of seizures
• NO role for antipyretics
Pediatric Heat Illness
• Prevention
– Loose layers
– “Wicking” fabrics
– Encourage hydration
– Sunblock
• SPF 30 or greater
– Avoid outdoor activities/exertion in middle of day
– Frequent rest breaks
Hypothermia/Cold exposure
• Infants/children increased susceptibility
– Increased surface area to mass ratio
– Decreased muscle mass
– Behavioral
• Seize every opportunity to get wet
• Unable to independently seek shelter
– Symptoms
• Early: clumsiness, shivering, sensation of cold
• Later: ataxia, altered mental status, loss of shivering
Hypothermia
Source: Auerbach: Wilderness Medicine 5th ed
Hypothermia/Cold exposure
• Treatment
– Removal of wet clothing
– Warm, dry shelter
• Sleeping bag with adult
– Warm fluids if able to take po
– Warming and immediate evacuation if severe
hypothermia/ not improving with above measures
Hypothermia/Cold exposure
• Prevention
– Dress in layers
– Absorbent/ “wicking” material
• Wool, synthetics
• NOT cotton
– HATS, mittens, appropriate footwear
• Up to 70% body heat dissipated through uncovered
head at cold temperatures
– Ensure hydration and high energy food intake
High Altitude Illness
• Spectrum of illness ranging from self-limited,
mild symptoms to potentially fatal cerebral
and pulmonary edema
• 10-20% adults at 2500m (8200ft) will have
symptoms
• Infants/young children may be more
susceptible, may have difficulty reporting
symptoms
High Altitude Illness
• Acute Mountain Sickness
– Classic: headache, anorexia, malaise, sleep
disturbance
– Infants/children: fussy, poor feeding, vomiting, sleep
disruption
– Treatment: rest, hydration, acetaminophen, high
carbohydrate diet
• Descent if symptoms not relieved with above or worsening
• Acetazolamide may prevent symptoms
– 5mg/kg day divided bid, up to 250mg max
High Altitude Illness
• High Altitude Pulmonary Edema (HAPE)
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Dyspnea at rest
Crackles on lung exam
Worsening Hypoxia
Pink, frothy sputum
• High Altitude Cerebral Edema (HACE)
– Confusion, somnolence, ataxia, coma
• Both are Emergencies
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Immediate descent
Supplemental oxygen
Dexamethasone (2-4 mg every 6-12 hours)
Hyperbaric chamber (if available)
Developmental Considerations
• Motivation and Interest
– Young children not goal oriented
– Travel should be flexible
– Tired, cold, hot, bored, hungry children are NO FUN
• Stamina and endurance
• Diminished judgement/capability for self-rescue
– Preferably >1 adult
– Plan for emergencies, need for evacuation
– Leave itinerary with someone
Hiking Distances
Source: Gentile BC, Kennedy BC. Wilderness medicine for children. 1991 Pediatrics 88.
Developmental Considerations
• Safety
– Exploration
• Provide safe area in campsites to explore
• Close supervision
– Lost children
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Whistle
Teach older children to stay put, not hide, call for help
Pack with water, food, garbage bag
“Hug a Tree and Survive” campaign
http://www.gpsar.org/hugatree.html
Travel Issues
• Motion sickness
– Common in ages 2-12
– Diphenhydramine 1mg/kg or
Dimenhydramate 1mg/kg
– Avoid scopolamine patches
• Eustacian tube dysfunction
– Common in infants/young children during air
travel
– Have child drink during ascent may help
Illness and Injury Prevention
• Equipment
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Appropriate clothing
Helmets
Personal flotation devices
Whistles
• Insect repellants
– DEET <30%
– Permetherin to clothing
• Sun exposure
– Hats, sunglasses, sunblock
Illness and Injury Prevention
• Vaccinations
– Routine childhood vaccinations
– Consider Hep A, typhoid in international travel
• Medications
– Appropriate dosing/formulations
• Food and Water
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Breastfeed infants whenever possible
Bottled / filtered / treated water
Avoid ice cubes
Avoid undercooked foods
Raw fruits/veggies only if peeled appropriately
Medical Kits
• Basic supplies
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Assorted bandages
Wound closure strips
Tape (duct tape)
Splint (SAM or other)
Tweezers
Scissors
Triangular bandage
Moleskin/blister treatment
ACE wrap
Safety pins
Syringe for irrigation
Alcohol pads
Hand sanitizer
Cotton tip applicator
Topical antibiotic
• Other supplies
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Hydrocolloid dressing
Topical steroid cream
Zinc oxide cream
Sting relief pads
Temporary filling/dental wax
Cold packs
Emergency blanket
Headlamp
Compass
Water purification
Knife/Multi-tool
Firestarter/waterproof match
Medical Kits
• Medications
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Epinephrine autoinjector
Diphenhydramine
Anti-nausea meds
Antibiotics
• Floroquinalone
• Azithromycin
– Oral rehydration salts
– Antipyretics /analgesics
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Tetracaine eye drops
Saline eye drops
Eye ointment
Disinfectant solution
• Povidone-iodine
• Chlorhexidene
Medical Kids – pediatric considerations
• Appropriate
dosing/formulation
– Liquids/chewables
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Formula for infants
Diapers
Bulb syringe
Saline drops/spray
Thermometer
Questions?