View
217
Download
1
Tags:
Embed Size (px)
Citation preview
Pediatric Disaster Life Pediatric Disaster Life Support (PDLSSupport (PDLS©)©)::Pediatric Disaster Medicine Pediatric Disaster Medicine
The Fundamentals: Anatomy, Physiology, The Fundamentals: Anatomy, Physiology, Disaster SpecificDisaster Specific
Patters of InjuryPatters of Injury
Body Size and CompositionBody Size and Composition
height and weight increase throughout height and weight increase throughout childhoodchildhood
less protective fat and muscleless protective fat and muscle
large surface area predisposes to large surface area predisposes to hypothermiahypothermia
Anatomic DifferencesAnatomic Differences
The youngest children have relatively larger and The youngest children have relatively larger and heavier headsheavier heads
Relatively larger and less protected abdomensRelatively larger and less protected abdomens- Penetrating injuriesPenetrating injuries
- Primary and secondary impact from objects or blast wavePrimary and secondary impact from objects or blast wave
Predisposition to Predisposition to more seriousmore serious traumatic traumatic damage during disasters compared to adult for damage during disasters compared to adult for the same injurythe same injury
Anatomic DifferencesAnatomic Differences
Smaller mass may cause children to be Smaller mass may cause children to be thrown further and faster, resulting in thrown further and faster, resulting in greater secondary injuries upon impactgreater secondary injuries upon impact
Surface to Body RatioSurface to Body Ratio
Higher surface area and thinner skinHigher surface area and thinner skin
Risk of exposure-related injuriesRisk of exposure-related injuries- BurnsBurns
- Hypothermia after decontaminationHypothermia after decontamination
- Toxic exposure to the skinToxic exposure to the skin
- DehydrationDehydration
Higher Baseline MetabolismHigher Baseline Metabolism
Faster Respiratory RateFaster Respiratory Rate- DehydrationDehydration- Ingestion of toxins, smoke, dustIngestion of toxins, smoke, dust
Lower Blood VolumeLower Blood Volume- Shock from bleedingShock from bleeding- Greater risk from dehydrationGreater risk from dehydration
Greater relative metabolic needsGreater relative metabolic needs- Higher risk for malnutrition sooner than adultsHigher risk for malnutrition sooner than adults- ↑ ↑ susceptibility to hypoglycemia? susceptibility to hypoglycemia?
SizeSize
Live Closer to the FloorLive Closer to the Floor- Risk of exposure to debris and waterRisk of exposure to debris and water
- Greater chance of exposure to chemical or Greater chance of exposure to chemical or radioactive residueradioactive residue
- ExampleExample: : Infant contracts cutaneous anthrax on Infant contracts cutaneous anthrax on arm after visiting ABC television studios targeted arm after visiting ABC television studios targeted during the 2001 attackduring the 2001 attack
SizeSize
Hand-to-Mouth ActivityHand-to-Mouth Activity- Children routinely place hands and objects in Children routinely place hands and objects in
mouth, increasing risk of exposure to chemicals, mouth, increasing risk of exposure to chemicals, toxinstoxins
- Increases risk of contracting vomiting and Increases risk of contracting vomiting and diarrheal illness during unsanitary conditions such diarrheal illness during unsanitary conditions such as in a shelter or with exposure to contaminated as in a shelter or with exposure to contaminated water supplywater supply
Immune SystemsImmune Systems
Young children do not have the same Young children do not have the same capacity as adults to respond to capacity as adults to respond to infectious diseaseinfectious disease- Biological agentsBiological agents
- Routine infections during shelteringRoutine infections during sheltering
How Children DecompensateHow Children Decompensate Differently than adultsDifferently than adults
Children rarely have primary cardiac eventChildren rarely have primary cardiac event
Pathway is predictablePathway is predictable- Focus is on respiratory problems and shockFocus is on respiratory problems and shock
- To know it is to prevent decompensationTo know it is to prevent decompensation
- Recognize early signs and symptoms of respiratory Recognize early signs and symptoms of respiratory distress and shockdistress and shock
Pathway to Decompensation
FULL ARREST
DEATH
RESPIRATORY FAILURE
Respiratory DistressDECOMPENSATED
Respiratory DistressCompensated
CIRCULATORY FAILURE
Circulatory DistressDECOMPENSATED
Circulatory DistressCompensated
Many CausesAsthma, ShockFB, Secretions
Toxins, etc.
