EMSC Connects
September 2023; Vol.12, Issue 9
Pedi points
Tia Dickson, RN, BSN
Primary Children's Hospital
While kids are heading back to school and respiratory season is on the horizon, the fall still offers us plenty of outdoor opportunities. Wilderness is what draws many of us to this beautiful state and understanding wilderness medicine is a must for first responders. Do you know your pediatric considerations for wilderness medicine?
The Doc Spot
Kids in the woods: pediatric pearls for wilderness first aid
Lindsey Fell, MD
Emergency Medicine at the University of Utah
Excerpts from August 14th PETOS
The most current definition of wilderness medicine is, "Wilderness medicine is medical care delivered in those areas where fixed or transient geographic challenges reduce availability of or alter requirements for, medical or patient movement resources."
Wilderness first aid basics
- Scene survey:
- I'm first
- What happened to you
- Don't get it on me (PPE)
- Are there any more (multiple patients, risk of reoccurrence such as an avalanche)
- Better alive
- Primary survey: MARCH mnemonic
- Secondary survey: SAMPLE mnemonic
- Ongoing assessment: AVPU mnemonic
What makes a child different?
Size and shape
Children are smaller and this can come into play in many wilderness medicine emergencies. For example, a snake will not give a pediatric dose of venom to a child. The dose makes the poison so bites and stings may cause more of an adverse reaction because of the patient's size. A child's larger surface area also makes cold and heat exposure risky for them. Their increased head size can lead to heat loss and affect how children experience trauma.
Respiratory and cardiovascular
Children have higher respiratory and heart rates. They will maintain their blood pressure until they've had 30-40% blood loss. Prevention of hypoxia and hypotension is the highest priority in trauma care.
Thermoregulation
Children are less efficient at thermoregulation. They generate more heat during activity. They have a lower cardiac output so they have a harder time pushing heat from their core and brain to the periphery. They sweat less and they are not as good at cooling themselves as adults. In hypothermia, increased surface area leads to increased heat loss. Infants can't shiver. Less fat means less insulation.
Immunologic and infection
Children have fewer antibodies and narrower parts (airway tube that leads to increased risk for obstruction from swelling and mucus).
Traumatic injuries
Blunt trauma is the leading cause of death in children. The airway is more prone to obstruction. Pliable bones provide less protection for organs. Large heads lead to a greater number of head, brain and neck injuries.
Environmental emergencies
Dehydration
Children are at increased risk because they lose less salt in sweating and don't always report thirst.
- Symptoms:
- Irritability, loss of appetite
- Weakness, fatigue, nausea, vomiting, lethargy
- Treatment:
- If you'll be out less than 2 hours, water is fine for rehydration. For longer trips consider carrying electrolyte solutions.
Hypothermia
- Symptoms:
- Mild—shivering, tachycardia, loss of coordination
- Moderate—loss of shivering, ataxia, confusion
- Severe—hemodynamic instability, dilated pupils
- Treatment:
- Limit cooling
- Normothermia cuddling
- Warm water bottles
- Warm oral rehydration
- If severe, evacuate and handle gently
- Prevention:
- Layered clothing
- Keep dry
Frostbite
Wet skin, constricting garments, fatigue, and dehydration all lead to a greater occurrence of frostbite in cold environments.
- It can be superficial vs. deep
- Growth plates are at risk and should be a consideration in the affected extremity
- Treatment:
- Treat hypothermia if present
- Warm water immersion
- Wound care
- Evacuation
- Avoid refreezing which can cause more damage
- Avoid vigorous rubbing
Hyperthermia
Kids generate more heat when they exercise and have impaired heat dispersion
- Symptoms:
- Flushing, tachycardia
- Weakness, lethargy, confusion
- Nausea, vomiting
- They may or may not sweat
- Treatment:
- Remove from heat source
- Remove excess clothing
- Encourage convective cooling
- Ice packs
- Cool-water immersion (control head position)
- Correct dehydration
- Prevention:
- Hydrate before/during
- For infants, provide extra water and dilute feedings or cow's milk
- Encourage shady activities
Sun damage
Sunburn, skin cancer, and photoallergic reactions are at higher risk for children who have less melanin and thinner skin.
- Treatment:
- Aloe vera, soothing gel
- Avoid further sun exposure
- Prevention:
- Protective clothing
- Sunscreen, especially between 10 a.m. and 4 p.m.
- Good eye protection, especially on water or snow
Drowning
Nationally, drowning is the 2nd leading cause of death and injury for children ages 1-14. More common in unsupervised toddlers and male teenagers.
