PEDIATRIC

SURGERY AND MEDICINE

FOR HOSTILE ENVIRONMENTS

Kevin M. Creamer, MD • Michael M. Fuenfer, MD

U

NITED

STATES ARMY MEDICAL DEPARTM

E

N

T

BORDEN INSTITUTE

Second Edition
i

Pediatric

Surgery and Medicine

for Hostile Environments

Second Edition

Borden Institute

US Army Medical Department Center and School 

Health Readiness Center of Excellence

Fort Sam Houston, Texas

Office of The Surgeon General

United States Army

Falls Church, Virginia
ii

The test of the morality of a society 

is what it does for its children.

—Dietrich Bonhoeffer (1906–1945)
iii

This book is dedicated to the military medical 

professional in a land far from home, standing at the 

bedside of a critically ill child.
Dosage Selection:

The authors and publisher have made every effort to ensure the accuracy of dosages 

cited herein. However, it is the responsibility of every practitioner to consult appropriate 

information sources to ascertain correct dosages for each clinical situation, especially 

for new or unfamiliar drugs and procedures. The authors, editors, publisher, and the 

Department of Defense cannot be held responsible for any errors found in this book.

Use of Trade or Brand Names:

Use of trade or brand names in this publication is for illustrative purposes only and does 

not imply endorsement by the Department of Defense.

Neutral Language:

Unless this publication states otherwise, masculine nouns and pronouns do not refer 

exclusively to men.

The opinions or assertions contained herein are the personal views of the authors and 

are not to be construed as doctrine of the Department of the Army or the Department of 

Defense. For comments or suggestions on additional contents in forthcoming editions, 

please contact the publisher (www.cs.amedd.army.mil/borden).

CERTAIN PARTS OF THIS PUBLICATION PERTAIN TO COPYRIGHT 

RESTRICTIONS. ALL RIGHTS RESERVED.

NO COPYRIGHTED PARTS OF THIS PUBLICATION MAY BE REPRODUCED 

OR TRANSMITTED IN ANY FORM OR BY ANY MEANS, ELECTRONIC OR 

MECHANICAL (INCLUDING PHOTOCOPY, RECORDING, OR ANY INFORMATION 

STORAGE AND RETRIEVAL SYSTEM), WITHOUT PERMISSION IN WRITING FROM 

THE PUBLISHER OR COPYRIGHT OWNER.

Published by the Office of The Surgeon General

Borden Institute

Fort Sam Houston, Texas

2016

Library of Congress Cataloging-in-Publication Data

Names: Creamer, Kevin M., editor. | Fuenfer, Michael M., editor. | Borden Institute (U.S.), issuing body. 

| United States. Department of the Army. Office of the Surgeon General, issuing body.

Title: Pediatric surgery and medicine for hostile environments / senior medical and critical care editor, 

Kevin M. Creamer ; senior surgical editor, Michael M. Fuenfer.

Other titles: Pediatric version of (work): Emergency war surgery (Borden Institute) Fourth United States 

revision. 2013.

Description: Second edition. | Fort Sam Houston, Texas : Borden Institute, US Army Medical 

Department Center and School, Health Readiness Center of Excellence ; Falls Church, Virginia : Office 

of The Surgeon General, United States Army, 2016. | Includes bibliographical references and index.

Identifiers: LCCN 2016049173

Subjects: | MESH: Emergencies | Wounds and Injuries--surgery | Child | Infant | Military Medicine | 

Handbooks

Classification: LCC RJ370 | NLM WO 39 | DDC 618.92/0025--dc23 LC record available at Cautionhttps://lccn.loc.gov/2016049173

Printed in the United States of America

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ublishing

ISBN 978-0-16-093629-6
v

Foreword xi

Prologue xiii

Introduction xix

Resuscitation and Critical Care 1

1. Basic Approach to Pediatric Trauma 3

2. Anesthesia 15

3. Vascular Access 27

4. Mechanical Ventilation 35

5. Transfusion Medicine 47

6. Hemodynamics and Shock 57

7. Managing Intracranial Pressure 65

8. Status Epilepticus 71

9. Care of the Newborn 75

10. Clinician-Operated Ultrasound 93

11. Aeromedical Evacuation 121

Surgery 129

12. Burns 131

13. Neurosurgery 153

14. Ophthalmology 175

15. Pediatric Dental Surgery 205

16. Face and Neck 217

17. Orthopedics 245

18. Thoracic Cavity 265

19. Vascular Surgery 279

20. Abdominal Wall, Peritoneum, and Diaphragm 291

21. Gastrointestinal Tract 313

22. Hepatobiliary Tract 355

23. Pancreas and Spleen 365

24. Genitourinary Tract 377
vi

Medicine 405

25. Basic Fluid and Electrolytes 407

26. Respiratory Emergencies 415

27. Cardiology 431

28. Gastroenterology 445

29. Infectious Diseases 455

30. Endocrinology 493

31. Common Neurological Problems 507

32. Hematology and Oncology 521

33. Pediatric Nephrology 543

34. Dermatology 549

35. Malnutrition and Emergency Nutrition for Sick or 577

Injured Infants and Children

36. Nursing Assessment 593

37. Behavioral Healthcare of Children in Austere 609

Environments

38. Pharmacotherapeutics 629

39. Bites and Stings 641

40. Hypothermia, Cold, and Heat Injuries 647

41. Casualties of Chemical, Biological, Radiological, 651

Nuclear, and Explosive Weapons

42. Children in Disasters 675

43. Humanitarian Operations and Medical 687

Civil-Military Activities

Appendix A: Resources for Deployed Physicians Caring 705

for Children

Appendix B: Contributors to First Edition 711

Appendix C: Comprehensive Pediatric Equipment 713

Sizing Table

Author Biographies 717

Abbreviations and Acronyms xxvii

Index xxxiii
vii

Pediatric Surgery and Medicine 

for Hostile Environments

Senior Medical and Critical Care Editor

Kevin M. Creamer, MD, FAAP

Colonel, Medical Corps, US Army Retired

Pediatric Hospitalist, Children’s National Medical Center, Washington, DC

Associate Professor of Pediatrics, Uniformed Services University of the Health 

Sciences and George Washington University School of Medicine 

Senior Surgical Editor

Michael M. Fuenfer, MD, FAAP, FACS

Colonel, Medical Corps, US Army Reserve

Assistant Professor of Surgery and Pediatrics, Uniformed Services University 

of the Health Sciences, Bethesda, Maryland

Associate Pediatrician, Massachusetts General Hospital, Boston, Massachusetts 

Instructor in Pediatrics, Harvard Medical School, Boston, Massachusetts 

Borden Institute Editorial Staff 

John H. Garr, MD, MSE, FACEP 

Colonel, MC, US Army

Director and Editor in Chief 

Ronda Lindsay 

Volume Editor 

Joan Redding

Managing Editor 

Douglas Wise

Layout Editor
viii
ix

Editorial Board 

Thomas R. Burklow, COL, MC, US Army

Mary J. Edwards, COL, MC, US Army

Patrick W. Hickey, LTC, MC, US Army 

Brian F. Gilchrist, MD

Marc S. Lessin, MD, JD

Bruce A. Ong, LTC, MC, US Army 

Peggy Rahbani, PharmD

Cynthia H. Shields, COL, MC, US Army (Ret)

Steven E. Spencer, COL, MC, US Army 

Christopher M. Watson, CDR, MC, US Navy 

Martin E. Weisse, COL, MC, US Army 

Contributors

Calliope Allen, CDR, MC, US Navy

Kelly A. Bear, MAJ, MC, US Army

Matthew A. Borgman, LTC, MC, US Army 

Mark E. Boston, COL, MC, US Air Force

Mark W. Burnett, COL, MC, US Army

Benjamin B. Cable, COL, MC, US Army

Charles W. Callahan, COL, MC, US Army (Ret)

Debora S. Chan, PharmD

Theodore J. Cieslak, COL, MC, US Army (Ret)

Margaret E. Clark, CPT, MC, US Army

Stephen J. Cozza, COL, MC, US Army (Ret) 

Kevin M. Creamer, COL, MC, US Army (Ret)

David H. Dennison, LTC, MC, US Army

Mary J. Edwards, COL, MC, US Army

Colleen M. Fitzpatrick, LTC, MC, US Air Force

Michael M. Fuenfer, COL, MC, US Army 

Gregory H. Gorman, CAPT, MC, US Navy 

Brian P. Green, MAJ, MC, US Army

John Hanna, DDS

Patrick W. Hickey, LTC, MC, US Army

Peyton H. Hurt, COL, MC, US Army

Romeo C. Ignacio, Jr, CAPT, MC, US Navy

David Jarrett, COL, MC, US Army (Ret)

Jefferson W. Jex, LTC, MC, US Army
x

Dwight C. Kellicut, III, COL, MC, US Army

Brent L. Lechner, LTC, MC, US Army 

Martha K. Lenhart, COL, MC, US Army 

Douglas A Lougee, COL, MC, US Army 

Jamie Mancuso, LTC, MC, US Army

Ashley Maranich, LTC, MC, US Army

Renee I. Matos, MAJ, MC, US Air Force

Joseph W. May, MAJ(P), MC, US Army

Randell R. McCafferty, COL, MC, US Air Force

Thomas C. Newton, COL, MC, US Air Force

Scott A. Norton, COL, MC, US Army (Ret)

Bruce A. Ong, LTC, MC, US Army 

James Palma, CDR, MC, US Navy

Dina Parekh, LTC, MC, US Army 

Timothy M. Phillips, LTC, MC, US Air Force

Thomas A. Pluim, CDR, MC, US Navy

William R. Raymond, COL, MC, US Army (Ret)

Katherine I. Schexneider, CAPT, MC, US Navy

Robert L. Sheridan, COL, MC, US Army

Cynthia H. Shields, COL, MC, US Army (Ret)

James B. Solomon, LCDR, MC, US Navy

Steven E. Spencer, COL, MC, US Army 

Robert Steelman, MD, DMD 

Frederick J. Stoddard Jr, MD 

Erik Su, MD

Christopher M. Watson, CDR, MC, US Navy

Martin E. Weisse, COL, MC, US Army 

Luke A. Zabrocki, CDR, MC, US Navy

Kathryn L. Zahner, RN
xi

Foreword

The top priority for the Joint Health Services Enterprise is 

readiness and health. In support of Combatant Commanders, a 

key component of readiness is the ability to deploy responsive 

medical capabilities: these include the provision of medical care 

to the full spectrum of patients that may present to our deployed 

medical facilities.

