33.1

Pediatric Care

Chapter 33

Pediatric Care

Introduction

The military surgeon needs to be familiar with the unique

challenges the pediatric population presents, not only in war,

but also in military-operations-other-than-war scenarios. This

includes proper diagnostic evaluation and resuscitation, and the

necessary equipment to ensure success. For US Army medical

units, the humanitarian augmentation medical equipment set

(MES), requested by the hospital commander through command

channels, provides medical supplies and equipment for a

population of 10,000 people. Additionally, the special care

augmentation team can be requested for this mission.

Anatomic and Physiologic Considerations

 Fluid, electrolyte, and nutrition.

ο Normal fluid requirements in children are estimated via a

weight-based method (Table 33-1).

Table 33-1

Weight (kg) Volume

0–10 120 mL/kg/d (after the first week of life)

11–20 1,000 mL + 50 mL/kg over 10 kg

over 20 1,500 mL + 20 mL/kg over 20 kg

o Maintenance IV fluid replacement is D51/2NS + 20 mEq/

dL KCl for children over 3 months or D101/2NS + 20 mEq/

dl KCl for children under 3 months.

ο Fluid resuscitation is best performed with isotonic fluids

at 20 cc/kg boluses. (See Evaluation and Diagnosis below.)

ο Total fluid requirement should be adjusted for a goal urine

output of 1–2 cc/kg/h.
33.2

Emergency War Surgery

ο Daily sodium requirements are 2–3 mEq/kg/d and daily

potassium requirements are 1–2 mEq/kg/d.

ο Daily caloric and protein requirements are estimated by

weight and age as follows (Table 33-2):

Table 33-2

Age (y) kcal/kg Protein (g/kg

body weight body weight)

0–1 90–120 2.0–3.5

1–7 75–90 2.0–2.5

7–12 60–75 2.0

12–18 30–60 1.5

> 18 25–30 1.0

ο Breast milk is always the first choice when initiating oral

intake in infants. Alternatively, infant formulas contain 20

kcal/oz. An estimate of the amount of formula needed to

provide 120 kcal/kg/d is

Infant’s wt (kg) • 22 = Amt (in cc) of formula needed q 4 h.

 Pulmonary.

ο Newborns tend to be obligate nasal breathers, thus nasal

airways should be avoided if possible.

ο The child’s larynx is positioned more anterior in the neck,

thus making it more difficult to visualize during

intubation, and necessitating a more forward position of

the head.

ο The acceptable range of PaO2 (60–90 mm Hg) correlates to

oxygen saturations of 92%–97%. A premature infant’s

oxygenation saturation should never exceed 94% to avoid

retinopathy of the premature.

ο Infants breathe mostly with their diaphragm, thus

increases in intraabdominal pressure or other problems

that limit diaphragmatic movement can significantly

inhibit respiration.

 Cardiovascular.

ο Vital signs by age group (Table 33-3).
33.3

Pediatric Care

Table 33-3

Age Weight Resp. Pulse BP

(kg) Rate (systolic)

Premie < 3 40–60 130–150 42±10

Term 3 40 120–140 60±10

1–5 yr ~10–20 20–30 100–130 95±30

6 –10 yr 20–32 12–25 75–100 100±15

Adolescent 50 12–18 70 120±20

ο Cardiac stroke volume in children is relatively fixed. Therefore,

bradycardia or relative bradycardia can significantly decrease

cardiac output. Stimulation and oxygen therapy are

corrective for over 90% of significant bradycardias in infants.

Limit peripheral IV access attempts to 2 within 60 seconds

for the child in shock, then immediately proceed to

saphenous vein cutdown or intraosseous (IO) infusion (see

Chapter 8, Vascular Access).

 Burns.

ο An infant or child’s head tends to encompass more of the

BSA, with the lower extremities being a smaller percentage.

The palm of the child’s hand can be used to estimate 1%

of total BSA for burn calculations (Fig. 33-1).

Fig. 33-1. BSA percentages

for infants and children.

 Gastrointestinal.

ο Reflux is a common finding,

especially in the newborn period.

This predisposes some children to

difficulty with digestion and

frequent emesis.

