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Pediatric Disaster Life
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Pediatric Disaster Medicine
The Fundamentals: Anatomy, Physiology,
Disaster Specific
Patters of Injury
Body Size and Composition
 height and weight increase throughout
childhood
 less protective fat and muscle
 large surface area predisposes to
hypothermia
Anatomic Differences
 The youngest children have relatively larger and
heavier heads
 Relatively larger and less protected abdomens
- Penetrating injuries
- Primary and secondary impact from objects or blast wave
 Predisposition to more serious traumatic
damage during disasters compared to adult for
the same injury
Anatomic Differences
 Smaller mass may cause children to be
thrown further and faster, resulting in
greater secondary injuries upon impact
Surface to Body Ratio
 Higher surface area and thinner skin
 Risk of exposure-related injuries
- Burns
- Hypothermia after decontamination
- Toxic exposure to the skin
- Dehydration
Higher Baseline Metabolism
 Faster Respiratory Rate
- Dehydration
- Ingestion of toxins, smoke, dust
 Lower Blood Volume
- Shock from bleeding
- Greater risk from dehydration
 Greater relative metabolic needs
- Higher risk for malnutrition sooner than adults
- ↑ susceptibility to hypoglycemia?
Size
 Live Closer to the Floor
- Risk of exposure to debris and water
- Greater chance of exposure to chemical or
radioactive residue
- Example: Infant contracts cutaneous anthrax on
arm after visiting ABC television studios targeted
during the 2001 attack
Size
 Hand-to-Mouth Activity
- Children routinely place hands and objects in
mouth, increasing risk of exposure to chemicals,
toxins
- Increases risk of contracting vomiting and
diarrheal illness during unsanitary conditions such
as in a shelter or with exposure to contaminated
water supply
Immune Systems
 Young children do not have the same
capacity as adults to respond to infectious
disease
- Biological agents
- Routine infections during sheltering
How Children Decompensate
 Differently than adults
 Children rarely have primary cardiac
event
 Pathway is predictable
- Focus is on respiratory problems and shock
- To know it is to prevent decompensation
- Recognize early signs and symptoms of
respiratory distress and shock
Many Causes
Asthma, Shock
FB, Secretions
Toxins, etc.
Respiratory Distress
Compensated
Circulatory Distress
Compensated
Respiratory Distress
DECOMPENSATED
Circulatory Distress
DECOMPENSATED
RESPIRATORY FAILURE
CIRCULATORY FAILURE
FULL ARREST
DEATH
Body Proportions
 body proportions account for unique injury
patterns in childhood
 large head increases risk of head injury
accompanying any other major traumatic
injury
 large, “unprotected” intraabdominal organs
increases risk of liver, spleen, bowel injury
following less severe trauma
Etiologies of Cardiopulmonary Failure
Many Etiologies
Respiratory
Failure
Circulation Failure
(shock)
Cardiopulmonary
Failure
Respiratory Distress and Failure
 respiratory distress: increased work of
breathing
 respiratory failure: inadequate
oxygenation and/or ventilation to meet
metabolic needs
Signs of Respiratory Distress and
Failure
 signs of respiratory distress:
- tachypnea, tachycardia
- retractions (intercostal, supraclavicular, nasal flaring)
- grunting
 signs of respiratory failure
- altered mental status
- poor color
- hypotonia
Infant with Increased
Respiratory Effort
 Note use of intercostal and
accessory muscles
Features of the Pediatric Upper
Airway
 large occiput
 small mouth
 large tongue
 anterior and cephalad larynx
 angled cords
 large, floppy epiglottis overriding airway
Neonatal Airway
 Large head
 Small nares
 Large tongue
 High glottis
 Overhanging
epiglottis
 Angled cords
 Narrow cricoid region
Airway Equipment for
the Young Pediatric Patient
 straight blade: compresses large tongue
and mandibular tissue
 uncuffed tube in children < 8 years
 tube size =
age years
+4
4
(for children over 2 years)
Features of the Pediatric Lower