Traditionally, military planning for medical support of combat 

operations has not included provisions for pediatric care. 

However, in response to unexpectedly large numbers of children 

presenting to US military medical facilities for treatment in the 

Iraq and Afghanistan theaters, the Borden Institute published 

a book, based on the pediatric experiences of deployed 

providers, that would serve as a basic reference for providers of 

pediatric care in practice environments with limited resources. 

The 2010 edition of Pediatric Surgery and Medicine for Hostile 

Environments significantly enhanced the ability of deployed 

military physicians whose scope of practice is primarily limited 

to adults in diagnosing and treating many of the most common 

medical and surgical conditions of childhood. This book has 

served as an invaluable resource for US military physicians 

caring for children in some of the most austere and hazardous 

environments imaginable, whether at a US Army battalion aid 

station, medical company, Forward Surgical Team, or Combat 

Support Hospital operating at a Forward Operating Base; in 

flight aboard US Air Force aircraft during medical evacuation 

operations; aboard Navy hospital or other surface ships; or in 

fixed medical facilities around the world. 

In this second edition, the content of each chapter has been 

thoroughly reviewed to reflect the most current and relevant 

clinical information. Additional chapters have been added based 

upon feedback from medical providers at all echelons of care, 

representing each of the uniformed services. The contributors—

military pediatric surgeons and physicians—have pooled their 

collective wisdom and experience gained through countless 

months and years of clinical practice and deployments into the 

content of this book, which is unique in its objectives. 
xii

Beyond its demonstrated utility to the US military, hundreds of 

copies of Pediatric Surgery and Medicine for Hostile Environments 

have been requested by and distributed to foreign military and 

civilian practitioners as well as nongovernmental organizations. 

To further enhance its utility, the Borden Institute has made the 

full content of the book available at no cost online (http://www.

cs.amedd.army.mil/borden).

This book supports the highest ideals of US military medicine: 

to provide exceptional medical care, at all times, under any 

condition, to all people. I extend my thanks to the selfless 

contributors, editors, illustrators, and reviewers whose time 

and effort has produced this second edition of an outstanding 

publication. 

Lieutenant General Nadja Y. West, MD

The Surgeon General, US Army

Commanding General, US Army Medical Command
xiii

Prologue

Since this book’s initial publication in 2010, comprehensive 

reviews of the pediatric care provided in Afghanistan and Iraq by 

military medical treatment facilities (MTFs) have helped define 

the scope of the pediatric wartime mission.1,2 From 2001 to 2011, 

a total of 7,505 patients under the age of 18 and 6,270 patients 

under the age of 15 were admitted to deployed Role 3 facilities.1

While these patients comprised 5.8% of total admissions, they 

comprised 11% of all bed days. Interestingly, the majority of 

admissions for patients under the age of 15 were for noncombatrelated conditions, either blunt injury from falls or motor vehicle 

collisions, burns in the home, elective surgeries, or medical 

conditions. This was especially the case in Afghanistan, a country 

with little existing medical infrastructure at the beginning of the 

war; however, in both Iraq and Afghanistan, pediatric combatrelated admissions and noncombat-related admissions increased 

during the troop surges, reflecting the increased need for care 

of medical and surgical diseases in children when the conflicts 

escalated. During times of war, children are not only “caught 

in the crossfire,” but suffer due to the chaotic environment and 

resulting destabilization of local infrastructure and services.1–4

Many lessons have been learned from the past decade regarding 

pediatric inpatient care in austere environments. Military MTFs 

and personnel must be prepared for the longer-term care of 

critically ill and injured children. This includes the transition 

from the MTF to the local medical facility and ultimately the 

patient’s community. Unlike our injured soldiers, who are 

typically evacuated out of theater via critical care air transport 

teams in 12 to 24 hours, children generally must remain in the 

austere environments where they were injured. We have learned 

that embarking on treatment regimens that cannot be supported 

long term in these environments are ultimately not beneficial. 

Overall pediatric mortality rates from trauma were higher than 

adult civilians and significantly higher than US coalition forces.1

We have identified the factors most associated with pediatric 

trauma mortality, including Injury Severity Score, Glasgow 
xiv

Coma Scale (GCS) score, base excess, younger age (less than 8 

years), burn injury, and, interestingly, female gender.1 Females 

were also more likely to be younger and admitted with a burn 

or another medical issue, perhaps related to a variety of societal 

dynamics.5 Another study found a strong association of base 

deficit and coagulopathy with mortality in these patients.6 A 

separate analysis utilized this data to derive a trauma “BIG 

Score,” which includes base deficit, international normalized 

ratio (INR), and GCS score, to predict mortality. This score 

was validated with civilian data (primarily blunt trauma).7 All 

these studies underscore the fact that head injuries and poor 

physiologic status at presentation are obstacles to successful 

treatment. They also suggest that local culture and social norms 

will inevitably affect the children who present for care. 

The conflicts of the past decade were notable for the overwhelming 

impact of the improvised explosive device. This weapon was 

responsible for the majority of pediatric combat injuries in 

Afghanistan and second only to gunshot wounds in Iraq. The 

blast injury complex, which became the face of the combatant 

casualties of this war, wrought similar havoc on civilians, both 

adults and children. In comparison to adults, blast-injured 

children were more likely to sustain a head injury and tended 

to have a higher Injury Severity Score and longer hospital stays, 

and require more operative interventions. One unique finding 

was that children who were burned as a result of a blast had a 

much higher mortality than those who were not. 

While a significant number of children were cared for at wellequipped and relatively well-staffed combat support hospitals, 

many children also sought care at Role 1 and 2 facilities under 

much more austere conditions, and little data is available 

documenting these encounters. Although much light has now 

been shed on the scope of the mission of pediatric combat 

casualty care, what is not clearly known are the outcomes. While 

pediatric in-hospital mortality was significantly higher than that 

seen in US hospitals, and significantly higher in patients under 

the age of 8 (compared to 9- to 18-year-olds), it is difficult to make 

comparisons between the two given disparities in equipment, 

facilities, provider background and experience, overall 
xv

conditions, and the baseline health of the patients. Long-term 

outcome measures beyond survival to discharge are not available. 

As a result, the ability to critically analyze the outcomes of these 

children is very limited and makes performance improvement 

challenging.1,8

Clearly there is a need for a robust pediatric registry to accurately 

capture data for outcomes analysis and mission preparation. 

The Department of Defense Trauma Registry has emerged as 

a powerful tool for improving combat casualty care in adults, 

and fueled the development of clinical practice guidelines. 

Implementation of these guidelines has resulted in improved 

outcomes for adults. Applying established adult clinical 

practice guidelines to children sometimes seems intuitive, but 

should be done with caution given lack of a proven benefit. 

Some examples of this are the use of tranexamic acid and also 

balanced component blood product resuscitation in pediatric 

patients. Unfortunately, using this type of registry for pediatric 

data analysis is fraught with problems involving capture of 

important data points (eg, weight, appropriate GCS score, 

recording blood products in specific volumes). It is essential 

to improve pediatric data capture as far forward as possible. 

Enhanced data acquisition systems will also facilitate more 

appropriate placement of pediatric subspecialty providers and 

more appropriate and useful predeployment training to those 

who do not have significant pediatric experience. 

We hope that this text provides military physicians, often 

practicing in austere environments, with a current and concise 

reference for the basic medical, surgical, and critical care of 

children. It should be used as a pragmatic reference but not 

as a substitute for current peer-reviewed articles or reasoned 

judgment. Operative procedures performed on children require 

careful assessment of the available resources and equipment, 

experience of the operating room team, potential complications, 

nonoperative options, availability of follow-up care, and an honest 

overall assessment of the risk to the child from the procedure to 

be undertaken. Fortunately, the operative procedures done to 

care for these patients are largely within the scope of practice of 

well-trained general and orthopedic surgeons.3
xvi

Despite wartime conditions, it is still our ethical obligation to 

counsel a patient’s parent or guardian, if available, about the 

risks and benefits of a procedure, and to obtain their consent for 

nonemergent operations. Local customs and the family’s desires 

must be respected in all cases, lest what was intended to be a 

humanitarian gesture results in unintended consequences that 

negatively impact the success of the overall military mission.

While much remains to be learned regarding optimizing pediatric 

combat casualty care, one fact is clear: the preparation for future 

conflicts and operations must include consideration of the sick 

and injured child, especially for those not primarily trained in 

pediatric critical care and surgery. This revised text is designed 

to support the men and women in uniform who continue to 

provide the best care possible for the smallest patients under 

the worst possible conditions. 

References

1. Borgman M, Matos RI, Blackbourne LH, Spinella PC. Ten years of 

military pediatric care in Afghanistan and Iraq. J Trauma Acute Care 

Surg. Dec 2012;73(6 Suppl 5):S509–S513.

