In the medical community, summertime involves a unique set of medical issues along with an increase in trauma patients. First responders must be prepared to treat these patients quickly and efficiently so that morbidity and mortality can be minimized.
Lauren Mutter, MD, is a pediatric emergency medicine fellow at Le Bonheur Children's Hospital.
Mark Meredith, MD, is associate professor of pediatric emergency medicine at Le Bonheur Children's Hospital.
2. OBJECTIVES
Review Bites & Stings
Review Drowning
Review Heat Exposure Spectrum
Understand common pediatric summertime emergencies and
their pathophysiology.
Know the treatment methods for each emergency.
Review initial stabilization and safe transport for each specific
emergency.
3. Key Terms
Anaphylaxis: An exaggerated, life- threatening hypersensitivity
reaction to a previously encountered antigen.
Drowning: Death by asphyxia after submersion.
Heat stroke: Life-threatening failure of the body's temperature-
regulating mechanisms after exposure to high or prolonged heat stress.
Laryngospasm: A sudden, temporary closure of the larynx.
4. Treating Pediatric Summertime
Emergencies
EMS is called to a daycare for a 4-year-old
child with difficulty breathing. On arrival,
they find a 33-lb child in moderate distress
with inspiratory and expiratory wheezing. A
quick history reveals that a bee stung the
patient 15 minutes prior to arrival. Ten
minutes later, the patient vomited and started
wheezing.
5. Treating Pediatric Summertime
Emergencies
The patient is quickly placed on a monitor
and vital signs show a heart rate of 160,
respiratory rate of 40, oxygen saturation of
88% and a blood pressure of 80/40. His
physical exam reveals a patient in obvious
distress, moist mucous membranes and
normal oropharynx without tongue swelling.
6. Treating Pediatric Summertime
Emergencies
His heart is tachycardic with a regular rhythm.
Auscultation of the chest shows the patient is
tachypneic with inspiratory and expiratory wheezing
coupled with intercostal and substernal retractions.
His abdomen is soft, non- tender and non-
distended. An examination of the skin show a
blanching, raised, erythematous rash around the
sting site on his leg that has spread to his trunk. The
patient is quickly placed on oxygen. The steps that
are taken next save this patient's life.
7. Deadly Season
Summer, a much-anticipated season of the year for
both adults and children, is unfortunately a time for
significant unintentional injury and death to kids.
This is secondary to a combination of children being
out of school and spending more time outdoors,
coupled with decreased adult supervision. Statistics
from the National SAFE Kid Campaign Study reveal
that nearly half of the unintentional deaths of
children under 14 years of age occur between May
and August, with a peak occurring in July.
8. Deadly Season
During these summer months approximately 9
million children are seen in EDs across the country
and over 9,000 children will die as a result of these
injuries.1 Through proper assessments and symptom
identification, first responders can provide key
initial stabilization for common summertime
emergencies and prevent further mortality.
9. Deadly Season
Children are at higher risk for traumatic injuries
based on anatomy alone. A smaller body size can
lead to multiple injuries from just a single impact.
Children also have a decreased circulating blood
volume indicating that hypovolemic shock can
result from a relatively small blood loss. A relatively
cartilaginous skeleton can lead to visceral and brain
injuries that are common in the absence of bony
injuries.
10. Bites & Stings
Reactions to insect stings are seen commonly in
pediatric practice, ranging from simple local
reactions to systemic anaphylaxis. Both warmer
weather and spending more time outdoors are risk
factors. Though a rare occurrence from a sting, one
has to be prepared for anaphylaxis when
transporting these patients. Stinging insects include
honeybees, bumblebees, wasps, yellow jackets,
hornets, harvester ants and fire ants. Biting insects
include mosquitoes, fleas, horseflies, ticks and
chiggers.
11. Bites & Stings - anaphylaxis
How it occurs: Immediately after contact with the
insect, a local reaction occurs at that site with
associated edema and pruritic local erythema.
Irritant substances concentrated in insect saliva
cause these local reactions in an insect bite. In insect
stings, the female insect has a barbed stinging
apparatus that becomes lodged in the skin and rips
away, along with the venom sac, from the insect's
body following a sting event.
