Toddlers to Teens: Medical Emergencies in the Backcountry and Beyond

That was the topic of discussion during last week’s free webinar by Duration Medical, a company like Jase, which provides prescription medications for emergency situations.

Terez Malka, pediatrician and emergency physician, was the doctor sharing info, and while the material is directed to those planning their backcountry trips, it is also applicable to people preparing for challenging times, particularly those who plan to “bug out” to higher altitudes.  I’ll be sharing the most pertinent information—hard copies are always good—however, I highly recommend watching it as well.  What follows are basically my notes of her webinar, a format that differs considerably from my normal posts.

She’s basically talking about the safe care of children in remote and wilderness settings.  And while Dr. Malka raises the question of the wisdom and propriety of allowing children and teens to freely participate in risky behaviors, we may find ourselves in similar situations not of our own volition.  How do the extreme conditions encountered in the backcountry, at high altitudes, affect children differently?  How do we prepare?

Some fast facts about the epidemiology of pediatric wilderness injuries:

• Children comprise 25% of all backpackers and campers in the US
• They account for 7% of all search and rescue operations in the US National Park Service.  Teens account for 14%.
• They sustain more lacerations, insect bites, and allergic reactions than adults.
• They are at greater risk for GI infections, respiratory illnesses, and falls, especially during longer expeditions.

As far as pediatric wilderness deaths (and this is data from Washington state)

• 90% male; 83% teens
• 26% over the age of 10 were accompanied by adults
• 80% of accompanied deaths were drownings of young children while boating or swimming
• Absence of PFD or helmet was predictive
• Only 5% had gear for bad weather

The data show that most of these deaths were preventable.  So supervise children closely and make sure they have appropriate equipment.  Prepare!

Continuing:

• Unintentional injury is leading cause of death in children, wilderness or not.
• Falls are the leading cause of nonfatal injury for children under 15.
• Closed head injury accounts of 80% of pediatric deaths.  Have them wear a helmet.  Prepare!

Now moving onto treatment:

SPRAINS AND FRACTURES

In pre-pubertal children, the bones are kinda rubbery and soft.  They don’t get sprains nearly as often as adults do.  The open growth plate and the developing bones are actually weaker than the surrounding ligaments.  Any focal point tenderness—anything right over the end of a bone—is likely a growth plate injury.  In a child, it’s time to splint and evacuate.  In a teen or adult, it’s probably a sprain and not a cause for concern.

PEDIATRIC HEAD TRAUMA

• If child is behaving normally and there are no obvious signs of skull fracture, consider field observation.
• Weighed against the risks of evacuation, this may be appropriate even if severe injury mechanism, transient loss of consciousness, amnesia to the event, headache or a single episode of vomiting are present.
• Red flags include a persistent change in behavior or level of alertness, repeated vomiting, severe intractable headache, prolonged loss of consciousness (longer than 1-2 minutes), or seizure.
• Outdated:  checking pupil size, keeping patient awake.

An absence of clinical findings reliably excludes unstable cervical spine injuries in children 5 years and younger.

• 2,972 children under 5 in the trauma registry
• All kids with a spine injury had signs of it:  weakness or numbness of an arm or leg, inability to move the neck, or severe neck pain.
• Overall c-spine injury very low (0.74%) and absent in children without symptoms. (This is even including children who fell out of windows or were in major car accidents.)  Basically, even with a significant fall, if a child is awake and has no signs of a spine injury, s/he does not have a spine injury.  If there are no concerning signs, the neck does not need to be immobilized and the child does not need to be evacuated.

A randomized trial on the oral administration of morphine versus ibuprofen to manage fracture pain in children showed no difference in pain reduction and significantly fewer side effects.

ENVIRONMENTAL

• Cold
• Children are much more susceptible to cold
• Undeveloped shivering mechanism
• Less insulation from subcutaneous fat and muscle
• Less ability to seek shelter or dress appropriately/make stupid choices about how to dress for cold weather
• Heat
• Greater metabolic heat production
• Lower cardiac output impairs ability to dissipate heat via the skin
• Less efficient sweating
• Thus more prone to heat and cold injuries
• More likely to get dehydrated
• Sweat is more dilute—greater free water loss
• Greater surface evaporative loss
• Less likely to drink adequately
• Prefer high sugar/hyperosmolar fluids.
• So need to dilute sports drinks or encourage kids to alternate water with sports drink
• For water purification:
• Choose non-iodine water purification for children.  Toxic iodine dose is 2-4 grams.

Infants much more susceptible to water-borne illnesses and dehydration. Breast feed whenever possible.

If mixing formula, use dual sterilization method (filter and boil) and avoid chemical purification.

