Pediatric Disaster Life Support (PDLS©): Pediatric Disaster Medicine Pediatric Disaster Life Support (PDLS) – The fundamentals: Anatomy, Physiology, Disaster Specific Patterns of Injury – Children in naturally occurring epidemics. (already covered – airway/ventilation & certain injuries) Discuss ↑ susceptibility of children compared to adults: Serious infection / sepsis Fluid and electrolyte diseases (diarrhea) - Extremes of temperature -smoke / lead injection Snake bites Anaplylaxis Kidney / liver failure (CCL4 exp.) Diabetes The Fundamentals: Anatomy, Physiology, Disaster Specific Patterns of Injury

Body Size and Composition height and weight increase throughout childhood less protective fat and muscle large surface area predisposes to hypothermia Quetzaltenango, Guatemala, November 2009

Quetzaltenango, Guatemala, November 2009 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 Quetzaltenango, Guatemala, November 2009

Quetzaltenango, Guatemala, November 2009

Quetzaltenango, Guatemala, November 2009 Anatomic Differences Smaller mass may cause children to be thrown further and faster, resulting in greater secondary injuries upon impact Quetzaltenango, Guatemala, November 2009

Quetzaltenango, Guatemala, November 2009 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 Quetzaltenango, Guatemala, November 2009

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? Quetzaltenango, Guatemala, November 2009

Quetzaltenango, Guatemala, November 2009 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 baby of an ABC news producer was diagnosed with a case of cutaneous (skin) anthrax; Tom Brokaw assistant Quetzaltenango, Guatemala, November 2009

Quetzaltenango, Guatemala, November 2009 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 Quetzaltenango, Guatemala, November 2009

Quetzaltenango, Guatemala, November 2009 Immune Systems Young children do not have the same capacity as adults to respond to infectious disease Biological agents Routine infections during sheltering Giardia, Ecoli, Norwalk virus Quetzaltenango, Guatemala, November 2009

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 Quetzaltenango, Guatemala, November 2009

Quetzaltenango, Guatemala, November 2009 Pediatric Assessment Triangle (PAT) is an observational first impression before touching the patient. What you see and hear as you first encounter the patient can allow you to formulate a visual and auditory first impression. It tells the experienced clinician how to prioritize further assessment. It determines life-threatening emergencies that need immediate attention. Identifies the general category of physiologic abnormality, which formalizes the general impression Establishes severity of illness Determines urgency of interventions The PAT can be completed in seconds and is based on three categories of observations: Appearance (mental status) Work of Breathing Circulation to the Skin Quetzaltenango, Guatemala, November 2009

Quetzaltenango, Guatemala, November 2009

Quetzaltenango, Guatemala, November 2009 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 Quetzaltenango, Guatemala, November 2009

Etiologies of Cardiopulmonary Failure Many Etiologies Respiratory Failure Circulation Failure (shock) Cardiopulmonary Failure Quetzaltenango, Guatemala, November 2009

Respiratory Distress and Failure respiratory distress: increased work of breathing respiratory failure: inadequate oxygenation and/or ventilation to meet metabolic needs Quetzaltenango, Guatemala, November 2009

Signs of Respiratory Distress and Failure tachypnea, tachycardia retractions (intercostal, supraclavicular, nasal flaring) grunting signs of respiratory failure altered mental status poor color hypotonia Quetzaltenango, Guatemala, November 2009

Quetzaltenango, Guatemala, November 2009 Infant with Increased Respiratory Effort Note use of intercostal and accessory muscles Quetzaltenango, Guatemala, November 2009

Features of the Pediatric Upper Airway large occiput small mouth large tongue anterior and cephalad larynx angled cords large, floppy epiglottis overriding airway narrow cricoid ring Quetzaltenango, Guatemala, November 2009

Quetzaltenango, Guatemala, November 2009 Neonatal Airway Large head Small nares Large tongue High glottis Overhanging epiglottis Angled cords Narrow cricoid region Quetzaltenango, Guatemala, November 2009

Quetzaltenango, Guatemala, November 2009 Posterior obstruction base of tongue…..simple manuevers FIRST Quetzaltenango, Guatemala, November 2009

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 Discuss other issues regarding airway and ventilation management. Broselow Tape Managing several children with airway +/- ventilation problems – tricks of the trade. 4 Quetzaltenango, Guatemala, November 2009

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 Ribs horizontal………diaphragm dependent Quetzaltenango, Guatemala, November 2009

Quetzaltenango, Guatemala, November 2009

Quetzaltenango, Guatemala, November 2009

Quetzaltenango, Guatemala, November 2009

Quetzaltenango, Guatemala, November 2009

Features of the Pediatric Cardiovascular System SHOCK: defined as the clinical state of inadequate perfusion to meet metabolic needs Quetzaltenango, Guatemala, November 2009