Body ProportionsBody Proportions
body proportions account for unique injury body proportions account for unique injury patterns in childhoodpatterns in childhood
large head increases risk of head injury large head increases risk of head injury accompanying any other major traumatic accompanying any other major traumatic injury injury
large, “unprotected” intraabdominal organs large, “unprotected” intraabdominal organs increases risk of liver, spleen, bowel injury increases risk of liver, spleen, bowel injury following less severe trauma following less severe trauma
Etiologies of Cardiopulmonary FailureEtiologies of Cardiopulmonary Failure
Many EtiologiesMany Etiologies
Cardiopulmonary Cardiopulmonary FailureFailure
Respiratory Respiratory FailureFailure
Circulation Failure Circulation Failure (shock)(shock)
Respiratory Distress and FailureRespiratory Distress and Failure
respiratory distress: increased work of respiratory distress: increased work of breathingbreathing
respiratory failure: inadequate respiratory failure: inadequate oxygenation and/or ventilation to meet oxygenation and/or ventilation to meet metabolic needs metabolic needs
Signs of Respiratory Distress and Signs of Respiratory Distress and FailureFailure signs of respiratory distress:signs of respiratory distress:
- tachypnea, tachycardiatachypnea, tachycardia
- retractions (intercostal, supraclavicular, nasal flaring)retractions (intercostal, supraclavicular, nasal flaring)
- gruntinggrunting
signs of respiratory failuresigns of respiratory failure- altered mental statusaltered mental status
- poor colorpoor color
- hypotoniahypotonia
Infant with Increased Infant with Increased Respiratory EffortRespiratory Effort
Note use of intercostal and Note use of intercostal and accessory musclesaccessory muscles
Features of the Pediatric Upper Features of the Pediatric Upper AirwayAirway
large occiputlarge occiput
small mouthsmall mouth
large tonguelarge tongue
anterior and cephalad larynxanterior and cephalad larynx
angled cordsangled cords
large, floppy epiglottis overriding airwaylarge, floppy epiglottis overriding airway
narrow cricoid ringnarrow cricoid ring
Neonatal AirwayNeonatal Airway
Large headLarge head
Small naresSmall nares
Large tongueLarge tongue
High glottisHigh glottis
Overhanging Overhanging epiglottisepiglottis
Angled cordsAngled cords
Narrow cricoid regionNarrow cricoid region
Airway Equipment forAirway Equipment forthe Young Pediatric Patientthe Young Pediatric Patient
straight blade: compresses large straight blade: compresses large tongue and mandibular tissuetongue and mandibular tissue
uncuffed tube in children < 8 yearsuncuffed tube in children < 8 years
tube size = age yearstube size = age years+ 44
(for children over 2 years)
Features of the Pediatric Lower Features of the Pediatric Lower AirwayAirway
short trachea short trachea
narrow caliber of all airway structuresnarrow caliber of all airway structures
chest wall compliance chest wall compliance
lung compliance & elastic recoillung compliance & elastic recoil
diaphragm as a respiratory musclediaphragm as a respiratory muscle
Features ofFeatures ofthe Pediatric Cardiovascular Systemthe Pediatric Cardiovascular System
shock: defined as the clinical state of shock: defined as the clinical state of inadequate perfusion to meet metabolic needsinadequate perfusion to meet metabolic needs
Features ofFeatures ofthe Pediatric Cardiovascular Systemthe Pediatric Cardiovascular System
degree of shock is based on evaluation of the degree of shock is based on evaluation of the end organs of perfusion:end organs of perfusion:
- skin (color, temperature, cap refill)skin (color, temperature, cap refill)
- CNS (developmentally appropriate behavior, CNS (developmentally appropriate behavior, lethargy, anxiety)lethargy, anxiety)