SUN

• 80% of lifetime sun exposure occurs in childhood
• Risk of melanoma correlates with number of childhood sunburns
• Sunburned skin has impaired vasoconstrictionàincreased risk of frostbite and hypothermia

INSECT PROTECTION

DEET can safely be used in children as young as 2 months of age.  Use 30-35% DEET for older children.  The risk of anything from DEET itself is much less than from the threat of mosquito-borne diseases.  IR3535 is a severe eye irritant, so don’t use it in children.  Picaridin and oil of lemon eucalyptus are less effective and have greater risks of skin irritation.

TRAVELER’S DIARRHEA

When visiting South America or Southeast Asia, or when camping, you may encounter E. coli and fall victim to gastroenteritis.  Adults may take Pepto-Bismol once per day as a prophylactic.  This should not be used in children under 18.  A probiotic with lactobacillus may help prevent diarrhea.

Infants under 6 months should always be treated with antibiotics for diarrhea when traveling in the backcountry, especially in primitive conditions.

• Azithromycin 10 mg/kg once, and then 5 mg/kg per day for 5 days.

For all people, treat diarrhea that is interfering with the trip with antibiotics. 

HIGH ALTITUDE SICKNESS

Dr. Malka then moved on to high altitude sickness.  She shared the following criteria for determining the extent of high altitude sickness. 

The Lake Louise Score is a very subjective scale.  These are hallmark symptoms.  A score of 10 or over is severe and puts the person at risk for developing more serious forms of altitude sickness.

• Headache (0-3)  
• GI symptoms (0-3)
• Fatigue/weakness (0-3)
• Dizziness (0-3)
• Insomnia (0-3)

The children’s Lake Louise Score is even more subjective.

• Pediatric symptom score
• Appetite (0-3)
• Playfulness (0-3)
• Sleep (0-3)
• Fussiness
• Fussiness score (0-6) 
• Intensity of fussiness (0-6) 

Total score of 7 for first group or 4 for second group indicates high altitude sickness.

Using those scales, 92-100% of babies, 50% of teens, and 23% of adults will develop high altitude sickness. (Defined here as altitudes over 8000 feet.)

The risk is elevated with a viral illness like a cold.

Oxygen levels in children under 4 years dropped to 70-80%, which is probably ok, but definitely not ok if the child already has an upper respiratory infection.  Teens 78-85%.  Adults 81-88%.

Young children/infants at high altitude will display a significant increase in periodic breathing, apneic spells, and low oxygen levels.  Viral infections predispose the young to high altitude pulmonary edema and possibly acute mountain sickness.  High altitude cerebral edema incidence and risk factors in children are unknown.  Acute mountain sickness incidence is higher in children than adults, and they are more prone to low oxygen levels.  Acetazolamide/Diamox dosing is 2.5 mg/kg/day in divided doses.  Side effects are tingling sensations to fingers, toes, face.  Acetazolamide causes carbonated drinks to taste bad. 

PUBERTY, GROWTH, ALTITUDE, AND EXTREME SPORTS

• Menstrual hormone patterns change with altitude exposure
• Pre-pubertal athletes consuming inadequate calories, iron, calcium, and/or protein are at high risk of puberty delay, osteoporosis, and long-term growth delay
• Children and teens are at higher risk of overuse injuries and growth plate damage
• Carrying a backpack of more than 10-20% of body weight can lead to brachial plexus damage, scoliosis, kyphosis, and potential loss of disc height
• Mortality rates increase 200% during adolescence
• Decision making – risk tolerance
• Developing brain.  Immature prefrontal cortex. Not developed until age 25 in men.
• Sudden decrease in dopamine receptors.  Less dopamine as age, so kids are looking for the thrills they used to have.  Become susceptible to peer pressure. 
• Inaccurate risk perception
• Imaginary audience effect “whole world is watching, seeking approval” become sensitive to opinions of others.  Parental influence, living up to parents’ encouragement/expectations.

She concludes with items to include in a backcountry first aid kit. 

In conclusion:

• The long term effects of altitude, extreme temperature, and exertion exposure on children and teens is unknown.
• Young children are more vulnerable to altitude, heat, cold, UV radiation and to musculoskeletal injuries.
• Preteens and teens are drawn towards sensation and reward-seeking behavior.
• Impulse control and ability to weigh the consequences is not fully developed until age 25.
• Most pediatric deaths and injuries are completely preventable with good supervision and proper equipment.

Those of you into this kind of thing may wish to check out their future webinars, links to which can be accessed using the first address below.  The second address is to the webinar I took these notes from.

References:

https://events.survivalmed.org/events/list/

https://survival-med.webinargeek.com/webinar/replay/qiiyaVpGI7QHjoXAzFb4RvNuxEoXBLrLQy5WIYPRI0U/