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 Quetzaltenango, Guatemala, November 2009

Simultaneous Palpation of Proximal and Distal Pulses Universal precautions Quetzaltenango, Guatemala, November 2009

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 Blood volume 8-9% of body weight Quetzaltenango, Guatemala, November 2009

Hemodynamic Changes with Blood Loss Quetzaltenango, Guatemala, November 2009

Quetzaltenango, Guatemala, November 2009 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 Quetzaltenango, Guatemala, November 2009

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 Quetzaltenango, Guatemala, November 2009

Quetzaltenango, Guatemala, November 2009

Quetzaltenango, Guatemala, November 2009

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 Increased susceptibility to head injury s Signs of CMS deterioration in the field Quetzaltenango, Guatemala, November 2009

Quetzaltenango, Guatemala, November 2009 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 Head trauma can be divided into penetrating and non-penetrating. The determination of whether the injury is penetrating or not is done during the initial assessment. Assessment: 1.) History (force, mechanism etc...) 2.) Vitals 3.) Local Findings (including Glasgow Coma scale modified scale if <3yrs old) With either penetrating or non-penetrating injuries the treatment goals should be the same: Treatment Goal: 1.) Prevent secondary brain damage 2.) Maintain good cerebral perfusion pressure Treatment: Remember: AIRWAY, BREATHING, AND CIRCULATION COMES FIRST 1.) Control external bleeding (ALL PROTRUDING OBJECTS SHOULD BE LEFT IN PLACE) 2.) oxygenate and hyperventilate if necessary 3.) fluid resuscitation to maintain adequate perfusion 4.) keep head position in midline and elevate HOB 30 degrees 5.) control seizures if possible Quetzaltenango, Guatemala, November 2009

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 Isolated trauma to the neck does not occur frequently in children. However, the potential for major disruption of the airway and large vessels demands a thorough evaluation. crepitus, unequal carotid pulses, expanding hematomas, and cervical spine tenderness. neurological exam with emphasis on spinal cord disruption is a must... history of the amount of force involved or the local findings raise the question of cervical spine injuries, the child requires immobilization of the cervical spine with a semirigid collar. extremely frightening to children and therefore close observation and lots of emotional support is needed.. Quetzaltenango, Guatemala, November 2009

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 Quetzaltenango, Guatemala, November 2009

Quetzaltenango, Guatemala, November 2009

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 Penetrating abdominal injuries can often cause moderate to severe trauma. Penetrating peritoneal injuries can cause visceral damage and often require surgery. Conservative mngt w/serial exams. In the disaster situation treatment is limited. Close monitoring and prevention of complications resulting from the injury are the main treatment goals. Example: abdominal distension which could cause respiratory distress. decompressing the abdomen with a naso-gastric tube. ventilatory assistance may also be necessary. Quetzaltenango, Guatemala, November 2009

Quetzaltenango, Guatemala, November 2009 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 assess the injury and to prevent complications. complications include inadequate vascular perfusion due do blood loss, or excessive swelling. Direct pressure . ice and elevation for reduction of swelling are simple practices that can help reduce some of these complications . Quetzaltenango, Guatemala, November 2009

Quetzaltenango, Guatemala, November 2009 Skeletal System Fractures seen exclusively in children: growth plate (Salter Harris) fracture torus fractures bowing fractures greenstick fracture Quetzaltenango, Guatemala, November 2009

Quetzaltenango, Guatemala, November 2009

Quetzaltenango, Guatemala, November 2009

Quetzaltenango, Guatemala, November 2009

Quetzaltenango, Guatemala, November 2009 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 Quetzaltenango, Guatemala, November 2009

Quetzaltenango, Guatemala, November 2009

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 mild nonpenetrating injuries often require an x-ray to detect an underlying fracture. deformity may be noticeable to the naked eye. Treatment is generally the same for either injury. Attempt to provide comfort and stabilization of injury by imobilizing that body part. Ice and elevation can often provide comfort. Distal nvs eval. Penetrating injuries to the extremities can be complicated by contamination and excessive bleeding. direct pressure for the bleeding and a dry covering to keep the wound as clean as possible. When sterile water is available gentle surface irrigation can be used. Quetzaltenango, Guatemala, November 2009

Environmental Emergencies Burns and Thermal Injuries Smoke and Inhalation Injuries Hyperthermia Hypothermia READ SLIDE Quetzaltenango, Guatemala, November 2009

Burns & Thermal Injuries Airway..Breathing..Circulation Assessment Fluid Therapy Care of the Burn Wound Pain Management The A B C’s hold true with burn victims just as they hold true with other injuries. Once we know these basics are stable we are ready to assess the burn injury itself. Quetzaltenango, Guatemala, November 2009

