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?

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."

• 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

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.

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.

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.

Children have fewer antibodies and narrower parts (airway tube that leads to increased risk for obstruction from swelling and mucus).

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.

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.

• 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

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

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

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

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

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"

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

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 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

• Symptoms:
• Tooth pain
• Sinus tenderness
• Visible abscess or rotten teeth
• Treatment:
• Analgesia (Tylenol and Motrin)
• Antibiotics (Amoxicillin)
• Evacuate for medical treatment

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

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.

Teach kids not to feed the animals!

• Treatment:
• Copious irrigation
• Typically no skin closure
• Antibiotics if available

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

• 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

• 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

• Prevent crisis
• Good hydration and hygiene
• Avoid high-altitude travel
• Any fever or infectious symptoms warrant emergency evacuation

• 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

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

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.

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.

National EMSC has a newsletter filled with fantastic pediatric information, resources, and links. Check it out!

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

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

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.

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.

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.

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.

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