12. Bites & Stings - anaphylaxis
Treatment: These local reactions usually last several
hours and respond to the application of cool
compresses. Antihistamines such as
diphenhydramine (Benadryl) and analgesics may
also be helpful. Stingers should be removed as
rapidly as possible using something stiff--such as
thick paper or a credit card--because venom can
continue to be released for several seconds.
13. Bites & Stings - anaphylaxis
Treatment (continued): The area should then be
washed with soap and water and elevated if on an
extremity. Larger local reactions can also occur,
involving areas of approximately 5–10 cm in
diameter that are adjacent to the site of the sting.
The swelling generally peaks in 24–48 hours, but the
reactions can last up to 10 days. Steroids are usually
not indicated for insect stings unless there's
anaphylaxis.
14. Bites & Stings - anaphylaxis
Severe cases: Although systemic reactions to insect
stings and bites are the exception with less than 1%
of children experiencing them, they can be life-
threatening.2 Anaphylaxis is a serious allergic or
hypersensitivity reaction that's rapid in onset and
may cause death secondary to rapid mast cell
degranulation. In order to have an anaphylactic
reaction, one must have had a previous sting.
Higher-risk patients are immunocompromised
patients (e.g. AIDS, cancer, medically fragile) or
patients with known anaphylaxis or severe allergies.
15. Bites & Stings - anaphylaxis
Severe cases: Per the latest guidelines from the American Academy
of Allergy, Asthma, and Immunology, there are different ways to diagnose
anaphylaxis but the important points are that it can be an abrupt or
delayed onset and usually two of the following criteria have to be met:
Skin or mucosal involvement;
Respiratory compromise such as wheezing or persistent cough;
Hypotension;
Persistent vomiting or diarrhea; or
End organ dysfunction.
16. Bites & Stings - anaphylaxis
Severe cases: The immediate initial therapy for
anaphylaxis is epinephrine (1:1,000) 0.01 mg/kg, with
max of 0.3 mg intramuscularly in the anterolateral
thigh. Please note that this is a change from the past
when epinephrine was given subcutaneously. Giving
it intramuscularly provides more rapid absorption.
17. Bites & Stings - anaphylaxis
Severe cases: In patients with true anaphylaxis,
intramuscular epinephrine should be given first
before IV access is obtained. Epinephrine can be
repeated if needed. Once IV access is established, an
antihistamine such as diphenhydramine should be
administered. A normal saline bolus should be
considered if the patient has decreased capillary
refill or is hypotensive.
18. Bites & Stings - anaphylaxis
Severe cases: Nebulized albuterol can be used if the
patient is wheezing or in respiratory distress. If EMS
protocol allows, a corticosteroid such as solumedrol
at a dose of 2 mg/kg should be given to a maximum
dose of 60 mg.
19. Bites & Stings - anaphylaxis
Severe cases: Patients who meet criteria for
anaphylaxis should never been left on the scene and
should always be transported to the nearest
appropriate ED, even if there's dramatic
improvement or complete resolution of symptoms
after epinephrine. This is because there's a rebound
phenomenon that can occur approximately 4–6
hours after the initial exposure.
21. Drowning
Drowning is the second leading
cause of injury related death in
children less than 15 years old.1
Recent studies conducted by the
CDC reveal that the rates of
drowning deaths in children less
than 19 years of age have decreased
in the past 10 years, but drowning
still remains the number one cause
of unintentional injury leading to
death in boys ages 1--4. Between the
months of May and August, two
thirds of all deaths from drowning
occur, with most of them occurring
on the weekends.
22. Drowning
Statistics for nonfatal drowning are even more
difficult to obtain, but nonfatal drowning events
may occur several hundred times as frequently as
reported drowning deaths.
23. Drowning
Risk factors: Risk factors for drowning include
inability to swim, as well as risk-taking behaviors,
particularly in adolescents. There's a bimodal age
distribution, which includes children less than 5
years of age and those 15--19 years of age who are
more likely to drown.