2. Edwards MJ, Lustik M, Burnett MW, Eichelberger M. Pediatric 

inpatient humanitarian care in combat: Iraq and Afghanistan 2002 

to 2012. J Am Coll Surg. May 2014;218(5):1018–1023.

3. Edwards MJ, Lustik M, Carlson T, et al. Surgical interventions for 

pediatric blast injury: an analysis from Afghanistan and Iraq 2002 

to 2010. J Trauma Acute Care Surg. Mar 2014;76(3):854–858.

4. Edwards MJ, Lustik M, Eichelberger MR, Elster E, Azarow K, 

Coppola C. Blast injury in children: an analysis from Afghanistan 

and Iraq, 2002–2010. J Trauma Acute Care. Nov 2012;73(5):1278–1283.

5. Creamer KM, Edwards MJ, Shields CH, Thompson MW, Yu CE, 

Adelman W. Pediatric wartime admissions to US military combat 

support hospitals in Afghanistan and Iraq: learning from the first 

2,000 admissions. J Trauma. Oct 2009;67(4):762–768.

6. Patregnani JT, Borgman MA, Maegele M, Wade CE, Blackbourne LH, 

Spinella PC. Coagulopathy and shock on admission is associated 

with mortality for children with traumatic injuries at combat 

support hospitals. Pediatr Crit Care Med. May 2012;13(3):273–277.
xvii

7. Borgman MA, Maegele M, Wade CE, Blackbourne LH, Spinella PC. 

Pediatric trauma BIG score: predicting mortality in children after 

military and civilian trauma. Pediatrics. Apr 2011;127(4):e892–897.

8. Matos RI, Holcomb JB, Callahan C, Spinella PC. Increased mortality 

rates of young children with traumatic injuries at a US army 

combat support hospital in Baghdad, Iraq, 2004. Pediatrics. Nov 

2008;122(5):e959–966.
xviii
xix

Introduction

Military Humanitarianism: Caring for Children in Disaster

Our Past and Future

In 2012, two-thirds of the world’s population was living in a country 

affected by a natural disaster or major conflict.1 In the summer of 

2014, Iraq, Syria, the Central African Republic, and South Sudan 

all experienced United Nations “level three” emergencies based 

on the number of people affected, the situation’s urgency and 

complexity, and the capacity of the local government to respond.2,3

The number of displaced people in these countries exceeded 8 

million, adding to the over 50 million displaced across the globe, 

numbers higher than any time since World War II.2 Many of those 

affected were children. The US military has frequently been called 

to respond to these types of crises, consistent with our long history 

of involvement in humanitarian emergencies.

As early as 1803, President Thomas Jefferson sent Captains 

Merriweather Lewis and William Clark on what remains the 

longest infantry patrol in US history. The explorers traveled 

8,000 miles in 28 months. Military humanitarianism was one of 

the key goals of their mission as they surveyed the health habits 

of Native American tribes and provided direct medical care to 

them and to local civilian settlers.4–6 Lewis and Clark were also 

prepared to provide smallpox vaccination to the “Indians,” at 

the behest of President Thomas Jefferson. 

The Indian Campaigns of the late nineteenth century were the 

first instance of America’s Armed Forces being permanently 

posted on its frontiers. Military medical officers shared all the 

hardships of post life and practiced military humanitarianism 

regularly. In the 1880s, Colonel William H Arthur was stationed 

at Fort Washakie on the Shoshone and Arapahoe Indian 

Reservations. He wrote:

I was there two years without ever seeing another doctor of 

any kind, and had to give medical care to the small garrison, 

to all the Indians on the reservation, about 4,000 . . . and to all 
xx

the cowboys, miners and odds and ends of civilians found on 

the frontier, who came in for a radius of 150 miles.7

After the Spanish American War, humanitarianism motivated 

Major Walter Reed’s research to discover the vector for yellow 

fever. After he had definitively proven the virus’s association 

with the Aedes aegypti mosquito, he wrote, “The prayer that has 

been mine for 20 or more years—that I may be permitted in 

some way, for some time, to do something to alleviate human 

suffering—has been answered.”8

In World Wars I and II, the American Red Cross and other 

nongovernmental agencies were closely embedded with and 

assisted by the military when providing humanitarian aid to 

civilians. The military bore the additional burden for the logistics 

of humanitarian support in World War II due to the scope of the 

devastation and disruption to civilian communities.9

In the immediate aftermath of the destruction of Hiroshima in 

1945, Dr Hachiya Michihiko commented on the impact of US 

military doctors who assisted him in treating Japanese civilians, 

saying, “They gave us great help, materially and spiritually in 

the reconstruction of our hospital. Two doctors removed fear and 

hostility from our hearts and left us with a bright, new hope.” Dr 

Michihiko finished his book with this thought: “When I think of 

the kindness of these people, I think one can overlook thoughts 

of revenge; and even at this moment, I feel something warm in 

my heart when I recall those days and those friends.”10

In 1946, Colonel Ogden Bruton established a 90-day pediatric 

training course for military physicians after a number of infants 

died accompanying their soldier fathers and European mothers 

on returning troop ships. Many point to this course as the genesis 

of pediatric training in the military.11

The beginning of the Cold War was punctuated by perhaps the 

most famous example of military humanitarianism: the 1947 

Berlin Airlift, in which an entire city was supported with millions 

of pounds of supplies by air for fifteen months.12 
xxi

The “Armed Forces Aid to Korea” program provided emergency 

medical aid to Korean civilians, as well as education programs 

for Korean doctors and nurses during the Korean conflict. 

Supplies, funds, and technology for the construction of hospitals 

were also included in the program. US soldiers donated cash 

to the program staffed by volunteer Army doctors and nurses. 

Eventually, more than $3.5 million was collected and 320,000 

medical procedures were performed.13

In Vietnam, the 3rd Marine Division operated a 110-bed 

children’s hospital near the Vietnamese Demilitarized Zone. 

It was staffed by Navy pediatricians, surgeons, and medical 

officers and saw more than 250 outpatient visits a day and 

100 admissions a month. Lieutenant “Skip” Burkle, working 

alongside Vietnamese medical personnel, reported an epidemic 

of bubonic plague in children, the scourge of war and refugees. 

Dr Burkle, a pediatrician, was in the Marine Children’s Hospital 

when it came under fire and was severely damaged in the 

September 1968 Tet Offensive.14

Throughout the decades following the Vietnam conflict, the 

Department of Defense (DoD) participated in several large 

international relief missions, including operations Sea Angel in 

Bangladesh (1991), Restore Hope in Somalia (1992–1993), Support 

Hope in Rwanda (1994), Restore Democracy in Haiti (1994), and 

the response to Hurricane Mitch (1998) in Central America.15,16 In 

the conflict in Kosovo, the care of civilian children was regular 

practice among pediatricians deployed with the Army (MAJ 

Mark Burnett, MC, USA, personal communication, April 4, 2001).

Operation “Provide Comfort” in Northern Iraq in 1991 is 

recognized for ushering in a decade of military humanitarianism 

and established the US military as collaborative experts in 

humanitarian disaster relief.15,16 Subsequent efforts during 

Operations Desert Storm and Desert Shield inspired a group 

of Army pediatricians to establish the “Military Medical 

Humanitarian Assistance Course” under the auspices of the 

Department of Pediatrics at the Uniformed Services University 

in Maryland. This training, coupled with extensive experience in 
xxii

humanitarian civic assistance projects, resulted in hundreds of 

DoD medical professionals becoming experts in refugee medicine 

and humanitarianism.17

Since 2001, the care of civilians and the development of 

civilian healthcare systems in Iraq and Afghanistan have been 

foundational to nation-building efforts. The care of children by 

uniformed providers in military healthcare facilities has been 

at the center of these efforts.17–23 DoD continues to be actively 

engaged around the world, responding to the challenges of 

natural and human-made disasters, including the 2014 Ebola 

epidemic in sub-Saharan Africa.24,25

Humanitarian disasters today—compounded by climate change, 

economic threats (eg, financial, food, and fuel), the changing 

nature of conflict, and sexual violence—disproportionately affect 

women and children.27 At the same time, medical professionals 

recently completing training may actually have less experience 

in caring for ill children. Recently I stood over an old surgical 

textbook in a primitive operating room with two surgeons, 

struggling to figure out how to save a 2-day-old infant with 

imperforate anus in sub-Saharan Africa. Clearly there remains 

a great need for resources like this book. Unfortunately, there 

will be abundant opportunity for its use. 

Our national strategy focuses on opportunities to avoid conflict 

by promoting peace.

Major General John Pearn, former Surgeon General of the 

Australian Defense Force, summarized his experience as follows: 

“Pediatrics and preventive medicine, as it applies to children, 

are no longer discretionary skills for all who serve in the health 

disciplines within the broader profession of arms.”26 As we focus 

our national energy on the care of infants and young families in 

desperate situations around the world, what impression will we 

leave? What will the young child be told as she grows up about 

the men and women who cared for her as a newborn? As we 

respond with expertise to the care of children in other nations, 

will our good efforts ultimately be an investment in the kind of 

national security we would hope to leave for our children?
xxiii

This book is for those engaged in this fight for the world’s 

children. We dedicate it to everyone standing at the bedside of 

a critically ill child in a dangerous place far from home.

Charles W. Callahan, DO

Colonel (Retired), United States Army Medical Corps

Department of Pediatrics

F. Edward Hébert School of Medicine

Uniformed Services University, Bethesda, Maryland 

Henry M. Jackson Foundation

September 17, 2014

1. United Nations Office for the Coordination of Humanitarian 

Affairs. World Humanitarian Data and Trends, 2013. New York, 

NY: OCHA; 2013. https://docs.unocha.org/sites/dms/Documents/

WHDT_2013%20WEB.pdf. Accessed January 26, 2015.