- Treatment:
- CPR with ventilation as needed
- Rescue breaths
- Protect the C-spine
- Evaluate lung sounds
- Evacuate and re-warm unless this is a cold water drowning and the child is unresponsive. In that case, follow hypothermia protocols
High-altitude illness
This can occur even as tourists travel to Salt Lake City and then head to our mountains. People who have previous episodes of altitude sickness are at risk for recurrence.
- Treatment:
- Recognize it
- Stop ascent, descend
- Rest, Tylenol, and hydration
- Zofran for nausea
- Prevention:
- Make a slow ascent; give them time to acclimate
- "Climb high, sleep low"
Bites and stings
More than 1/3 of bites and stings occur in patients younger than 18 years of age.
- Prevention:
- Protective clothing, tucking pants into socks
- Sturdy footwear
- Chemical barriers (bug spray)
- Education
- For long trips carry 2 epi-pens for anaphylactic reactions
Common medical complaints in the wilderness
Traveler's diarrhea
Any time there is a 2 times increase in unformed stools with or without a fever is cause for concern. Eighty percent of traveler's diarrhea is caused by bacteria. The highest risk is in those who have poor hygiene, oral exploration, and immature immune systems, aka children.
- Treatment:
- Rehydration
- Prevention
- Wash hands
- "Boil it, cook it, peel it, or forget it"
Abdominal pain
Abdominal pain is common in children and can range from benign to life-threatening. Typically in the wilderness, if the pain includes vomiting or diarrhea you are safe to observe them for 12 hours with good hydration. If they have urinary symptoms you can observe and treat them for 2-3 days but you want to evacuate if:
- Worsening/failure to resolve
- Focal pain
- High fever
- if they are pregnant or might be pregnant
Dental infections
- Symptoms:
- Tooth pain
- Sinus tenderness
- Visible abscess or rotten teeth
- Treatment:
- Analgesia (Tylenol and Motrin)
- Antibiotics (Amoxicillin)
- Evacuate for medical treatment
Rash
Contact dermatitis is common in the wilderness. It is typically caused by an oil.
- Treatment:
- Rinse the skin
- Wash with Dawn dish soap, if possible
- Remove clothing and wash it
- Don't scratch the rash. Leave the blisters in place
- Short, lukewarm baths
- Calamine lotion
- Cold compresses
Poisoning
Plants, flowers, mushrooms, and medications all can be found in the wilderness. Prevention is key because we likely won't have antidotes or poison control resources in the wild. Suspect this if "weird" symptoms occur.
Common traumatic injuries in the backcountry
Animal bites
Teach kids not to feed the animals!
- Treatment:
- Copious irrigation
- Typically no skin closure
- Antibiotics if available
Lacerations
Lacerations are a common pediatric occurrence.
- Treatment
- Irrigation (purified drinking water is fine)
- Ensure no foreign bodies, remove with tweezers
- Leave the wound open in the backcountry, cover with a clean dressing
- If it's over a joint, splint the joint to prevent movement
Chronic medical conditions in foreign environments
Asthma
- Minimize known triggers
- Be sure asthma is well-controlled before you embark on a trip
- Bring extra inhalers, high-dose asteroids
- If there is a history of intubation, carry Epinephrine
Diabetes
- Assume no medical supplies will be available (bring it all)
- Bring a spare glucometer
- Encourage hydration
- Carry glucose tablets and bring food you know they will eat
- Increased activity will lead to insulin dose changes
- They will be at a greater infection risk
Sickle cell
- Prevent crisis
- Good hydration and hygiene
- Avoid high-altitude travel
- Any fever or infectious symptoms warrant emergency evacuation
Epilepsy
- Seizure should be under control for 3-6 months prior to the trip
- Carry sufficient anti-epileptic medications
- Bring rectal rescue meds (diazepam)
- Evacuation for any trauma/illness, prolonged seizure activity, or recurrent seizures
The 10 essentials for a wilderness kit
Packing the “10 Essentials” whenever you step into the backcountry, even on day hikes, is a good habit. True, on a routine trip you may use only a few of them or none at all. It’s when something goes awry that you’ll truly appreciate the value of carrying these items that could be essential to your survival.
The original 10 Essentials list was assembled in the 1930s by The Mountaineers, a Seattle-based organization for climbers and outdoor adventurers, to help people be prepared for emergency situations in the outdoors. Back then, the list included a map, compass, sunglasses and sunscreen, extra clothing, headlamp/flashlight, first-aid supplies, fire starter, matches, knife, and extra food.