Airway
 short trachea
 narrow caliber of all airway structures
 chest wall compliance
 lung compliance & elastic recoil
 diaphragm as a respiratory muscle
Features of
the Pediatric Cardiovascular System
 shock: defined as the clinical state of
inadequate perfusion to meet metabolic needs
Features of
the Pediatric Cardiovascular System
 degree of shock is based on evaluation of the
end organs of perfusion:
- skin (color, temperature, cap refill)
- CNS (developmentally appropriate behavior,
lethargy, anxiety)
- central vs. peripheral pulses
- renal (urine output)
- Lactate levels
- Central venous pressures & mixed venous sats
Simultaneous Palpation of Proximal
and Distal Pulses
Features of
the Pediatric Cardiovascular System
 cardiac output is rate dependent: infants
cannot increase stroke volume to
compensate for shock
 smaller total blood volume: 80-100cc/kg
 increased parasympathetic output:
increased vagal tone
Hemodynamic Changes with Blood
Loss
Pediatric Vital Signs
 mean heart rate decreases with age
 tachycardia is an early and nonspecific sign of
shock
 mean blood pressure increases with age
 blood pressure is usually normal even in a child
with moderate-severe hypoperfusion
 increased peripheral vascular tone allows for
normal blood pressure until end-stage shock
 vital signs not helpful in gauging degree of shock in
children
Pediatric Cervical Spine
 fulcrum is at C2-3
 growth plate of dens
 weak neck muscles
 large head increases momentum
 SCIWORA because of ligamentous laxity
 most fractures occur at C1-2
 difficulty with immobilization: large head/small
chest allow for excessive flexion in supine
position
Head Injury in
the Young Pediatric Patient
 skull is more compliant offers less
protection to the brain
 open sutures and fontanel
 mobile middle meningeal artery
 intracranial bleeds occur without
accompanying fracture
 intracranial bleed can cause shock
Localized Head Trauma
 Assessment
- history
- vital signs
- local findings
 Treatment Goals
- prevent secondary brain damage
- maintain good cerebral perfusion pressure
 Treatment
- control external bleeding
- oxygenate & hyperventilate as needed
- fluid resuscitate to maintain adequate perfusion
- keep head in midline position and HOB elevated 30 degrees
- control seizures if possible
Isolated Spinal Trauma
 Assessment
- history (mechanism, amount of force)
- vital signs
- local findings (thorough neuro exam, palpation etc.)
 Treatment Goals
- immobilization of the cervical spine and the child
 Treatment
- appropriate size hard collar or rolls to immobilize the neck
- back board or modified board with proper restraints
Features of the Pediatric Abdomen
 thinner abdominal wall with less fat and
muscle
 decreased anterior-posterior diameter
 large liver and spleen extend below ribs
 kidney contains less perinephric fat
 gastric distention (with ventilation or
crying) can present as a tense abdomen
Isolated Abdominal Trauma
 Assessment
- history
- vital signs
- local findings
 Goal of Treatment
- early assessment and prevention of complications
 Treatment
- monitor ventilatory status and assist when necessary
- decompress abdomen
Soft Tissue Injuries
 Assessment
- visual and palpation exam
- vital signs
 Treatment Goals
- prevention of complications
 Treatment
- close monitoring of oxygenation
- maintenance of adequate ventilation with assist if needed
- oxygen delivery as needed
- restore intravascular volume if needed for excessive blood
loss
Skeletal System
 Fractures seen exclusively in children:
- growth plate (Salter Harris) fracture
- torus fractures
- bowing fractures
- greenstick fracture
Skeletal System
 physis is site of growth
 physis is the weakest part of bone
 physis is composed of cartilage and
separates epiphysis from metaphysis
 fractures of the physis are described by
the Salter Harris Classification
Musculoskeletal Injuries
 Assessment
- history (mechanism, force)
- vital signs (peripheral perfusion)
- local findings (discoloration, deformity etc.)