24. Drowning
Risk factors (continued): The location of the
drowning accident is also age dependent; children
less than 1 year of age drown most frequently in the
bathtub, children ages 1–4 drown in swimming
pools, and adolescents and teens are most likely to
drown in natural bodies of water.
25. Drowning
Risk factors (continued): Children of low-to-
middle income background account for 90% of all
drownings, indicating that children of lower
economic status are at higher risk.1 Various primary
medical conditions preclude some children to
drowning accidents such as children with seizures,
who are 4 times more likely to drown. Likewise,
children with a primary cardiac arrhythmia are at
high risk, particularly if it is a cold- water drowning
or a significant amount of exercise is involved.
26. Drowning
Pathophysiology: Both fatal and non- fatal
drownings begin with a period of panic. Contrary to
popular belief, the victim won't wave his or her arms
and call for help. With panic, there will be a loss of
the normal breathing pattern, air hunger and
periods of breath holding.
27. Drowning
Pathophysiology (continued): The patient will
be holding himself upright with arms extended
laterally to assist with posture and lung expansion,
and may be mistaken for playing or splashing as
they struggle to stay above water. The struggle for
children to remain above water may only last for 10
seconds, while adults may struggle for 60 seconds.
28. Drowning
Pathophysiology (continued): In 20% of cases, reflexive
laryngospasm occurs and water isn't aspirated into the lungs.3 The
combination of hypoxia, hypercarbia and acidosis can decrease
myocardial contractility, elevate pulmonary artery and systemic
vascular resistance, and produce cardiac arrhythmias, seizures and
death.
29. Drowning
Initial assessment and transport: The initial
presentation of a victim of a submersion injury is
quite varied, depending on initial submersion time
and resulting hypoxemia. Signs and symptoms may
include loss of consciousness, apnea, dyspnea,
tachypnea, tachycardia, altered mental status,
seizures, coughing or decreased breath sounds on
exam.
30. Drowning
Initial assessment and transport (continued):
Initial treatment of the potential drowning child
includes supporting the ABC's (airway, breathing
and circulation) by providing high-quality CPR. If
the patient doesn't have an adequate respiratory
effort, it's acceptable to provide bag-mask
ventilation if good chest rise is noted and transport
time is short.
31. Drowning
Initial assessment and transport (continued):
If the patient aspirated a significant amount of
water, they may require a slightly higher pressure
(positive end-expiratory pressure) to bag. Should the
patient be difficult to bag or there will be a
prolonged transport time, intubation should be
considered.
32. Drowning
Initial assessment and transport (continued):
If intubation isn't necessary, the patient should be
placed on a non-rebreather mask with 100% oxygen
to help correct hypoxia.
33. Drowning
Initial assessment and transport (continued):
One should avoid the Heimlich or other techniques
to remove water as they haven't proven to
demonstrate any benefit. Correction of the hypoxia
is the key to a positive patient outcome.
34. Drowning
Initial assessment and transport (continued):
Near-drowning patients should always be
transported to the nearest appropriate ED given the
risk of rapid decompensation. Even the
asymptomatic near-drowning victim requires
observation of at least four hours.
35. Heat Exposure Spectrum
Heat illnesses occur along a spectrum of very minor
(heat rash, cramps) to life-threatening conditions
such as heat stroke. Most episodes of heat illness
occur during times of increased environmental heat
as well as increased exposure to heat. The heat
exposure spectrum includes heat rash (miliaria),
heat cramps, heat edema, heat syncope, heat
exhaustion and heat stroke.
36. Heat Exposure Spectrum
Pathophysiology: A normal body temperature of
98.6 degrees F is maintained within a narrow range
by balancing heat load and dissipation. As the
body's core temperature rises from hot weather or
exercise, heated blood is transferred to the skin
surface if it's cooler.
37. Heat Exposure Spectrum
Pathophysiology (continued): In an effort to more
rapidly dissipate heat, the body dilates blood vessels
and pores and evaporates sweat to help with cooling.