- central central vs.vs. peripheral pulses peripheral pulses
- renal (urine output)renal (urine output)
- Lactate levelsLactate levels
- Central venous pressures & mixed venous satsCentral venous pressures & mixed venous sats
Simultaneous Palpation of Proximal Simultaneous Palpation of Proximal and Distal Pulsesand Distal Pulses
Features ofFeatures ofthe Pediatric Cardiovascular Systemthe Pediatric Cardiovascular System
cardiac output is rate dependent: infants cardiac output is rate dependent: infants cannot increase stroke volume to cannot increase stroke volume to compensate for shockcompensate for shock
smaller total blood volume: 80-100cc/kgsmaller total blood volume: 80-100cc/kg
increased parasympathetic output: increased parasympathetic output: increased vagal toneincreased vagal tone
Hemodynamic Changes with Blood Hemodynamic Changes with Blood LossLoss
Pediatric Vital SignsPediatric Vital Signs
mean heart rate decreases with agemean heart rate decreases with age
tachycardia is an early and nonspecific sign of shocktachycardia is an early and nonspecific sign of shock
mean blood pressure increases with agemean blood pressure increases with age
blood pressure is usually normal even in a child with blood pressure is usually normal even in a child with moderate-severe hypoperfusionmoderate-severe hypoperfusion
increased peripheral vascular tone allows for normal increased peripheral vascular tone allows for normal blood pressure until end-stage shock blood pressure until end-stage shock
vital signs not helpful in gauging degree of shock in vital signs not helpful in gauging degree of shock in childrenchildren
Pediatric Cervical SpinePediatric Cervical Spine
fulcrum is at C2-3fulcrum is at C2-3
growth plate of densgrowth plate of dens
weak neck musclesweak neck muscles
large head increases momentum large head increases momentum
SCIWORA because of ligamentous laxity SCIWORA because of ligamentous laxity
most fractures occur at C1-2 most fractures occur at C1-2
difficulty with immobilization: large head/small chest allow difficulty with immobilization: large head/small chest allow for excessive flexion in supine position for excessive flexion in supine position
Head Injury inHead Injury inthe Young Pediatric Patientthe Young Pediatric Patient
skull is more compliant offers less skull is more compliant offers less protection to the brainprotection to the brain
open sutures and fontanelopen sutures and fontanel
mobile middle meningeal arterymobile middle meningeal artery
intracranial bleeds occur without intracranial bleeds occur without accompanying fractureaccompanying fracture
intracranial bleed can cause shockintracranial bleed can cause shock
Localized Head TraumaLocalized Head Trauma AssessmentAssessment
- historyhistory- vital signsvital signs- local findingslocal findings
Treatment GoalsTreatment Goals- prevent secondary brain damageprevent secondary brain damage- maintain good cerebral perfusion pressuremaintain good cerebral perfusion pressure
TreatmentTreatment- control external bleedingcontrol external bleeding- oxygenate & hyperventilate as neededoxygenate & hyperventilate as needed- fluid resuscitate to maintain adequate perfusionfluid resuscitate to maintain adequate perfusion- keep head in midline position and HOB elevated 30 degreeskeep head in midline position and HOB elevated 30 degrees- control seizures if possiblecontrol seizures if possible
Isolated Spinal TraumaIsolated Spinal Trauma
AssessmentAssessment
- history (mechanism, amount of force)history (mechanism, amount of force)
- vital signsvital signs
- local findings (thorough neuro exam, palpation etc.)local findings (thorough neuro exam, palpation etc.)