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 Hypovolemia is common in thermal or burn injuries due to the fact that sodium and water are lost through the damaged capillaries and tissue. Formulas for fluids therapy in burn patients must be used carefully with children. The Parkland Formula is a common formula used. READ SLIDE... Adjustment of infusion rates are the rule and not the exception. One good way of determining the effectiveness of the fluid therapy is done by monitoring urine output. 10kg x 50% X 4ml/kg = 2000ml/24h or 1000ml/1st 8h + maintenance

Children should produce 1 ml/kg/hr of urine . . . Rule of Thumb Children should produce 1 ml/kg/hr of urine . . . READ SLIDE

Care of the Burn Wound Goals Cleanse Cover promote rapid healing, prevent infection Cleanse using large volumes of lukewarm sterile saline Cover with loose, clean, preferably sterile dressings or sheets READ SLIDE.......Many times at the scene of a disaster the above supplies may not be available. This is when we must use our judgment as to what would be the best treatment with what we have available. PREVENT HYPOTHERMIA!!!!!!!!!!!!!!

Pain Management for Burn Victim Covering burn from moving air Analgesic medications Drug of Choice Morphine 0.1-0.5 mg/kg Fentanyl 1-2 mcg/kg READ SLIDE... Remember these suggestions are for immediate and pre hospital treatment if the needed supplies are even available at that time

Smoke & Inhalation Injuries Assessment Clinical Manifestations Treatment Assessment: What would we expect to see with a child suffering from smoke inhalation ? Treatment: What would the immediate treatment consists of ? Quetzaltenango, Guatemala, November 2009

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. READ SLIDE................carbonaceous sputum

Treatment of Smoke Inhalation Remove from contaminated environment CPR as needed Provide 100% supplemental oxygen Ensure patent airway…..ABC’s Intubate early READ SLIDE.............

Quetzaltenango, Guatemala, November 2009 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 The most common types of Hyperthermia that we might see in a disaster patient are the following: ..... READ SLIDE... Peds/elderly/non-acclimized Approx 400 annual deaths due heat illness CNS dysfunction: change MS, seizures, coma………….ARF, DIC, Rhabdo, Quetzaltenango, Guatemala, November 2009

Quetzaltenango, Guatemala, November 2009

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 READ SLIDE.......... Radiation conduction convection evaporation

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 Definition: core temp <35 degrees Ambient Temp vs. tox/sepsis/endocrine With moderate to severe hypothermia we may expect to see the following ...............READ SLIDE............. Shivering max at ~35; absent at 87-88.

Quetzaltenango, Guatemala, November 2009

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 READ SLIDE......... Again treatments will vary according to what materials you have available Chest Tubes and foley catheter

Hazardous Materials Exposure Goal: -provide guidelines for scene management -care and transportation of patients contaminated by radiation or hazardous chemicals READ SLIDE.....

Quetzaltenango, Guatemala, November 2009 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 decontamination Read slide . Quetzaltenango, Guatemala, November 2009

Quetzaltenango, Guatemala, November 2009 Additional Rules Don’t be a hero... Always maintain a high index of suspicion Secondary devices Always provide for your own safety first and foremost. Don’t be a hero and don’t over focus on the patient. Always maintain a high index of suspicion when responding to a disaster especially when responding to transportation and occupational scenes. If there is any chemical involvement whether it be a solid, liquid or gas, suspect a Hazmat environment. Quetzaltenango, Guatemala, November 2009

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. Local effects: These symptoms are caused by dermal lesions and irritation to the eyes, ears, nose and throat. Commonly the patient complains of burning skin, teary eyes, dry or sore throat, a cough or sneezing. Systemic effects: The most common systemic effect involves the respiratory system. The patient may complain of difficulty breathing. This is because pulmonary edema frequently occurs with Hazmat inhalation. The next common area affected is the central nervous system. These effects include bizarre behavior, combativeness, drunken stupor, seizures and coma.

Psychological & Social Emergencies Separation Anxiety Child Safety Lack of Communication and Comprehension Skills It is extremely important to remember that in addition to the anxiety due to the disaster a child often suffers increased anxiety if he is separated from his or her parents. If the disaster situation involves both parents and child it is important to keep them as together as possible during triage and treatment. It must also be understood that there are times that this is not possible for various reasons. When possible children should be kept together in an area of least activity. A calm health provider is much more comforting to a child than a loud anxious one. Child safety is an important factor. This is another reason why the children should be kept together in the same area. Designate individuals to provide a safe area for the children to wait and receive health care and support. When assessing the child, the health care must keep these things in mind. - Often a child can’t tell you exactly where he or she hurts. - -- - A child may deny pain due to fear of what you will do. - - a child may not understand you when you ask a question or explain a situation or a procedure to him or her. REMEMBER: SMILE, USE GENTLE TOUCH, REMAIN CALM... Quetzaltenango, Guatemala, November 2009

Quetzaltenango, Guatemala, November 2009 Questions? Quetzaltenango, Guatemala, November 2009