Over the years, the list has evolved to a “systems” approach rather than including individual items. Here’s what it looks like today:
- Navigation: Map, compass, altimeter, GPS device, personal locator beacon (PLB) or satellite messenger
- Headlamp: or other light with extra batteries
- Sun protection: sunglasses, sun protective clothes, and sunscreen
- First aid: Include foot care and insect repellent
- Knife: Plus a gear repair kit
- Fire: Matches, lighter, tinder, and/or stove
- Shelter: Carried at all times
- Extra food: Beyond the minimum expectations
- Extra water: Beyond the minimum expectations
- Extra clothes: Beyond the minimum expectations
Protocols in practice—general trauma
CME credit for this issue
Training officers may review the topic above as a team training AND perform a simulation/skills check as directed here. Once complete, send a roster of participants to Utah.PETOS@gmail.com and those listed will be issued 1 hour of CME credit from the DHHS Office of EMS and Preparedness.
Simulation training
News from national EMSC
Cold and flu season is nearly here! Help prevent a pediatric respiratory surge by spreading the word about the importance of vaccines. Access CDC resources.
EMSC Pulse
National EMSC has a newsletter filled with fantastic pediatric information, resources, and links. Check it out!
News from Utah EMSC
Seasonal safety
We can unite to prevent suicide. By knowing what to look for and being familiar with resources, we can help each other live the healthiest—and longest—lives possible. Learn the warning signs and how you can volunteer for Suicide Prevention Month.
Read more
Also
- Suicide and Self-Harm Prevention Change Package
- State Technical Assistance Webinar 19: Cultural Approaches to Child and Adolescent Suicide Prevention and Postvention
- Culturally Relevant Approaches to Preventing Suicide Among American Indian and Alaska Native Youth Webinar
- Firearm Safety: Preventing Death by Suicide Infographic
- Suicide Prevention Fact Sheet: Means of Suicide
- Addressing Mental Health Among Youth to Reduce Suicide Risk Blog Post
- Preventing Suicide and Self-Harm Among Black Youth Webinar
- Screening Youth for Suicide Risk Webinar
Autism awareness trainings (for agencies and hospitals)
We are excited to introduce the John Wilson autism kits that will be made available during our autism trainings. The training and kits are free to you. These kits can be stocked in the ambulance to enhance your care of neuro-divergent children.
Contact Jeff Wilson jeffwilson122615@gmail.com to set up a training.
The Medical Home Portal is a unique source of reliable information about children and youth with special health care needs (CYSHCN), offering a “one-stop shop” for their:
· Families
· Physicians and Medical Home teams
· Other Professionals and Caregivers
PECC development
For Utah hospital and EMS agency PECCs
Introducing the 2023 Pediatric Prehospital Guideline (Moderate/Severe Traumatic Brain Injury)
Research has shown that we can improve outcomes for patients who have a traumatic brain injury (TBI), especially in the prehospital setting. First, we must understand the importance of managing ventilation and blood pressure. "A single saturation <90% or an episode of hypotension is associated with a 2x mortality for severe TBI patients." PECCs, look at this guideline and find ways to incorporate it into your agency and hospital protocols. This will be available on the UPTN website soon.
Our Northern PECC workshop
The Northern PECC workshop was held in Salt Lake City on September 1, 2023 and we had a blast! There were great presentations, hands-on learning opportunities, good discussion, and lots of food and swag. We hope you will join us for the next one in St. George in March 2024.
Pediatric readiness
For EMS agencies: Three Ways to Improve your EMS Agency’s Pediatric Readiness.
For hospitals: The EIIC is excited to announce that the National Pediatric Readiness Project (NPRP) Toolkit for EDs has a new look. Sections are organized to align with the joint policy statement and NPRP Checklist resources. In the next few months, an in-depth review of evidence-based practices will begin to further update the toolkit.
Upcoming PECC events
PECC quarterly meeting
You will receive an invitation with the link through email. If you are a PECC and don't receive this invitation contact our program manager, Jared Wright jaredwright@utah.gov.
Tuesday, Nov 21, 2023, 10:00 AM
Southern PECC workshop
PECCs are encouraged to attend an in-person PECC workshop yearly to receive up-to-date pediatric training, direction for your PECC role, and to participate in networking with other PECCs statewide. These workshops are free to designated hospital and agency PECCs. We will offer 1 in the northern part of Utah and 1 in the southern part each year on next planned workshop is March 15, 2024 in St. George Utah.
Friday, Mar 15, 2024, 08:00 AM
St. George, UT, USA
Pediatric Education from Utah EMSC
Pediatric Emergency Trauma Outreach series (PETOS)
PETOS (pediatric emergency and trauma outreach series)
This course provides 1 free CME credit from the DHHS Office of Emergency Medical Services for EMTs and paramedics. The lectures are presented by physicians and pediatric experts from Primary Children’s Hospital. The format is informal; inviting questions and discussion.