Treatment GoalsTreatment Goals
- immobilization of the cervical spine and the childimmobilization of the cervical spine and the child
TreatmentTreatment
- appropriate size hard collar or rolls to immobilize the neckappropriate size hard collar or rolls to immobilize the neck
- back board or modified board with proper restraintsback board or modified board with proper restraints
Features of the Pediatric AbdomenFeatures of the Pediatric Abdomen
thinner abdominal wall with less fat and thinner abdominal wall with less fat and musclemuscle
decreased anterior-posterior diameterdecreased anterior-posterior diameter
large liver and spleen extend below ribslarge liver and spleen extend below ribs
kidney contains less perinephric fatkidney contains less perinephric fat
gastric distention (with ventilation or gastric distention (with ventilation or crying) can present as a tense abdomencrying) can present as a tense abdomen
Isolated Abdominal TraumaIsolated Abdominal Trauma
AssessmentAssessment
- historyhistory
- vital signsvital signs
- local findingslocal findings
Goal of TreatmentGoal of Treatment
- early assessment and prevention of complicationsearly assessment and prevention of complications
TreatmentTreatment
- monitor ventilatory status and assist when necessarymonitor ventilatory status and assist when necessary
- decompress abdomendecompress abdomen
Soft Tissue InjuriesSoft Tissue Injuries
AssessmentAssessment- visual and palpation examvisual and palpation exam
- vital signsvital signs
Treatment GoalsTreatment Goals- prevention of complicationsprevention of complications
TreatmentTreatment- close monitoring of oxygenationclose monitoring of oxygenation
- maintenance of adequate ventilation with assist if neededmaintenance of adequate ventilation with assist if needed
- oxygen delivery as neededoxygen delivery as needed
- restore intravascular volume if needed for excessive blood restore intravascular volume if needed for excessive blood lossloss
Skeletal SystemSkeletal System
Fractures seen exclusively in children:Fractures seen exclusively in children:
- growth plate (Salter Harris) fracture growth plate (Salter Harris) fracture
- torus fracturestorus fractures
- bowing fracturesbowing fractures
- greenstick fracture greenstick fracture
Skeletal SystemSkeletal System
physis is site of growth physis is site of growth
physis is the weakest part of bonephysis is the weakest part of bone
physis is composed of cartilage and physis is composed of cartilage and separates epiphysis from metaphysisseparates epiphysis from metaphysis
fractures of the physis are described by fractures of the physis are described by the Salter Harris Classificationthe Salter Harris Classification
Musculoskeletal InjuriesMusculoskeletal Injuries
AssessmentAssessment- history (mechanism, force)history (mechanism, force)- vital signs (peripheral perfusion)vital signs (peripheral perfusion)- local findings (discoloration, deformity etc.)local findings (discoloration, deformity etc.)
Goal of TreatmentGoal of Treatment- prevention of complicationsprevention of complications- minimize discomfortminimize discomfort
TreatmentTreatment- ice, elevation, immobilizationice, elevation, immobilization- frequent evaluation of peripheral vascular perfusionfrequent evaluation of peripheral vascular perfusion- reassess neuromuscular functionreassess neuromuscular function
Environmental EmergenciesEnvironmental Emergencies
Burns and Thermal InjuriesBurns and Thermal Injuries
Smoke and Inhalation Injuries Smoke and Inhalation Injuries
HyperthermiaHyperthermia
HypothermiaHypothermia
Burns & Thermal InjuriesBurns & Thermal Injuries
Airway..Breathing..CirculationAirway..Breathing..Circulation
AssessmentAssessment
Fluid TherapyFluid Therapy
Care of the Burn WoundCare of the Burn Wound
Pain ManagementPain Management
Parkland FormulaParkland Formula
- 4 ml/kg/%BSA of crystalloid over the first 24 4 ml/kg/%BSA of crystalloid over the first 24 hours.hours.
- Half during the first 8 hours and half over the Half during the first 8 hours and half over the next 16 hoursnext 16 hours
Fluid Therapy for the Burn VictimFluid Therapy for the Burn Victim
Rule of ThumbRule of Thumb
Children should produce 1 ml/kg/hr of urineChildren should produce 1 ml/kg/hr of urine .. .. ..
Care of the Burn WoundCare of the Burn Wound
Goals Goals - promote rapid healing, prevent infectionpromote rapid healing, prevent infection
CleanseCleanse
- using large volumes of lukewarm sterile salineusing large volumes of lukewarm sterile saline
CoverCover- with loose, clean, preferably sterile dressings or with loose, clean, preferably sterile dressings or
sheetssheets
Pain Management for Burn VictimPain Management for Burn Victim
Covering burn from moving airCovering burn from moving air
Analgesic medicationsAnalgesic medications
Drug of ChoiceDrug of Choice
- Morphine 0.1-0.5 mg/kgMorphine 0.1-0.5 mg/kg
Smoke & Inhalation InjuriesSmoke & Inhalation Injuries
AssessmentAssessment
- Clinical ManifestationsClinical Manifestations
TreatmentTreatment
Hints of Smoke InhalationHints of Smoke Inhalation
Exam may show:Exam may show:- facial burnsfacial burns
- singed nasal hairssinged nasal hairs
- soot in pharynxsoot in pharynx
- mental confusionmental confusion
Tachypnea, cough or stridor may or may Tachypnea, cough or stridor may or may not be present.not be present.