 Goal of Treatment
- prevention of complications
- minimize discomfort
 Treatment
- ice, elevation, immobilization
- frequent evaluation of peripheral vascular perfusion
- reassess neuromuscular function
Environmental Emergencies
 Burns and Thermal Injuries
 Smoke and Inhalation Injuries
 Hyperthermia
 Hypothermia
Burns & Thermal Injuries
 Airway..Breathing..Circulation
 Assessment
 Fluid Therapy
 Care of the Burn Wound
 Pain Management
Fluid Therapy for the Burn Victim
 Parkland Formula
- 4 ml/kg/%BSA of crystalloid over the first 24
hours.
- Half during the first 8 hours and half over the
next 16 hours
Rule of Thumb
Children should produce 1 ml/kg/hr of urine ...
Care of the Burn Wound
 Goals
- promote rapid healing, prevent infection
 Cleanse
- using large volumes of lukewarm sterile saline
 Cover
- with loose, clean, preferably sterile dressings or
sheets
Pain Management for Burn Victim
 Covering burn from moving air
 Analgesic medications
 Drug of Choice
- Morphine 0.1-0.5 mg/kg
Smoke & Inhalation Injuries
 Assessment
- Clinical Manifestations
 Treatment
Hints of Smoke Inhalation
 Exam may show:
- facial burns
- singed nasal hairs
- soot in pharynx
- mental confusion
Tachypnea, cough or stridor may or may
not be present.
Treatment of Smoke
Inhalation
 Remove from contaminated environment
 CPR as needed
 Provide 100% supplemental oxygen
 Ensure patent airway…..ABC’s
 Intubate early
Hyperthermia
Assessment & Exam
 Heat exhaustion
- T <41C, dry or wet skin, lethargy, thirst,
headache, increased heart rate
 Heat stroke
- T > 41C, hot skin, severe CNS dysfunction,
circulatory collapse
Treatment of Hyperthermia
 Remove clothing
 Begin active cooling
 Transport to cool environment
 Cardiovascular support
 Fluid Resuscitation: 20 mg/kg
lactated Ringers or 0.9% sodium
chloride
Hypothermia
Assessment & Exam
 Internal vs. External Etiologies
 Pale or cyanotic
 Shivering mechanism
 CNS function progressively impaired with
falling temp. Comatose at approx 27 C.
 Decreased BP, heart rate, or both
Treatment for Hypothermia
 Mild [32-35C/89.6-95F]

Passive External Rewarming
• Warm environment, dry clothes
 Moderate [28-32C/82.4-89.6F]
 Active External Rewarming
• Bair Hugger, radiant sources, warm water bottles
 Severe [<28C/<82.4F]

Active Core Rewarming
• Warm peritoneal lavage, nasogastric lavage, IV fluids, thoracotomies
• Extracorporeal Blood Rewarming – Cardiopulmonary bypass
Hazardous Materials Exposure
Goal:
to provide guidelines for scene
management , care and
transportation of patients
contaminated by radiation or
hazardous chemicals
General Instructions
 Upon discovery of Hazmat scene, notify
communication center to dispatch Hazmat
expert
 Delay entry until appropriate team and
protective equipment is available
 Expect the Hazmat team to initially remove
any patients
 Follow advice of Hazmat team regarding
personal protection or patient
Additional Rules
 Don’t be a hero...
 Always maintain a high index of suspicion
- Secondary devices
General Signs and Symptoms of
Hazmat Exposure
 Local Effects
- complaints of burning
skin, teary eyes,
dry or sore throat, a cough or sneezing.
 Systemic Effects
- complaints of difficulty breathing, bizarre
behavior, stupor, seizures, coma.
Psychological & Social Emergencies
 Separation Anxiety
 Child Safety
 Lack of Communication and
Comprehension Skills