Page 73 - Journal of Special Operations Medicine - Spring 2017

IV access in pediatric patients. Interosseous (IO) access even in comfortable ambient temperatures. The key to
is an easily performed procedure that requires minimal prehospital management of the pediatric patient is to
education and should be considered first line in a hypo- optimize their airway, breathing, and circulation with
volemic pediatric patient. Pediatric IO insertion requires minimal interventions and to arrange swift and safe
the same technique as adult IO insertion, so the skills transport to the forward surgical team or CSH for de-
learned for adults are applicable to the pediatric popula- finitive treatments.
tion, with only minor modifications. The preferred sites
of insertion are the same as in adult patients and include Common Combat Pediatric Injury Patterns
the proximal tibia 2cm inferior to the tibial tuberosity, and Management
the distal tibia, the proximal humerus, and last, the ster- During OIF and OEF, known causes of injuries were
num. Care should be taken to ensure adequate spacing generally due to high-energy mechanisms like explo-
from the end of the bone and to aim the needle slightly sions, gunshot wounds, and motor vehicle accidents.
1,2
away from the joint to minimize the risk of injury to Borgman et al. reported that mechanisms of injury in
1
the growth plate of the bone. Anatomic and equipment pediatric patients admitted to the intensive care unit
factors cause an increased risk for injury to the pediatric were blast (37%), penetrating (27%), blunt (23%), and
lungs and mediastinum with the sternal approach and burns (13%). Common injury patterns described include
make that location a less desirable insertion site. lower extremity injuries, head injuries, upper extrem-
ity injuries, burns, abdominal wounds, face/head/neck
Additional considerations for prehospital management wounds, chest wounds, ophthalmic injuries, spinal in-
of the pediatric trauma patient include cervical spine juries, vascular injuries, and airway injuries (Table 2). 1,2
immobilization, exposure, and temperature regulation.
When preparing for transport, one should maintain an Table 2 Pediatric Mechanism of Injury Comparison for OEF
anatomically neutral alignment of the spinal cord and and OIF
airway that should also be tailored to the patient. Com- Mechanism of Injury OIF, % OEF, %
mercially available cervical collars may not accurately Blast 40 35
maintain positioning and they may interfere with air- Blunt 29 17
way patency. In addition, and most medic bags are not
stocked with properly sized pediatric cervical collars. Burn 10 14
When necessary, use towels, a SAM splint (SAM Medi- Penetrating 23 33
cal Inc.; http://www.sammedical.com/), and/or sheets OEF, Operation Enduring Freedom; OIF, Operation Iraqi Freedom.
for cervical stabilization, recognizing that each child Source: Borgman et al. 2
will need varying amounts of padding to maintain neu-
tral position. Padding goes under the torso, not just un- In general, these injury patterns do require major de-
der the shoulders and/or neck (Figure 2). viations in management when compared with the adult
patient. However, adult medication and fluid-dosage
Figure 2 Neck position without and with torso padding. recommendations are not appropriate for the pediatric
patient. Medications and fluids require weight-based
dosing. Several commercially available reference tapes
exist for a quick, simplified approach to pediatric resusci-
tation (Figure 3). When resuscitation tapes are not avail-
able, standard resuscitation rules are as follows. Fluid
should be administered as a 10–20mL/kg bolus; this
bolus may be repeated and maintenance fluids should
be started immediately thereafter. A simple calculation
for maintenance fluids is: 4mL/kg/h for the first 10kg
plus 2mL/kg/h for the next 10kg plus 1mL/kg/h for all
kilograms greater than 20kg. When blood products are
necessary, they are administered in the following quanti-
ties: packed red blood cells, 10–20mL/kg; fresh frozen
Once the patient’s spinal cord is stabilized, remove debris plasma, 10–20mL/kg; platelets, 10mL/kg; cryoprecipi-
like shrapnel or clothing fragments that may be a source tate, 0.2–0.3units/kg; and factor VIII, 25units/kg.
of obstruction, suffocation, or burn injury. It is impor-
tant to leave impaled debris in place because it may be TXA should be considered in patients with persistent
tamponading an unseen source of significant bleeding. hemorrhage. Currently, there are no guidelines on ap-
Once concerning debris is removed, apply blankets and propriate dosing, but recent literature suggests that the
warming sheets to the patient; hypothermia can occur adult dosing regimen of a 1g bolus with the potential

Pediatric Trauma in an Austere Environment 51