2. Fragoso AD. UN: Four countries face humanitarian crises, worst 

since WWII. McClatchy DC News Service. August 22, 2014. http://

www.mcclatchydc.com/2014/08/22/237452/un-four-countries-facehumanitarian.html. Accessed January 26, 2015.

3. Buskie A. On defining emergencies. UNA-UK New World Magazine. 

Spring 2014. http://www.una.org.uk/magazine/spring-2014/

alexandra-buskie-defining-emergencies. Accessed August 29, 2014.

4. Chuinard EG. Only One Man Died: The Medical Aspects of the Lewis 

and Clark Expedition. Glendale, CA: The Arthur H. Clark CO; 1980: 

405.

5. Ambrose S. Undaunted Courage. New York, NY: Simon and Schuster; 

1996.

6. Callahan C. The roots of military medical humanitarianism. 

AMEDD Journal. 2001;PB8‐01‐7/8/9.

7. Ashburn PM. A History of the Medical Department of the United States 

Army. Boston, MA: Houghton Mifflin Company; 1929.

8. Pierce J. Waiter J. Yellow Jack. How Yellow Fever Ravaged America and 

Walter Reed Discovered Its Deadly Secrets. Hoboken, NJ: J. Wiley and 

Sons; 2005.

9. de Montclos M. The (de)militarization of humanitarian aid: a 

historical perspective. Humanities. 2014;3:232–243.
xxiv

10. Michihiko H. Hiroshima Diary. Wells W, trans. New York, NY: Avon 

Publications; 1955: 220.

11. Callahan C, Bass J, Person D, Shira J. History of military pediatrics. 

Fifty years of training and deploying uniformed pediatricians. 

Pediatr. 1999;103:1298–1303.

12. Cuny FC. Use of the military in humanitarian relief. Address to 

the Finland Military Academy on Peacekeeping, November 1989. 

http://www.pbs.org/wgbh/pages/frontline/shows/cuny/laptop/

humanrelief.html. Accessed January 26, 2015.

13. Naythons M. The Face of Mercy: A Photographic History of Medicine 

at War. New York, NY: Random House; 1993.

14. Burkle FM. Delta Med: a fitting memorial. US Naval Institute 

Proceedings. 1970;96(11):36–39.

15. Seiple C. The US Military/NGO Relationship in Humanitarian 

Interventions. Carlisle Barracks, PA: Peacekeeping Institute, Center 

for Strategic Leadership, US Army War College; 1996.

16. Weiss TG. Military-Civilian Interactions. Intervening in Humanitarian 

Crises. Lanham, MD: New Millennium Books in International 

Studies, Rowman & Littlefield Publishers; 1999.

17. Drifmeyer J, Llewellyn, C. Military training and humanitarian and 

civic assistance. Mil Med. 2004;169;1:23–29.

18. Callahan C, Doyle A, Schobitz E. Military pediatricians in Southwest 

Asia. (Letter.) Pediatr. 2004;114:898.

19. Burnett M, Callahan C. American pediatricians at war: a legacy of 

service. Pediatr. 2012:129;S33–S48.

20. Young RSK, Eccles TG, Giangiulio L, Taylor CE. Pediatricians in 

Iraq. Clin Pediatr. 2005:44:189–192.

21. Matos R, Spinella P, Holcomb J, Callahan C. Increased mortality 

of young children with traumatic injuries at a U.S. Army hospital. 

Pediatr. 2008;122:e959–966.

22. Burnett M, Spinella, P, Azarow K, Callahan C. Pediatric care as a part 

of the U.S. Army medical mission in the global war on terrorism: 

Afghanistan and Iraq December 2001 to December 2004. Pediatr. 

2008;121:261–265.
xxv

23. Creamer K, Edwards MJ, Shields C, Thompson, M, Yu CE, Adelman 

W. Pediatric wartime admissions to US Combat Support Hospitals 

in Afghanistan and Iraq: Learning from the first 2,000 admissions. 

J Trauma. 2009;67:762–768.

24. Cronk TM, Pellerin C. Military responders help battle Ebola 

outbreak. August 1, 2014. http://www.defense.gov/news/

newsarticle.aspx?id=122826. Accessed January 26, 2015.

25. Lamothe D. Meet the new U.S. military force that Obama is 

deploying to fight Ebola. Washington Post. September 16, 2014. http://

www.washingtonpost.com/news/checkpoint/wp/2014/09/16/meetthe-new-u-s-military-force-that-obama-is-deploying-to-fight-ebola. 

Accessed January 26, 2015.

26. Pearn J. Pediatric diseases and operational deployments. Mil Med. 

2000;4:283–286.

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org/har2010/index_lead.html. Accessed January 26, 2015. 
xxvi
1

Basic Approach to Pediatric Trauma

Resuscitation and Critical Care
2

Pediatric Surgery and Medicine for Hostile Environments
3

Basic Approach to Pediatric Trauma

Chapter 1

Basic Approach to Pediatric Trauma

Background 

• Recent epidemiologic reviews of pediatric wartime injuries 

have found significantly higher trauma mortality rates for 

infants, younger children, and females.

• Extremity injuries are the most frequent injuries overall. 

• Children injured by explosive devices demonstrate a unique 

blast pattern primarily involving injury to the face and neck 

with associated burns, and result in a higher mortality.

• Independent predictors of mortality on presentation include 

Glasgow Coma Scale (GCS) score less than 4, shock (base 

deficit ≥ 6), and coagulopathy (international normalized ratio 

≥ 1.5).

• Triage for pediatric trauma is similar to that for adults. It is a 

system used to prioritize treatment, taking into account the 

extent (ie, polytrauma or a single injury) and type of trauma 

(ie, blunt or penetrating) or illness.

Anatomic and Physiologic Considerations

• Vital signs are based on age (Table 1-1).

• Abnormal general appearance is indicative of a serious illness 

or injury.

• Normal responses differ by age (ie, developmental stages).

• Both bradypnea and bradycardia are ominous.

• Children have a greater body surface area-to-weight ratio than 

adults, increasing risk of hypothermia. 

• Hypothermia increases oxygen demand and predisposes to 

apnea and bradycardia.

° Obtain rectal temperature; monitor and maintain 

temperature at 36.5°C to 37.5°C.

° The head is a major source of heat loss; mitigate heat loss 

by covering the head with a hat or cap.
4

Pediatric Surgery and Medicine for Hostile Environments

• Children have greater insensible water loss and have different 

fluid requirements than adults (see Chapter 25, Basic Fluids 

and Electrolytes).

• The larynx is funnel shaped, cephalad, and anterior. The 

cricoid is the narrowest portion of the airway. An infant’s 

trachea is approximately 5 cm long and a toddler‘s is 

approximately 7 cm long. Table 1-1. Normal Vital Signs by Age Group

Weight Respiratory Rate Heart Rate Systolic Blood Pressure

Age (kg)* (Breaths/Min) (Beats/Min) (mmHg)†Premature infant < 3 40–60 130–170 45–60Term newborn 3 35–60 120–160 60–70

( < 28 days)

Infant (1 mo–1 y) 4–10 25–50 110–150 70–100Toddler (1–2 y) 10–13 20–30 90–130 75–110Young child (3–5 y) 13–18 20–30 80–120 80–110Older child (6–12 y) 18–40 15–25 70–110 90–120Adolescent (13–18 y) > 40 12–20 55–100 100–120*Weight norms based on US children. Expect lower weights in countries where malnutrition is more prevalent.†For children 1 to 10 years old, use the following equation: 70 + 2 (age) = lowest acceptable systolic pressure for age.
5

Basic Approach to Pediatric Trauma

• The pediatric skull has expandable sutures until 18 to 24 

months of age.

• Children’s short, fat necks make assessing for tracheal 

deviation or jugular venous distention difficult.

• Cervical spine fractures are less common than ligamentous 

injury, and higher-level cervical injury is more common. Spinal 

cord injury without radiographic abnormality can be seen in 

up to 50% of children with spinal cord injuries.

• Highly elastic ribs make fractures less likely; transmitted 

energy is more likely to cause pulmonary contusion.

• Tension pneumothorax is more likely in children than in adults 

due to the mobile contents of the mediastinum.

• Solid abdominal organs are more susceptible to injury 

because of their proportionally larger size, closer proximity 

to each other, limited protection by ribs, and less-developed 

abdominal walls with limited muscle and subcutaneous fat.

• Fractures of long bones with active growth plates can result 

in length discrepancies.

• Special considerations for neonates (≤ 28 days) and young 

infants:

° This age group is at increased risk for sepsis due to 

decreased white blood cell function and count, decreased 

antibody synthesis, and decreased inflammatory response.

° Neonates are more sensitive to drugs because of their 

immature blood–brain barrier.

° Hypoglycemia is more common in this age group because 

of neonates’ smaller glycogen stores.

° Neonates’ smaller functional residual capacity makes 

desaturation more common.

° Apnea and bradycardia may occur in response to decreased 

partial pressure of oxygen and increased carbon dioxide.

° Hypocalcemia will result in hypotension; intravenous (IV) 

calcium is an inotrope in young infants.

• Psychological impact considerations:

° Very young children may regress in response to pain, stress, 

or perceived threats.

° Involving a parent or guardian may help in calming the 

child and acquiring a history.
6

Pediatric Surgery and Medicine for Hostile Environments

° See Chapter 37, Behavioral Healthcare of Pediatric Patients 

in an Austere Environment.

• Medications are all dosed as units per kilogram per dose. 

Use a Broselow tape for emergency equipment sizing and 

medication dosing (see inside back cover) as well as a reference 

for all routine pediatric drug doses (eg, The Harriet Lane 

Handbook). See Appendix C for a comprehensive pediatric 

equipment table.