ο Children are predisposed to

hypoglycemia due to low

glycogen storage capacity of their

liver. Full-term infants will tolerate

NPO status for approximately 5

days (with an appropriate D10

solution). Premature infants will

tolerate only 3 days of NPO status

prior to the initiation of TPN.

18%

9% 9% 

18% 

Back 13%

Unilateral

buttock 2.5%

Legs 7.5% on

each side 15% 15%
33.4

Emergency War Surgery

ο A child’s GI tract is very sensitive to most insults, including

electrolyte abnormalities and systemic illnesses. This can

result in an ileus and manifest as feeding intolerance, and

may precipitate necrotizing enterocolitis (NEC).

ο Gastroenteritis with diarrhea, often associated with fevers,

is also a very common cause of severe dehydration.

 Hematology and blood volume.

ο Infants have a physiologic anemia during the first 3–5

months with a hematocrit of 30%–33%.

ο Estimates of blood volume are as follows:

Age Volume (cc/kg)

Premature 85–100

Term ~80

1–3 mo 75–80

> 3 mo ~70

 Renal.

ο Infants and young children have a limited ability to

concentrate urine (max 400–600 mOsm/L) and a fixed

ability to excrete sodium, causing an inability to handle

excess sodium, resulting in hypernatremia if they receive

too much sodium. Premature infants are salt wasters and

full-term infants are salt retainers. It takes 6 years to achieve

normal tubular concentrating ability.

ο Infants can excrete water just like an adult. At 2 weeks of age

the glomerular filtration rate (GFR) is 75% of the eventual

adult rate and reaches maximum capacity at 2 years.

ο Total body water is 80% at 32 weeks, 75% at term, 60%

beyond 1 year.

 Thermoregulation.

ο Infants and young children are predisposed to heat loss

and they poorly compensate for wide fluctuations in

ambient temperatures. Children have a higher ratio of

body surface area to mass, and therefore are likely to

become dehydrated earlier than adults when febrile.

ο Reduce exposure and keep infants and children in a

regulated warm environment.

 Immune system.
33.5

Pediatric Care

ο Premature infants have incomplete development of their

immune system, causing a 60-fold increased risk of sepsis.

All elective surgery in infants under 30 days of age requires

48 hours of prophylactic antibiotics (with anaerobic coverage

added when appropriate) after the first week of life.

ο Early signs of sepsis can include lethargy, intolerance to

feedings, fever, hypothermia, tachycardia, and irritability

before a rise in the white blood cell count.

Evaluation and Diagnosis

 History.

ο Duration/location of pain is important in injury diagnosis.

Over one third of pediatric patients evaluated for

abdominal pain lasting more than a few hours will have

an underlying pathologic condition.

ο Any bilious emesis, especially in the newborn period, may

be a sign of intestinal obstruction, and mandates further

workup.

ο GI bleeding requires immediate attention. The character

(bright red vs melena), quantity, and associated stool

history (ie, diarrhea with infectious source or currant-jelly–

like with intussusception) may provide clues as to the

underlying disorder.

 Physical examination.

ο Basic ATLS guidelines should direct the initial assessment

and evaluation for all children involved in traumas. It is

essential to keep the patient warm because children are

much more prone to heat loss than adults.

♦ Modified GCS for children < 4 years old:

Verbal Response V-Score

Appropriate words/social 5

smile/fixes/follows

Cries, but consolable 4

Persistently irritable 3

Restless, agitated 2

None 1

 Radiological studies.
33.6

Emergency War Surgery

ο All bilious vomiting in infants and children should be

evaluated with contrast radiographic imaging. As a general

rule contrast enemas are safer as an initial approach.

♦ Ultrasound is an excellent screening test for the

identification of free abdominal fluid and is also used

in cases of abdominal pain to evaluate appendicitis

(noncompressible appendix with fecolith) and

intussusception (target sign), and others.

♦ Constipation is a common complaint in children that

can be readily diagnosed with plain radiographs and

by history.

Treatment

 The treatment algorithm shown below provides the proper

sequence for the rapid sequence intubation (RSI) of the

pediatric patient (Fig. 33-2).