Unfortunately, this mechanism becomes ineffective
once the relative humidity is over 75%. With heavy
work, the body may lose 1--2 liters of fluid.
38. Heat Exposure Spectrum
Pathophysiology (continued): After several hours
of fluid loss, a person may start to become
symptomatic with loss of endurance, increased
thirst and becoming uncomfortable. After 3–5 hours,
the body has decreased blood to circulate to the rest
of the body, which may lead to decreased alertness,
nausea, muscle cramps, headache and/or loss of
strength.
39. Heat Exposure Spectrum
Pathophysiology (continued): If not treated with
fluid resuscitation, this may lead to heat stroke.
Heatstroke by definition is a core temperature
greater than 105 degrees F, decreased level of
consciousness and an environment consistent with
heat stroke.
40. Heat Exposure Spectrum
Initial assessment and transport: The key to
treating heat exposure spectrum is to identify
approximately where the patient is on the spectrum.
Heat rash presents with a possibly pruritic
maculopapular rash treated by cool baths, loose
clothing and removing the patient from the
environment.
41. Heat Exposure Spectrum
Initial assessment and transport (continued):
Heat cramps present as brief, intermittent muscular
cramps that are relieved by increased salt intake. If
they're more severe they may require IV fluids.
42. Heat Exposure Spectrum
Initial assessment and transport (continued):
Heat syncope is a temporary loss of consciousness
associated with vasodilation and venous pooling. It
occurs usually after standing a long time or a quick
adjustment in position. These patients usually have
a normal core temperature and mental status will
quickly improve once supine and IV fluids are
administered.
43. Heat Exposure Spectrum
Initial assessment and transport (continued):
The definition of heat exhaustion involves a known
heat exposure and core temperature between 37--40
degrees C. These patients present with evidence of
mild tomoderate volume depletion, variable
nonspecific symptoms including nausea, fatigue,
confusion, headache and tachycardia. Treatment
consists of removal from the heat to a cool
environment, removal of excessive clothing, chilled
oral rehydration with salt containing fluids or IV
hydration.
44. Heat Exposure Spectrum
Initial assessment and transport (continued):
Central nervous system dysfunction is the hallmark
for heat stroke. When first assessing these patients,
the ABCs are paramount as these patients may need
an airway intervention. Wet sheets without air
movement tend to increase the core temperature
and should be avoided.
45. Heat Exposure Spectrum
Initial assessment and transport (continued):
When treating these patients, it's helpful to recall
the treatment mantra of Corey Slovis, MD, chairman
of emergency medicine at Vanderbilt Medical
Center: "Wet and windy." Use ice packs on the groin
and the axilla, fans to help with convection cooling,
and IV fluids as needed for hydration. Those
patients with altered mental status, vital sign
changes or evidence of dehydration should be
transferred to the nearest hospital for observation
and further treatment.
46. Conclusion
In the medical community, summertime involves a
unique set of medical issues along with an increase
in trauma patients. First responders must be
prepared to treat these patients quickly and
efficiently so that morbidity and mortality can be
minimized.
Lauren Mutter, MD, is a pediatric emergency medicine fellow at Le
Bonheur Children's Hospital.
Mark Meredith, MD, is associate professor of pediatric emergency
medicine at Le Bonheur Children's Hospital.
47. References
Unintentional Drowning: Get the facts. (Oct. 24, 2014.) Centers for Disease
Control and Prevention. Retrieved May 4, 2015, from
www.cdc.gov/HomeandRecreationalSafety/Water-Safety/waterinjuries-
factsheet.html.
Curtis J. Insect sting anaphylaxis. Pediatr Rev. 2000;21(8):256.
Salomez F, Vincent JL. Drowning: A review of epidemiology, pathophysiology,
treatment and prevention. Resuscitation. 2004;63(3):261–268.
Resources
Campbell RL, Li JT, Nicklas RA. Et al. Emergency department diagnosis and
treatment of anaphylaxis: A practice parameter. Ann Allergy Asthma Immunol
2014;113(6):599–608.
Jardine DS. Heat illness and heat stroke. Pediatr Rev. 2007;28(7):249–258.