Join us on Zoom each second Monday at 02:00 PM Mountain Time (US and Canada)
Archived presentations can be viewed and also qualify for CME credits. You can access them at https://intermountainhealthcare.org/primary-childrens/classes-events/petos.
To obtain a completion certificate
- For live virtual participants: to receive a certificate of completion for attendance be sure to include your email address when the host requests it in the chat during the live presentation. Certificates are e-mailed out after verification of attendance and processing.
- For archived viewing: after viewing archived presentations (link above) e-mail utah.petos@gmail.com with the date and title of presentation viewed. You will receive a 3 question quiz to verify participation. Once the quiz is returned, certificates are e-mailed out.
We try to have certificates out within a week but will occasionally have delays.
Monday, Oct 9, 2023, 02:00 PM
PEPP classes
Looking for a PEPP class?
Pediatric education for the prehospital provider
Register online at www.peppsite.com. Look up classes in Utah and find the 1 that works for you. Once you find the class, go to jblearning.com, and look up pepp als in the search tool. Purchase the number ($21.95). Return to peppsite.org to register for the class and follow the prompts.
If you have any questions, email Erik Andersen at erikandersen@utah.gov or text/call 435-597-7098. Continue to watch the website for additional classes.
Other pediatric education
University of Utah injury prevention learning series
Univeristy of Utah trauma/injury prevention learning series
September 19, 2023 11:30 AM, October 17, 2023 11:30 AM, November 21, 2023 11:30 AM, December 19, 2023 11:30 AM
To view previous sessions for all these series visit this link.
Tuesday, Sep 19, 2023, 11:30 AM
University of Utah Pediatrics ECHO 2023
University of Utah Pediatric ECHO
The Pediatrics ECHO fall series is in progress and registration is open. For those new to Pediatrics ECHO, you can earn CME for participating in a case-based learning session with experts in a variety of pediatric topics.
9/13/23 Obsessive Compulsive Disorder (OCD)
9/20/23 Utah Outdoor Sports Injuries
10/4/23 Postural-orthostatic tachycardia syndrome (POTS)
10/11/23 Unique Equipment for Unique Individuals - Shriners Children's Journey with Conjoined Twins Halloween Wheelchair Costume Clinic - a Need in Disguise for our Young Clients
You can view previous session recordings and other programs on the Project ECHO page. CME is available for participating in these classes.
Wednesday, Sep 13, 2023, 11:30 AM
EMS-focused education
2023 Intermountain Health EMS Conference
University of Utah's EMS grand rounds
University of Utah's EMS grand rounds (Offered every 2nd Wednesday of even months)
Wednesday, Oct 11, 2023, 08:00 AM
Utah Trauma Network conference
Annual Utah trauma network
The Utah Trauma Network (UTN) was created in 2003 when trauma leaders from AirMed, Lifeflight, LDS Hospital, Ogden Regional Medical Center, Primary Children’s Medical Center, University of Utah Medical Center, and the DHHS Bureau of Emergency Medical Services saw a collaborative opportunity to provide advanced trauma education to health care providers throughout Utah. What was our primary goal? To save lives.
Friday, Sep 29, 2023, 07:00 AM
Hospital-focused pediatric education
Primary Children's pediatric grand rounds
Primary Children's pediatric grand rounds (offered every Thursday, September-May)
The pediatric grand rounds weekly lecture series covers cutting-edge research and practical clinical applications, for hospital and community-based pediatricians, registered nurses, and other physicians and practitioners who care for children of any age.
The series is held every Thursday, 8 a.m. to 9 a.m. from September through May in the 3rd Floor Auditorium at Primary Children's Hospital. The lectures are also broadcast live to locations throughout Utah and nationwide.
Connect live
Click here for the PGR PCH YouTube channel to find the live broadcast. Archives (without continuing education credit) will be posted here within 1 week of the broadcast.
Thursday, Sep 14, 2023, 08:00 AM
Save the date
Need follow up from PCH?
Emergency Medical Services for Children Utah, Office of EMS and Preparedness
The Emergency Medical Services for Children (EMSC) Program aims to ensure emergency medical care for the ill and injured child or adolescent is well integrated into an emergency medical service system. We work to ensure the system is backed by optimal resources and that the entire spectrum of emergency services (prevention, acute care, and rehabilitation) is provided to children and adolescents, regardless of where they live, attend school, or travel.
Email: tdickson@utah.gov
Website: https://bemsp.utah.gov/
Phone: 801-707-3763
Facebook: facebook.com/Chirp-UtahDepartmentofHealth