The Pediatric Assessment

• With the 2010 American Heart Association Basic Life 

Support update, increased emphasis is placed on the 

rapid identification of pulselessness and early initiation of 

cardiopulmonary resuscitation.

• For unresponsive patients, begin with the sequence of C-A-B 

instead of A-B-C: chest compressions (or circulation), airway, 

and breathing/ventilation. If pulselessness is identified, 

begin basic life support with high-quality cardiopulmonary 

resuscitation and proceed with advanced management 

according to Pediatric Advanced Life Support (PALS) 

algorithms (inside front cover).

• For responsive patients, begin with a PALS rapid 

cardiopulmonary assessment using the pediatric assessment 

triangle in the first seconds based on visual and auditory cues 

to determine if the condition is life-threatening.

° Appearance: assess for alertness, color, speech, motor 

function, eye contact, and whether the child is distractible.

° Work of breathing: assess for abnormal sounds (wheezing, 

stridor, grunting), positioning, retractions, and nasal 

flaring.

° Circulation to skin: assess for temperature, pulse, and 

capillary refill time.

• The pediatric assessment triangle allows for rapid 

categorization of pediatric illness.

° Increased work of breathing indicates respiratory distress.

° Increased work of breathing with abnormal appearance 

indicates respiratory failure.

° Abnormal color indicates further observation is needed.
7

Basic Approach to Pediatric Trauma

° Abnormal color with abnormal appearance indicates shock.

° Abnormal appearance only indicates brain dysfunction.

• Following the initial rapid PALS assessment, begin the 

Advanced Trauma Life Support primary survey, which is a 

hands-on assessment based on the ABCDE (airway, breathing, 

circulation, disability, exposure) approach and should take no 

more than 5 to 10 minutes.

• Life-threatening conditions should be treated as soon as they 

are identified.

Airway 

• The most common cause of cardiac arrest in children is 

respiratory failure.

• Determine if the child’s airway is clear, maintainable with 

simple maneuvers, or compromised, needing advanced 

interventions.

• A child’s relatively large tongue and prominent occiput cause 

the head to flex forward and potentially obstruct the pediatric 

airway. The child’s head should be placed in the sniffing 

position (Figure 1-1). Use a jaw thrust if injury to the cervical 

spine is a concern.

• Position and suction the airway as necessary; consider 

placing an oropharyngeal (in an unconscious patient) or 

nasopharyngeal airway.

• Indications for endotracheal (ET) intubation include any of 

the following:

° GCS score less than or equal to 8.

Figure 1-1. Pediatric airway positioning.
8

Pediatric Surgery and Medicine for Hostile Environments

° No protecting airway reflexes (cough, gag).

° Inability to oxygenate, despite intervention.

° Inability to ventilate, despite intervention.

° Prolonged transport.

° Hemodynamic benefit (hypotension, cardiac arrest).

• Performing rapid sequence intubation:

° Preoxygenate with 100% oxygen by a nonrebreather mask 

for 2 minutes or 4 vital capacity breaths.

° Administer an appropriate adjunct, induction agent (or 

agents), and neuromuscular blockade (Table 1-2).

° Apply cricoid pressure using the thumb and index finger. 

° Perform direct laryngoscopy using appropriately sized 

equipment (see Appendix C).

▶ ET tube size is rapidly estimated as: (age in years + 16)/4.

▶ Consider rounding down in malnourished patients.

° Place ET tube under direct visualization.

▶ Cuffed ET tubes are recommended for children older 

than 8 years.

▶ If there is expected need for high-ventilation pressures 

(ie, pulmonary contusions or edema), early placement 

of cuffed ET tubes, sized 0.5 mm smaller than expected 

for age, may be appropriate.

° Confirm tube position with examination (ie, bilateral 

auscultation, adequate chest rise) and quantitative 

capnography or qualitative carbon dioxide detection.

° Release cricoid pressure.

° Secure tube.

° Confirm with chest radiograph, if available.

• For patients unable to be intubated, transtracheal ventilation 

via needle cricothyroidotomy is a rescue airway option.

° Use a 14- to 16-g IV catheter connected to a resuscitation 

bag with a 2.5 or 3.0 ET tube adapter.

° Alternatively, use a 14- to 16-g IV catheter connected to 

a 3-mL syringe with the plunger removed; connect the 

syringe to a resuscitation bag with a 6.5 or 7.0 ET tube 

adapter.

• Tracheostomy is preferred; surgical cricothyroidotomy should 

not be performed in children under 12 years of age due to risk 

of long-term trauma.
9

Basic Approach to Pediatric Trauma

Table 1-2. Rapid Sequence Intubation Drugs and Doses

Drug Dose Characteristics

Adjunct

Atropine 0.01–0.02 mg/kg IV/IM; Vagolytic; use if < 1 y or 

min 0.1 mg, max 1 mg < 5 y and receiving 

succinylcholine

Lidocaine 1–2 mg/kg IV May decrease ICP during RSI

Sedative/Anesthetic

Etomidate 0.2–0.3 mg/kg IV Few cardiovascular effects; 

decreases cerebral metabolic 

rate and ICP

Fentanyl 2–4 μg/kg IV/IM May cause respiratory 

depression, hypotension, 

chest-wall rigidity

Ketamine 1–2 mg/kg IV May increase heart rate, 

3–5 mg/kg IM blood pressure and secretions; 

recommended for hemodynamic instability

Midazolam 0.1–0.3 mg/kg IV May cause hypotension, 

respiratory depression; no 

analgesia

Propofol 2 mg/kg IV May cause hypotension, 

particularly in hypovolemic 

patients

Thiopental 2–5 mg/kg IV Negative inotrope; decreases 

cerebral metabolic rate and 

ICP

Paralytic

Rocuronium 0.6–1.2 mg/kg IV Few cardiovascular effects

Succinylcholine 2 mg/kg IV (infant) Recommend coadminis1 mg/kg IV (child) tration of atropine if < 8 y;

Double dose for IM contraindicated with history 

of malignant hyperthermia, 

skeletal muscle myopathies, 

acute phase injury following 

major burns/polytrauma 

ICP: intracranial pressure

IM: intramuscular

IV: intravascular

RSI: rapid sequence intubation
10

Pediatric Surgery and Medicine for Hostile Environments

Breathing

• Assess for age-appropriate respiratory rate. Tachypnea greater 

than 60 breaths per minute is abnormal for any age.

• A declining respiratory rate to an expected age norm may 

be reassuring if it is associated with improved appearance; 

however, with worsening appearance, such a decline may be 

indicative of impending respiratory failure.

• Assess efficacy of respiratory effort on examination. Signs of 

respiratory distress include:

° retractions (inspiratory);

° grunting (expiratory), which indicates airway or alveolar 

collapse;

° inspiratory stridor, which indicates extrathoracic 

obstruction; and

° wheezing, which indicates intrathoracic obstruction.

• Assess efficacy of ventilation based on chest wall excursion 

and air movement on auscultation.

° Decreased air entry is a sign of parenchymal lung disease 

or poor effort.

° Hypoventilation is common in pediatric trauma.

° Avoid hypercarbia.

• Apply supplemental high-flow oxygen and positive-pressure, 

bag-valve mask ventilation as necessary.

° Deliver 1 breath every 3 to 5 seconds (12 to 20 breaths/min) 

for nonintubated patients, and every 6 to 8 seconds (8 to 10 

breaths/min) with an advanced airway in place.

° Deliver enough volume to generate good chest rise.

• Perform needle decompression, then insert a chest tube for 

tension pneumothorax (diagnostic signs and symptoms 

include hypoxemia, hypotension, and absent breath sounds).

Circulation

• Observe the child’s mental status; level of reactivity and 

responsiveness are usually a reflection of cerebral perfusion.

• Compare central and peripheral pulse rate and quality.

• Observe capillary refill time. Normal is less than 2 seconds; 

longer than 3 seconds can indicate shock.
11

Basic Approach to Pediatric Trauma

• Evaluate the patient’s skin temperature centrally and distally 

using the back of the hand. Cooler extremities may indicate 

poor distal perfusion. Patient temperature should also be 

considered in the context of the room temperature. 

• Rapidly identify ongoing hemorrhage and control bleeding.

• Begin cardiorespiratory monitoring with 3-lead electrocardiography and pulse oximetry; determine heart rate and rhythm.

• Measure blood pressure and pulse pressure early.

° A child can still be in shock with a normal blood pressure 

(compensated shock).

° Low blood pressure for the child’s age indicates 

decompensated shock.

• Establish vascular access (intraosseous if necessary).

° Treat shock and hypotension aggressively (see Chapter 6, 

Hemodynamics and Shock).

° The preferred isotonic fluid is either 0.9% normal saline or 

Lactated Ringer’s.

° The standard bolus volume for a child is 20 mL/kg, repeated 

twice up to 60 mL/kg total. 

• Blood products should be transfused if a resuscitation volume 

greater than 60 mL/kg is necessary, though earlier transfusion 

should be considered for hemorrhagic shock. Use a bolus of 

10- to 15-mL/kg packed red blood cells for blood replacement 

(see Chapter 5, Transfusion Medicine).

• Diagnose and treat pericardial tamponade. Diagnostic signs 

and symptoms include tachycardia, pulsus paradoxus, and 

narrow pulse pressure, as well as Beck’s triad (systemic 

hypotension, muffled heart sounds, and jugular venous 

distension). Tamponade may precipitate cardiac arrest with 

pulseless electrical activity.

Disability 

• Quantify modified GCS score (Table 1-3).

• Evaluate for signs of neurological deficit and/or increased 

intracranial pressure, such as headache, vomiting, altered 

mental status, pupillary dilation, or posturing.

