Page 74 - Journal of Special Operations Medicine - Spring 2017

Figure 3 Braslow pediatric tape. Figure 4 Pediatric burn percentages.

TCCC guidelines for mild pain include acetaminophen
and meloxicam, and are consistent with the American
College of Emergency Physicians recommendations for
for a second infusion decreased mortality in 10% of the management of mild to moderate pain in the pedi-
9
receiving patients. Data from the CRASH-2 (Clini- atric patient. For severe pain, IV, intramuscular, or in-
cal Randomization of an Antifibrinolytic in Significant tranasal routes are preferred. Intranasal administration
Hemorrhage-2) trial suggest the possibility of increased is easy, quick, and has been shown to be efficacious in
16
mortality from bleeding in adult patients when TXA treating pediatric pain. Intranasal administration via
was administered after 3 hours of initial injury. Be- an atomizer also allows for the use of fentanyl in mod-
14
cause there is wide practice variation and potential for erate to severe pain. Last, for patients in severe pain,
increased mortality with delayed use, recommendations TCCC guidelines recommend the use of intramuscular
for TXA use in pediatric patients should be obtained ketamine. Ketamine is well studied in the pediatric pop-
from the medical command before use. ulation, has minimal adverse effects, and is an excellent
agent for pain control.
In patients with suspected increased intracranial pres-
sures from TBI, hypertonic saline (3%) and mannitol are Per TCCC guidelines, antibiotic recommendations for
acceptable agents for treatment of impending herniation open combat wounds are moxifloxacin, if an oral agent
(posturing, papillary changes, and Cushing response), is tolerated, and cefotetan or ertapenem if patient not
and/or progressive neurologic deterioration. The patient able to take oral medications. Safety and efficacy have
must be assessed for volume status to determine the best not been established for moxifloxacin use in pediat-
agent. If the patient is hypovolemic, hypertonic saline ric patients. Historically, the fluoroquinolone class of
(3%) is administered at 3–5mL/kg given over 30–60 antibiotics has been avoided by providers because of
minutes. In a euvolemic patient, mannitol is an accept- concerns about joint and/or cartilage toxicity in the pe-
able option and is administered as a bolus of 0.5–1g/kg. diatric population. Most of the support for this claim
stems from observational data in juvenile animal studies
Body surface measurements in burn victims should be and it may not be a reasonable concern. To date, there
determined using a pediatric scale because applying the are no formal recommendations specific to the pediatric
adult scale to children will result in inaccurate calcula- patient and there is wide practice variation depending
tions and administration of too much fluid, potentially on the type of injury, managing specialist, and where
resulting in increased mortality (Figure 4). child is being treated. In general, a cephalosporin is a
reasonable and safe option for antibiotic coverage in
Analgesic recommendations provided by the Tactical open fractures.
Combat Casualty Care (TCCC) guidelines are generally
appropriate for children. Exceptions to TCCC rec- Conclusion
15
ommendations are as follows: the use of transmucosal
fentanyl lozenges and/or transbuccal films is not recom- Anatomic features of pediatric patients need to be un-
mended in children 16 years or younger. All medications derstood to provide optimal resuscitation. The airway
must be dosed per weight in kilograms for pediatric pa- of children between 2 and 8 years of age poses a unique
tients (i.e., patients of less than adult size and weight). set of anatomic characteristics; these are predictable,

52 Journal of Special Operations Medicine Volume 17, Edition 1/Spring 2017