1. 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
Patters of Injury

2. Body Size and Composition
height and weight increase throughout childhood
less protective fat and muscle
large surface area predisposes to hypothermia

3. 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

5. Anatomic Differences
Smaller mass may cause children to be thrown further and faster, resulting in greater secondary injuries upon impact

6. 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

7. 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?

8. 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

9. 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

10. 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

11. 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

12. 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

14. 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

15. Etiologies of Cardiopulmonary Failure
Many Etiologies
Respiratory Failure
Circulation Failure (shock)
Cardiopulmonary Failure

16. Respiratory Distress and Failure
respiratory distress: increased work of breathing
respiratory failure: inadequate oxygenation and/or ventilation to meet metabolic needs

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

18. Infant with Increased Respiratory Effort
Note use of intercostal and accessory muscles

19. 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

20. Neonatal Airway Large head Small nares Large tongue High glottis
Overhanging epiglottis
Angled cords
Narrow cricoid region

22. 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
Discuss other issues regarding airway and ventilation management. Broselow Tape
Managing several children with airway +/- ventilation problems – tricks of the trade.
(for children over 2 years)

23. 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

28. Features of the Pediatric Cardiovascular System
shock: defined as the clinical state of inadequate perfusion to meet metabolic needs

29. 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

30. Simultaneous Palpation of Proximal and Distal Pulses
Universal precautions

31. Features of the Pediatric Cardiovascular System
cardiac output is rate dependent: infants cannot increase stroke volume to compensate for shock
smaller total blood volume: cc/kg
increased parasympathetic output: increased vagal tone

32. Hemodynamic Changes with Blood Loss

33. 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

34. 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

37. 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

38. Localized Head Trauma Assessment Treatment Goals Treatment 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

39. 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. The examiner should palpate for crepitus, unequal carotid pulses, expanding hematomas, and cervical spine tenderness. A thorough neurological exam with emphasis on spinal cord disruption is a must...
Once again if a penetrating injury is noticed and there are protruding objects, They should always be left in place.
When either the 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 or sandbags This procedure is extremely frightening to children and therefore close observation and lots of emotional support is needed..

40. 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

42. 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.
Most injuries that penetrate the peritoneum cause visceral damage and often require surgery. In the disaster situation treatment is limited. Close monitoring and prevention of complications resulting from the injury are the main treatment goals. Example: Often times when there is abdominal trauma there is also abdominal distension which could cause respiratory distress. This can often be relieved by decompressing the abdomen with a naso-gastric tube. ventilatory assistance may also be necessary.

43. Soft Tissue Injuries Assessment Treatment Goals Treatment
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
The main objective with soft tissue injuries is to assess the injury and to prevent complications. These complications include inadequate vascular perfusion due do blood loss, or excessive swelling. Direct pressure for bleeding control as well as ice and elevation for reduction of swelling are simple practices that can help reduce some of these complications .

44. Skeletal System Fractures seen exclusively in children:
growth plate (Salter Harris) fracture
torus fractures
bowing fractures
greenstick fracture

48. 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

50. 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
Children with mild nonpenetrating injuries often require an x-ray to detect an underlying fracture. With moderate to severe injuries the 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. It is important with all extremity injuries to check peripheral pulses in order to assess peripheral perfusion. Penetrating injuries to the extremities can be complicated by contamination and excessive bleeding. These complications can be minimized with 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.

51. Environmental Emergencies
Burns and Thermal Injuries
Smoke and Inhalation Injuries
Hyperthermia
Hypothermia
READ SLIDE

52. 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.

53. 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.

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

55. 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.

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

57. 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 ?

58. 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

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

60. Hyperthermia Assessment & Exam Heat exhaustion Heat stroke
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,

62. 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

63. 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

65. Treatment for Hypothermia
Mild [32-35C/ F]
Passive External Rewarming
Warm environment, dry clothes
Moderate [28-32C/ F]
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

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

67. 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 .

68. 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.

69. 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.

70. 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...