• Cushing’s triad (irregular respirations, hypertension, and 

bradycardia) is a late finding of neurological decline.
12

Pediatric Surgery and Medicine for Hostile Environments

Table 1-3. Modified Glasgow Coma Scale

Activity Infant Child/Adult Score

Eye Opening Spontaneous Spontaneous 4

To speech To speech 3

To pain only To pain only 2

No response No response 1

Verbal Coos and babbles Oriented, appropriate 5

Irritable cries Confused 4

Cries to pain Inappropriate words 3

Moans to pain Incomprehensible 2

 sounds

No response No response 1

Motor Moves spontaneously Obeys commands 6

and purposefully

Withdraws to touch Localizes painful 5

 stimulus

Withdraws to pain Withdraws to pain 4

Abnormal flexion Flexion in response to 3

posture to pain pain

Abnormal extension Extension in response 2

posture to pain to pain

No response No response 1 

Data source: The Merck Manual. Traumatic Brain Injury. Modified Glasgow 

Coma Scale for Infants and Children. Table 3. http://www.merckmanuals.com/

professional/injuries_poisoning/traumatic_brain_injury_tbi/traumatic_brain_

injury.html?qt=&sc=&alt=. Accessed October 31, 2014.

• Spinal cord injury may present with neurogenic shock, a type 

of distributive shock characterized by loss of sympathetic tone 

with peripheral vasodilation, hypotension with wide pulse 

pressure, and sometimes bradycardia.

• Minimize secondary brain injury by avoiding or aggressively 

treating hypotension, hypoxemia, hyperthermia, hypercarbia, 

and hyperglycemia.

• Consider administering 2 to 4 mL/kg of 3% hypertonic saline 

to decrease intracranial pressure and help restore intravascular 

volume.
13

Basic Approach to Pediatric Trauma

Exposure

• Look for other injuries and be wary of heat loss.

• Adjuncts to the primary survey include cardiorespiratory 

monitoring, pulse oximetry, end-tidal carbon dioxide, arterial 

blood gas monitoring, urinalysis, placement of a Foley or 

gastric catheter, and radiographs (chest, pelvis, lateral cervical 

spine).

Secondary Survey

• The secondary survey should be completed in 10 to 15 

minutes and includes a focused history and detailed headto-toe examination, with particular attention to identifying 

all injuries requiring surgical intervention.

• The SAMPLE pneumonic (signs/symptoms, allergies, 

medications, past medical history, last meal, and events) is 

often used to obtain the focused history.

• Standard secondary survey adjuncts include complete blood 

count; coagulation studies; liver function, amylase, and lipase 

tests; blood type and cross match; computed tomography 

scans; complete cervical spine series (including thoracolumbar 

spine if necessary); and angiography (if necessary and 

available).

• Prioritize management of injuries found in secondary survey.

• Inadequate resuscitation is common; continuously reassess 

vital signs and airway, breathing, and circulation.

Further Reading

1. American College of Surgeons. Advanced Trauma Life Support (ATLS) 

Student Course Manual. 9th ed. Chicago, IL: ACS; 2012.

2. Berg MD, Schexnayder SM, et al. 2010 American Heart Association 

Guidelines for Cardiopulmonary Resuscitation and Emergency 

Cardiovascular Care. Part 13: Pediatric basic life support. Circulation. 

2010;122(18 Suppl 3):S862–S875.

3. Kleinman ME, Chameides L, Schexnayder SM, Samson RA, 

Hazinski MF, Atkins DL. 2010 American Heart Association 

Guidelines for Cardiopulmonary Resuscitation and Emergency 

Cardiovascular Care. Part 14: Pediatric advanced life support. 

Circulation. 2010;122(18 Suppl 3):S876–S908.
14

Pediatric Surgery and Medicine for Hostile Environments

4. Borgman M, Matos RI, Blackbourne LH, Spinella PC. Ten years of 

military pediatric care in Afghanistan and Iraq. J Trauma Acute Care 

Surg. 2012 Dec;73(6 Suppl 5):S509–S513.

5. Borgman MA, Maegele M, Wade CE, Blackbourne LH, Spinella PC. 

Pediatric trauma BIG score: predicting mortality in children after 

military and civilian trauma. Pediatrics. 2011 Apr;127(4):e892–e897. 

6. Creamer K, Edwards MJ, Shields C, Thompson M, Yu CE, Adelman 

W. Pediatric wartime admissions to US combat support hospitals 

in Afghanistan and Iraq: learning from the first 2,000 admissions. 

J Trauma. 2009;67:762–768.

7. Edwards MJ, Lustik M, Eichelberger MR, Elster E, Azarow K, 

Coppola C. Blast injury in children: an analysis from Afghanistan 

and Iraq, 2002–2010. J Trauma Acute Care Surg. 2012 Nov;73(5):1278–

1283.

8. Gausche-Hill M, Fuchs S, Yamamoto L, eds. The Pediatric Emergency 

Medicine Resource. Revised 4th ed. Sudbury, MA: Jones & Bartlett; 

2007.

9. Madden MA, ed. Pediatric Fundamental Critical Care Support. 2nd 

ed. Mount Prospect, IL: Society of Critical Care Medicine; 2013.

10. Matos R, Spinella P, Holcomb J, Callahan C. Increased mortality 

of young children with traumatic injuries at a U.S. Army hospital. 

Pediatrics. 2008;122:e959–e966.

11. Patregnani JT, Borgman MA, Maegele M, Wade CE, Blackbourne LH, 

Spinella PC. Coagulopathy and shock on admission is associated 

with mortality for children with traumatic injuries at combat 

support hospitals. Pediatr Crit Care Med. 2012 May;13(3):273–277.

12. Spinella PC, Borgman MA, Azarow KS. Pediatric trauma in 

an austere combat environment. Crit Care Med. 2008 Jul;36(7 

Suppl):S293–S296.

13. Tschudy MM, Arcara KM, eds. The Harriet Lane Handbook. 19th ed. 

New York, NY: Mosby; 2012.
15

Anesthesia

Chapter 2

Anesthesia

Pediatric trauma anesthesia varies significantly from adult 

trauma anesthesia because of the anatomical and physiological 

differences between adults and children (Table 2–1).

Table 2-1. Anatomical Considerations

Airway Anatomy Implications

Infants have a large The traditional sniffing position will flex the infant’s

occiput, anterior airway large head downward and is not helpful; place a 

rolled towel under the shoulders to facilitate 

intubation

Small airway means Tube can easily become plugged with blood or 

small endotracheal tube secretions

Cricoid is the narrowest Ensure leak at less than 20–25 cm H2O pressure to 

part of the airway avoid edema*

Short trachea Endobronchial intubation is common; making 

auscultation of bilateral breath sounds 

imperative; extubation can be caused by small 

movements of the head or ET tube

Infants have increased Bronchospasm is common, especially during light 

airway reactivity anesthesia or if ET tube is near the carina

Infants have an increased Increased risk of rebreathing carbon dioxide; avoid

dead space/minute adding connectors between ET tube and Y-piece

ventilation ratio of the circuit

ET: endotracheal

*For significant pulmonary contusions and edema, short-term cuff pressure > 25 cm H2

O 

may be needed and outweighs long-term risks. Ventilating pediatric patients is difficult 

with manually adjusted field anesthesia machines. Intensive-care-unit-grade ventilators 

are more effective at generating exact tidal volumes and can be used with intravenous 

anesthesia.
16

Pediatric Surgery and Medicine for Hostile Environments

Physiological Considerations

• Infants and small children are unable to increase their stroke 

volume, making them dependent on heart rate to maintain 

cardiac output. 

• In infants less than 6 months old, consider using atropine 

before induction or rapid sequence intubation to maintain 

heart rate (see Chapter 1, Basic Approach to Pediatric Trauma, 

Table 1-1 for normal vital signs).

• Hypoventilation is the most common cause of cardiac arrest 

in children.

• Respiratory acidosis, further exacerbating a metabolic 

acidosis, is a common occurrence in injured children.

• Hypotension is a late sign of hypovolemia in children.

° Blood pressure usually remains normal until more than 

25% blood volume is lost.

° Poor perfusion, evidenced by cool extremities, delayed 

capillary refill, and diminished distal pulses, is an early 

sign of hypovolemia.

° The most common causes of hypotension in pediatric 

patients are hypovolemia or excessive concentrations of 

volatile anesthetics once under anesthesia.

• If the patient is not responding to volume, medications may 

be needed to increase blood pressure.

° Phenylephrine should not be a first-line choice for treating 

intraoperative hypotension in children.

° Small doses of epinephrine are a better first-line choice.

▶ Start with 1 to 4 μg and titrate to effect.

▶ At low doses, the β effects of epinephrine predominate, 

increasing heart rate and contractility.

° Consider a continuous infusion of inotropes or pressors 

if hypotension persists despite adequate fluid and blood 

product resuscitation. Dopamine and epinephrine are the 

preferred vasopressor infusions for pediatric patients.

Intubation

• Indications include altered level of consciousness, impending 

or actual upper airway obstruction, and hemodynamic 

instability.
17

Anesthesia

• Orotracheal intubation is the most reliable means of 

establishing an airway and ventilating a child. The risk of 

penetrating the cranial vault or injuring the nasopharyngeal 

soft tissue is a relative contraindication to the use of the 

nasotracheal route in patients less than 12 years old.

• In head-injured or comatose patients, intubation should be 

performed with cervical spinal immobilization.

• Video laryngoscopes can be a useful adjunct when intubating 

patients with cervical spine immobilization.

• For chronically malnourished children, consider starting with 

a slightly smaller tube.