Treatment of Smoke Treatment of Smoke InhalationInhalation
Remove from contaminated environmentRemove from contaminated environment
CPR as neededCPR as needed
Provide 100% supplemental oxygenProvide 100% supplemental oxygen
Ensure patent airway…..ABC’sEnsure patent airway…..ABC’s
Intubate earlyIntubate early
HyperthermiaHyperthermia
Assessment & ExamAssessment & Exam
Heat exhaustionHeat exhaustion- T <41C, dry or wet skin, lethargy, thirst, T <41C, dry or wet skin, lethargy, thirst,
headache, increased heart rateheadache, increased heart rate
Heat stroke Heat stroke - T > 41C, hot skin, severe CNS dysfunction, T > 41C, hot skin, severe CNS dysfunction,
circulatory collapsecirculatory collapse
Treatment of HyperthermiaTreatment of Hyperthermia
Remove clothingRemove clothing
Begin active coolingBegin active cooling
Transport to cool environmentTransport to cool environment
Cardiovascular supportCardiovascular support
Fluid Resuscitation: 20 mg/kg Fluid Resuscitation: 20 mg/kg lactated Ringers or 0.9% sodium lactated Ringers or 0.9% sodium chloridechloride
HypothermiaHypothermia
Assessment & ExamAssessment & Exam
Internal vs. External EtiologiesInternal vs. External Etiologies
Pale or cyanoticPale or cyanotic
Shivering mechanismShivering mechanism
CNS function progressively impaired with CNS function progressively impaired with falling temp. Comatose at approx 27 C.falling temp. Comatose at approx 27 C.
Decreased BP, heart rate, or bothDecreased BP, heart rate, or both
Treatment for HypothermiaTreatment for Hypothermia
Mild [32-35C/89.6-95F]Mild [32-35C/89.6-95F] Passive External Rewarming Passive External Rewarming
• Warm environment, dry clothesWarm environment, dry clothes
Moderate [28-32C/82.4-89.6F]Moderate [28-32C/82.4-89.6F] Active External RewarmingActive External Rewarming
• Bair Hugger, radiant sources, warm water bottlesBair Hugger, radiant sources, warm water bottles
Severe [<28C/<82.4F]Severe [<28C/<82.4F] Active Core RewarmingActive Core Rewarming
• Warm peritoneal lavage, nasogastric lavage, IV fluids, thoracotomiesWarm peritoneal lavage, nasogastric lavage, IV fluids, thoracotomies• Extracorporeal Blood Rewarming – Cardiopulmonary bypassExtracorporeal Blood Rewarming – Cardiopulmonary bypass
Hazardous Materials ExposureHazardous Materials Exposure
Goal:Goal:
to provide guidelines for scene to provide guidelines for scene management , care and management , care and transportation of patients transportation of patients contaminated by radiation or contaminated by radiation or hazardous chemicalshazardous chemicals
General InstructionsGeneral Instructions
Upon discovery of Hazmat scene, notify Upon discovery of Hazmat scene, notify communication center to dispatch Hazmat expertcommunication center to dispatch Hazmat expert
Delay entry until appropriate team and protective Delay entry until appropriate team and protective equipment is availableequipment is available
Expect the Hazmat team to initially remove any Expect the Hazmat team to initially remove any patientspatients
Follow advice of Hazmat team regarding personal Follow advice of Hazmat team regarding personal protection or patient decontaminationprotection or patient decontamination
Additional RulesAdditional Rules
Don’t be a hero...Don’t be a hero...
Always maintain a high index of suspicionAlways maintain a high index of suspicion- Secondary devicesSecondary devices
General Signs and Symptoms of General Signs and Symptoms of Hazmat ExposureHazmat Exposure
Local EffectsLocal Effects-complaints of burning skin, teary eyes, complaints of burning skin, teary eyes,
dry or sore throat, a cough or sneezing.dry or sore throat, a cough or sneezing.
Systemic EffectsSystemic Effects-complaints of difficulty breathing, bizarre complaints of difficulty breathing, bizarre
behavior, stupor, seizures, coma.behavior, stupor, seizures, coma.
Psychological & Social EmergenciesPsychological & Social Emergencies
Separation AnxietySeparation Anxiety
Child SafetyChild Safety
Lack of Communication and Lack of Communication and Comprehension SkillsComprehension Skills