Fig. 33-2. Rapid sequence intubation for the pediatric patient.

Preoxygenate

Atropine sulfate, 0.1–0.5 mg

Sedation

Midazolam HCl, 

0.1 mg/kg (5 mg max) 

Thiopental sodium

4–5 mg/kg

Cricoid Pressure

Paralysis

Succinylcholine chloride

Weight < 10 kg: 2mg/kg

Weight > 10 kg: 1 mg/kg

Intubate, Check Tube Position, Release Cricoid Pressure
33.7

Pediatric Care

Equipment and Supplies

 Accessory pediatric medical/surgical equipment arranged

according to age and weight (Table 33-4).

 Surgical instruments.

ο If a pediatric surgical set

is not immediately

available, a peripheral

vascular set will usually

contain instruments

delicate enough to

accomplish most tasks in

newborns.

Commonly Used Drugs and

Dosages

 Phenobarbital 2–3 mg/kg

IV.

 Diazepam 0.25 mg/kg IV

 Midazolam HCl 0.1 mg/

kg IV (max 5 mg).

 Atropine 0.1–0.5 mg IV.

 Phenytoin 15–20 mg/kg,

administered at 0.5 to 1.5

ml/kg/min as a loading

dose, then 4–7 mg/kg/d

for maintenance.

 Mannitol 0.5–1.0 g/kg IV.

 Succinylcholine chloride 2

mg/kg IV for < 10 kg, and

1 mg/kg IV for > 10 kg.

 Ampicillin 25–50 mg/kg IV

q8h (q12–18h in newborns).

 Gentamicin 2.5 mg/kg IV

q8h (q12–18h in newborns).

 Metronidazole 10 mg/kg

IV.

 Acetaminophen 15 mg/kg

T

po.

able 33-4

AIRWAY/BREATHING CIRCULATION SUPPLEMENTAL EQUIPMENT

AGE,WEIGHT Oral Bag- Laryngo- IV NG Chest Urinarykg) O2 Mask Airway valve scope ET Tube Stylet Suction BP Cuff Cath Tube Tube Cath C-collarPremie Premie 2.5–3.0 Premie 24- 5 F3 kg Newborn Infant Infant 0 Straight No Cuff 6 F 6–8 F Newborn gauge 12 F 10–14 F Feeding —0–6 mo Infant 3.0–3.5 Newborn 22- 5–8 F

—

3.5 kg Newborn Small Infant 1 Straight No Cuff 6 F 8 F Infant gauge 12 F 12–18 F Feeding —6–12 mo 3.5–4.0 Infant 22-7 kg Pediatric Small Pediatric 1 Straight No Cuff 6 F 8–10 F Child gauge 12 F 14–20 F 8 F Small

1–3 y 4.0–4.5 20–22- 10–12 kg Pediatric Small Pediatric 1 Straight No Cuff 6 F 10 F Child gauge 12 F 14–24 F 10 F Small

4–7 y 2 Straight 5.0–5.5 20-

16–18 kg Pediatric Medium Pediatric or Curved No Cuff 14 F 14 F Child gauge 12 F 20–32 F 10–12 F Small

8–10 y Medium Pediatric 2–3 Straight 5.5–6.5 Child 18–20-24–30 kg Adult Large Adult or Curved Cuffed 14 F 14 F Adult gauge 12 F 28–38 F 12F Medium
33.8

Emergency War Surgery

Surgical Management

 Basics.

ο As a general guideline, transverse incisions should be used

in infants. This minimizes the risk of postoperative

dehiscence, while still allowing adequate exposure.

ο Absorbable suture such as Vicryl or PDS (2-0) should be

used to close the rectus fascia, regardless of the incision.

The skin can then be closed using staples or absorbable

monofilament suture (eg, Monocryl 4-0).

ο When placing retention sutures for severe malnutrition,

permanent sutures such as Prolene or nylon can be used

as a full thickness through the rectus muscle and skin. Care

should be taken to avoid the epigastric vessels. The sutures

can be passed through small pieces of a 14F red rubber

catheter prior to tying to avoid excess pressure on the skin.

ο Personnel: Remember that if obstetrics is part of the

mission, pediatric support will be required!