Pediatric Wilderness Medicine Concerns

Wendalyn K Little MD, MPHAssistant Professor of Pediatrics and Emergency Medicine

Emory UniversityChildren’s Healthcare of Atlanta

Quick PSA

Why paperwork and quality improvement is important….

What is wilderness medicine?

• 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, MSAuerbach: Wilderness Medicine, 5th ed2007 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• Injury patterns• Susceptibility to illness• Physiologic response to illness and injury• Psychological /behavioral response • Dependence on caregivers• Medication dosing

Kid SizesAge 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• 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

• 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

• 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)

– Dyspnea at rest– Crackles on lung exam– Worsening Hypoxia– Pink, frothy sputum

• High Altitude Cerebral Edema (HACE)– Confusion, somnolence, ataxia, coma

• Both are Emergencies– 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• 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– 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– 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

– 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– 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– Epinephrine autoinjector– Diphenhydramine– Anti-nausea meds– Antibiotics

• Floroquinalone• Azithromycin

– Oral rehydration salts– Antipyretics /analgesics

– Tetracaine eye drops– Saline eye drops– Eye ointment– Disinfectant solution

• Povidone-iodine• Chlorhexidene

Medical Kids – pediatric considerations

• Appropriate dosing/formulation– Liquids/chewables

• Formula for infants• Diapers• Bulb syringe• Saline drops/spray• Thermometer

Questions?