Page 231 - 2025 Ranger Medic Handbook

ondansetron. Also, provide frequent reassessments of cardiopulmonary status through vitals and AVPU assessments
after giving ketamine or opioids. Intranasal and rectal routes of medication administration are very effective in children.
Transmucosal fentanyl lozenges should not be given to casualties under the age of 16. Have naloxone available for
reversal of opioid medications to manage respiratory depression if it occurs.
Antibiotics: Recommended for all combat wounds. If a child can take oral medication, start with the same adult
guidelines: cephalexin, 25mg/kg orally every 6hr (max 500mg/dose). If IV/IO/IM dosing is necessary, give ceftriaxone,
50–100mg/kg IV/IO/IM, every 24hr (max 2g/dose). Consider ertapenem for all abdominal or polytrauma wounds, where
both aerobic and anaerobic organisms could be the source of infection (< 12 years: 15mg/kg IV/IM every 12hr: > 12 years:
20–40mg/kg IV/IM once).
Burns: Children have smaller airways than adults, making them more susceptible to edema and obstruction from inhala-
tion injuries. Be vigilant for signs of respiratory distress / evidence of burns in the oropharynx, and be prepared for early
airway intervention.
Given their higher body surface to mass ratio, children are more prone to hypothermia and fluid loss from burns. The
estimation of total body surface area (TBSA) differs from that used for adults because of children’s larger heads and
smaller thighs. To estimate burn size, use the Lund and Browder chart, or use the child’s palm and fingers, which equals
1% of their body surface area. Only include partial thickness (or worse) burns in the fluid resuscitation calculation.
Children have a higher fluid requirement per kilogram of body weight than adults. Greater than 10% TBSA of partial
thickness (or worse) burns requires IV fluid resuscitation. If the child is not taking oral fluids well, shows signs of dehydra-
tion, or has other injuries, consider fluid resuscitation and/or maintenance fluids even with smaller burns. Calculate initial
fluid needs based on the Pediatric Parkland formula (3mL × kg × % TBSA burned = total mL in first 24 hr). For children
over 40kg, use “rules of 10s.” Remember that children are especially susceptible to abdominal and respiratory fluid
overload during resuscitation. If an escharotomy is indicated, be aware that children have thinner skin, smaller limbs, and
different body fat distribution than adults. The margin for error is extremely small, especially in infants.
Splinting: Most pediatric fractures are not surgical and will only require splinting or casting. Ensure there is additional
padding to protect bony prominences. SAM splints can be bent into shape, but do not cut them to size as internal
aluminum can cause skin and soft tissue injuries. Pediatric fractures are a risk for compartment syndrome, including
supracondylar and tibial fractures.
Given the emotional immaturity of some children, they will require sedation in addition to pain control during reduction
and splinting. IN/IV fentanyl and midazolam are ideal for simple reductions/procedures. Ketamine is recommended if
reduction is anticipated to take more than 20min or if pain cannot be adequately controlled by other means. Gross
deformity of the elbow often require urgent surgical intervention. Consider hematoma or peripheral nerve blocks as
adjuncts to pain control. SECTION 7
Triage
Communication: Regardless of age and injury, children may feel upset or have strong emotions after an emergency. It
is important to explain the “need to know” information in simple terms, so the child can understand. Sit down or squat
to be at the child’s eye level. Allow time for the child to ask questions and be patient with the child’s responses. Medical
providers should acknowledge the child’s feelings and reassure the child that it is okay to feel their emotions. If possible,
use the parents/caregivers to comfort the child and use visual aids to explain medical concepts. Do not talk down to
the child or make false promises, like stating that an intervention will not hurt if it is likely to cause some degree of pain.
Evacuation: Most existing litter systems are not pediatric-size specific, making safely securing casualties challenging.
Consider using ACE wraps, rolled towels/clothes/medical tape or modified straps to adequately secure children. Before
evacuating a child, consider the medical rules of engagement and the type of facility the child will be relocated to.
Class VIII Considerations and Modifications of Adult Equipment
■ Recommended minimum equipment: 100mL normal saline bags, 10mL normal saline pre-filled syringes, 3mL or
smaller syringes, intranasal mucosal atomizer device.
■ Oral/nasal gastric tubes are required for effective positive-pressure ventilation and can facilitate rehydration and
feeding in severely injured patients (i.e., those with burns).
■ Adult needle decompression devices may be used for pediatric tension pneumothoraces. Adult BVMs may be rotated
180° and used as a full-face mask (with the rounded portion covering the nose/eyes). Remember to only use enough
pressure to generate adequate chest rise, much less than required for an adult.
■ An aluminum malleable splint can be used for pressure points into the femoral triangle and combined with a U.S.
military approved tourniquets as a pelvic binder.

2025 RANGER MEDIC HANDBOOK 217