Airway Formulas

• Ways to estimate the appropriate endotracheal tube size:

° (Age + 16)/4

° Height (cm)/20

° Size of child’s small finger (fifth digit on hand)

° Premature infant: 2.5 

° Term infant: 3.0 

• Ways to estimate appropriate depth of endotracheal tube (cm; 

from tip to lip):

° Infant: 6 + weight (kg)

° Child: 3 × size (inner diameter) of tube

• NOTE: These are only estimates; always evaluate clinically.

Surgical Airway

In infants and small children, cricothyroidotomy may cause 

long-term damage to the larynx, so tracheostomy is preferred. 

Cricothyroidotomy can be safely performed in children older 

than 11 years.

Initial Ventilator Settings

• Set tidal volume to 7 to 10 mL/kg.

• If using pressure control, peak inspiratory pressure (PIP) 

should be 20 to 25 cm H2O.

• Positive end-expiratory pressure (PEEP) should be 3 to 5 cm 

H2O.

• Age-appropriate respiratory rates:
18

Pediatric Surgery and Medicine for Hostile Environments

° Adolescents: 10 to 15 breaths per minute (bpm)

° Children: 15 to 25 bpm

° Infants: 25 to 30 bpm

• Titrate minute ventilation to achieve end tidal carbon dioxide 

35 to 40 mmHg.

• Fraction of inspired oxygen should be set to 100% initially, 

then titrate to nontoxic levels as permissible.

Pediatric Equipment Sizing

In an emergency, the preferred method of determining 

equipment size for pediatric patients is using the Broselow 

Pediatric Measuring Tape (see inside back cover). To use the 

tape, measure the patient from the top of the head to the heels 

and use the equipment and drug doses indicated on the tape. For 

central line sizes, refer to Chapter 3, Vascular Access. Otherwise, 

refer to the equipment table in Appendix C.

Pediatric Trauma Resuscitation

Acidosis, hypothermia, and coagulopathy are a deadly triad 

for patients presenting with major exsanguinating trauma.

Hypothermia

• Pediatric patients are predisposed to hypothermia because of 

their large surface-area-to-weight ratio, thin skin, and paucity 

of subcutaneous fat.

• Hypothermia worsens preexisting acidosis by causing a 

leftward shift in the oxyhemoglobin dissociation curve, 

leading to decreased oxygen delivery to the tissues.

• It can cause decreased drug metabolism and, in infants, can 

lead to apnea and hypoglycemia.

• Aggressive rewarming and normothermia maintenance 

must be initiated immediately upon a pediatric trauma 

patient’s arrival. Strategies for increasing or maintaining body 

temperature include, but are not limited to:

° increasing the room temperature,

° using forced-air warmers,

° preparing and working on one body part at a time while 

leaving the rest of the child covered, and 
19

Anesthesia

° wrapping the child’s body and head in plastic bags.

• Fluid-warming devices are helpful; however, the volume of 

fluid and blood products administered to the pediatric patient 

must be controlled. One way to do this is to use a syringe at 

the end of the warming line to carefully measure the volume 

of intravenous (IV) fluids and blood products being given.

Fluid Resuscitation

• In cases where blood products are not the initial therapy of 

choice, begin fluid resuscitation with a 20 mL/kg bolus of 

normal saline (NS) or Lactated Ringer’s (LR).

° The best locations for large-bore IV access are the saphenous 

veins; for difficult patients consider the hands, feet, scalp, 

underside of wrist, or external jugular vein.

° If IV access is not rapidly achieved (in 1–3 min), immediately 

proceed to intraosseous (IO) access.

° Resuscitate through the IO access and then obtain reliable 

IV access.

° IO sites along the proximal tibia and distal femur can be 

used.

° The patient should be reassessed after each bolus of NS 

to evaluate whether more fluid or a change to blood is 

required.

° If the child remains hypotensive after three 20 mL/kg 

boluses, administer 10 to 20 mL/kg packed red blood cells.

• For small IV catheters (22 gauge and 24 gauge), bolusing with a 

10- to 20-mL syringe is the most efficient way to rapidly deliver 

fluids and blood products (see Table 2-2 for maintenance fluid 

recommendations).

Table 2-2. Maintenance Fluid Requirements

Weight (kg) Intravenous Fluid Rate

Up to 10 4 mL/kg/h

10–20 kg 40 mL/h + 2 mL/kg/h for each kg > 10

> 20 kg 60 mL/h + 1 mL/kg/h > 20 kg
20

Pediatric Surgery and Medicine for Hostile Environments

• Small children (< 2 years old) can occasionally become 

hypoglycemic during long operative cases. The tendency 

toward hypoglycemia is usually counterbalanced by the stress 

response of surgery. If potential hypoglycemia is concerning, 

run a maintenance-only infusion using an infusion of D5 0.45% 

NS (do not include glucose in any of the resuscitation fluids 

to avoid hyperglycemia).

Monitoring

• All patients should have American Society of Anesthesiologists standard monitors in place (blood pressure cuff, electrocardiogram, pulse oximetry, temperature, capnometry).

• Consider placing an arterial line if large fluid shifts or frequent 

blood draws are anticipated.

° Arterial lines can be placed in the radial, posterior tibial, 

or dorsal pedis arteries (< 5 kg use 24 g, > 5 kg use 22 g).

° A femoral arterial line can be placed if other sites are 

unavailable, but requires a longer catheter.

Blood Therapy

• See Chapter 5, Transfusion Medicine, for guidance on routine 

and massive transfusion strategies.

• Hypocalcemia is associated with rapid infusion of colloids, 

including blood products (particularly fresh frozen plasma 

and fresh warm whole blood).

° Severe cardiac depression and hypotension can result 

from ionized hypocalcemia (potent inhalational agents 

dramatically exacerbate hypotension).

° Do not routinely transfuse at a rate faster than 1 mL/kg/

min.

° Prevention includes limiting the rate of fresh frozen plasma 

transfusion to less than 1 mL/kg/min and administering 

calcium chloride (5 mg/kg) or calcium gluconate (15 mg/

kg) via a central line if available. When both are available, 

calcium gluconate is preferred, as calcium chloride can 

sclerose peripheral veins.

• To minimize coagulopathy if a patient is at risk for massive 

transfusion (> 1⁄2 circulating blood volume), packed red blood 

cells and fresh frozen plasma should be transfused in a 1:1 
21

Anesthesia

ratio, with appropriate alternating weight-based repletion 

of platelets and cryoprecipitate, if available (see Chapter 5, 

Transfusion Medicine, for details).

Burns (see also Chapter 12, Burns)

• In children with unrecognized inhalational injuries, severe 

airway swelling may occur after fluid resuscitation. 

• If there is uncertainty about whether an inhalational injury 

has occurred, intubate early.

• In addition to maintenance fluids (see Table 2-2), use the 

Parkland formula to estimate additional resuscitation fluids 

in the first 24 hours based on body weight (BWt) and total 

body surface area (TBSA) burned:

° Adult: 4 mL × BWt (kg) × TBSA (%)

° Pediatric: 3 mL × BWt (kg) × TBSA (%)

• Use LR as the resuscitation fluid in the first 24 hours.

• Give half of resuscitation fluids in the first 8 hours, half over 

the next 16 hours.

• For patients that weigh less than 30 kg, use D5LR for 

maintenance fluids.

• The goal is to give enough fluids to maintain a urine output 

of 1 mL/kg/h for children weighing less than 30 kg, and 0.5 

to 1 mL/kg/h in adults.

• Consider pulmonary injury, carbon monoxide poisoning, and 

chemical exposure, particularly in closed-space burns.

• Consider airway burns and edema when patient presents with 

discolored sputum.

• Nutritional support is critical; start tube feedings as soon as 

possible postoperatively.

• Blood loss during burn excision: 3% of blood volume for every 

1% of BSA excised.

• Blood loss during skin grafting: 2% of blood volume for every 

1% of BSA grafted.

Preoperative Sedation

Children who require repeated operations after sustaining initial 

trauma will benefit from preoperative sedation. However, the 

effects of most preoperative anxiolytics will extend into the 

postoperative period. In children for whom IV access has been 
22

Pediatric Surgery and Medicine for Hostile Environments

established, dose-adjusted preoperative sedation regimens 

similar to those used in adults are appropriate. 

• For children without IV access, the following are some of the 

available options:

° Oral: midazolam 0.5 to 1 mg/kg (maximum dose 20 mg) 

20 minutes prior to the procedure.

° Rectal: methohexital 25 to 30 mg/kg, for children weighing 

less than 15 kg. Mix 500 mg methohexital with water to a 

volume of 5 mL (100 mg/mL).

° Intramuscular: 

▶ 0.2 mg/kg midazolam, and

▶ 2 to 5 mg/kg ketamine, and

▶ 5 to 10 μg/kg glycopyrrolate.

▶ Use midazolam 5 mg/mL to minimize volume.

Postoperative Pain Management

• Use a continuous IV opioid infusion (Table 2-3) if unable to 

use patient-controlled analgesia (PCA).

Table 2-3. Intravenous Narcotics: Continuous Infusion*

Drug Loading Dose Continuous Infusion

Morphine 0.05 mg/kg 0.01–0.06 mg/kg/h

Fentanyl 1 μg/kg 0.2–3 μg/kg/h

Hydromorphone 10 μg/kg 0.5–4 μg/kg/h

*Bolus to achieve analgesia and start infusion at a lower rate. If analgesia is inadequate, 

rebolus with half the first dose, and increase rate by 25%.

• Respiratory depression or arrest is a known complication of 

continuous narcotic infusions, and continuous pulse oximetry 

monitoring is indicated.

• Infants less than 6 months old can have decreased metabolism 

and narcotics clearance, which requires consideration when 

administering frequent narcotic doses or a continuous 

infusion. Children with a significant narcotic use history can, 

however, develop tolerance quickly and require escalating 

doses.

• PCA is usually suitable for children older than 6 years (Table 

2-4).
23

Anesthesia

° Communication must be sufficient to ensure both the 

patient and parent understand appropriate PCA use.

° Loading dose is the same as for continuous infusion.

° Basal rates are associated with overdoses in adults; monitor 

closely or avoid if possible.

° Prevent the family from pushing PCA button.

• Intermittent IV opioid dosing is as follows:

° Morphine: 0.05 to 0.1 mg/kg IV every 5 to 10 minutes, titrate 

to effect. Use this total dose as basis for IV every 2- to 4-h 

dosing.

° Fentanyl: 0.5 to 1 μg/kg IV every 5 to 10 minutes, titrate 

to effect. Use this total dose as basis for IV every 1- to 2-h 

dosing.

• Oral opioids and other adjuvant medications

° Acetaminophen has opioid-sparing effects.

▶ IV: 2 years: 7.5 to 15 mg/kg/dose every 6 h, max 60 mg/

kg/day. 2 to 12 years: 15 mg/kg/dose every 6 h, max 75 

mg/kg/day.

▶ Oral: 10 to 15 mg/kg every 4 to 6 h; max 75 mg/kg/day.

▶ Per rectum: 25 to 45 mg/kg load, then 10 to 20 mg/kg 

every 6 h, max 100 mg/kg/day.

° Ketorolac

▶ Dose: 0.5 mg/kg IV every 6 h for no more than 5 days.

▶ Avoid if patient is less than 6 months old or has renal 

dysfunction.

° Tramadol is a weak μ opioid receptor agonist. Dose: 1–2 

mg/kg orally every 6 h, max 400 mg/day.

° Acetaminophen with codeine 

▶ Codeine dosing is 0.5 to 1 mg/kg/dose orally every 4 to 

6 h, max 60 mg/dose.

Table 2-4. Patient-Controlled Analgesia Dosing*

Drug Dose Basal Rate Lock out

Morphine 10–30 μg/kg 5–30 μg/kg/h 6–12 min

Fentanyl 0.25–1.0 μg/kg 0.25–1 μg/kg/h 6–12 min

Hydromorphone 2–6 μg/kg 1–3 μg/kg/h 6–12 min

*Patient-controlled analgesia can be used in a normal, cooperative child as young as 6 

years old.
24

Pediatric Surgery and Medicine for Hostile Environments

▶ Dose is limited by maximum daily dose of acetaminophen.

▶ 25% of patients cannot convert codeine to its active 

formulation, and it will not be effective in these patients. 

▶ Adjust codeine dose in the presence of renal or liver 

dysfunction.

° Oxycodone 

▶ Oral: 0.05 to 0.15 mg/kg/dose every 4 to 6 h, max 10 mg/

dose.

▶ If combined with acetaminophen, daily dose is limited 

by maximum dose of acetaminophen.

• Consider proactively adding a laxative while patient is on 

narcotics.

Regional Anesthesia

Regional anesthesia (Tables 2-5–2-7) may be contraindicated 

by shock or sepsis at initial presentation, but can be effective after 

initial stabilization and is usually performed while the child is 

anesthetized. 

• Cardiorespiratory monitoring should be used for all patients 

less than 6 months old receiving continuous infusions, and 

for all patients receiving clonidine.

Table 2-5. Pediatric Caudal or Epidural Blocks Dosing

Age Bupivacaine Ropivacaine Clonidine Fentanyl

Single Injection

< 1 y 0.25%, 1 mL/kg 0.2%, 1.2 mL/kg 1 μg/kg 2 μg/mL

> 1 y 0.25%, 1 mL/kg, 0.2–0.5%, max 20 1 μg/kg 2 μg/mL

max 20 mL mL or 3.5 mg/kg

Continuous Infusion

< 6 mo 0.0625%, 0.2 0.1%–0.2%, 0.2 0.15 μg/kg/h 2 μg/mL

mg/kg/h mg/kg/h

6–12 mo 0.125%, 0.3 0.1-0.2%, 0.3 0.15 μg/kg/h 2 μg/mL

mg/kg/h mg/kg/h

> 1 y 0.125%, 0.3–0.4 0.1%–0.2%, 0.4 0.15 μg/kg/h 2 μg/mL

mg/kg/h mg/kg/h 

Reproduced from: Buckenmaier C, Bleckner L. Military Advanced Regional Anesthesia and 

Analgesia Handbook. Washington, DC: Borden Institute; 2009: Table 30-2.
25

Anesthesia

Table 2-6. Pediatric Spinal Dosing

Bupivacaine Tetracaine* Ropivacaine

Age (mg/kg) (mg/kg) (mg/kg)

Infants 0.5–1 0.5–1 0.5–1

1–7 y† 0.3–0.5 0.3–0.5 0.5

> 7 y† 0.2–0.3 0.3 0.3–0.4

*With tetracaine, use epinephrine wash (epinephrine aspirated from vial and then fully 

expelled from the syringe prior to drawing up local anesthetic) to increase duration up to 

120 minutes.

†

Additives: clonidine 1–2 μg/kg for children > 1 year of age.

Reproduced from: Buckenmaier C, Bleckner L. Military Advanced Regional Anesthesia and 

Analgesia Handbook. Washington, DC: Borden Institute; 2009: Table 30-3.

Table 2-7. Drug Dosing for Pediatric Single-Injection 

Peripheral Nerve Block*

Dose Range Midrange Dose Maximum Volume

Block (mL/kg) (mL/kg) (mL)

Parascalene 0.2–1 0.5 20 

Infraclavicular 0.2–1 0.5 20 

Axillary 0.2–0.5 0.3 20 

Paravertebral 0.5–1 0.7 5 

Femoral 0.2–0.6 0.4 17 

Proximal sciatic 0.3–1 0.5 20 

Popliteal 0.2–0.4 0.3 15 

Lumbar plexus 0.3–1 0.5 20

*Children < 8 y: 0.2% ropivacaine or 0.25% bupivacaine. Children > 8 y: 0.5% ropivacaine 

or 0.5% bupivacaine. Do not exceed maximum recommended doses of local anesthetic.

Reproduced from: Buckenmaier C, Bleckner L. Military Advanced Regional Anesthesia and 

Analgesia Handbook. Washington, DC: Borden Institute; 2009: Table 30-4.

• Lower the infusion rates of continuous bupivacaine and 

ropivacaine, due to immature liver metabolism in infants less 

than 6 months old that may lead to drug accumulation.

• Spinal anesthesia is more commonly performed in awake 

patients and is used as the primary anesthetic for surgery.

Further Reading

1. American College of Surgeons. Advanced Trauma Life Support (ATLS) 

Student Course Manual. 9th ed. Chicago, IL: ACS; 2012.
26

Pediatric Surgery and Medicine for Hostile Environments

2. US Department of Defense. Emergency War Surgery. 4th ed. Fort 

Sam Houston, TX: Borden Institute; 2014.

3. Mattei P. Pediatric Surgery: Surgical Directives. 1st ed. Philadelphia, 

PA: Lippincott Williams & Wilkins; 2003.

4. O’Neill JA Jr, Grosfeld JL, Fonkalsrud EW, Coran AG, Caldamone 

AA. Principles of Pediatric Surgery. 2nd ed. St Louis, MO: Mosby; 

2003.

5. Davis PJ, Cladis FP, Motoyama EK. Smith’s Anesthesia for Infants 

and Children. 8th ed. Philadelphia, PA: Mosby Elsevier; 2011.

6. Barcelona SL, Coté CJ. Pediatric resuscitation in the operating room. 

Anesthesiol Clin North America. 2001;19(2):339–365.

7. Smith HM, Farrow SJ, Ackerman JD, Stubbs JR, Sprung J. Cardiac 

arrests associated with hyperkalemia during red blood cell 

transfusion: a case series. Anesth Analg. 2008;106:1062–1069.

8. Duchesne JC, Hunt JP, Wahl G, et al. Review of current blood 

transfusions strategies in a mature level 1 trauma center: were we 

wrong for the last 60 years? J Trauma. 2008;65:272–276.

9. González EA, Moore FA, Holcomb JB, et al. Fresh frozen plasma 

should be given earlier to patients requiring massive transfusion. 

J Trauma. 2007;62:112–119.

10. Al-Said K, Anderson R, Wong A, Le D. Recombinant factor VIIa for 

intraoperative bleeding in a child with hepatoblastoma and a review 

of recombinant activated factor VIIa use in children undergoing 

surgery. J Pediatr Surg. 2008;43:e15–e19.

11. Perkins JG, Schreiber MA, Wade CE, Holcomb JB. Early versus 

late recombinant factor VIIa in combat trauma patients requiring 

massive transfusion. J Trauma. 2007;62:1095–1101.

12. Spinella PC. Warm fresh whole blood transfusion for severe 

hemorrhage: US military and potential civilian applications. Crit 

Care Med. 2008;36:S340–S345.

13. Larsson BA, Lonnqvist PA, Olsson GL. Plasma concentrations of 

bupivacaine in neonates after continuous epidural infusion. Anesth 

Analg. 1997;84:501–505.

14. Fishman SM, Ballantyne JC, Rathmell JP. Bonica’s Management of 

Pain. 4th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2010.

15. Berde CB, Sethna NF. Analgesics for the treatment of pain in 

children. N Engl J Med. 2002;347:1094–1103. 
27

Vascular Access

Chapter 3

Vascular Access

Introduction

Obtaining vascular access in infants and children can be difficult 

even under optimal conditions. Attempting emergent venous 

access in a hypotensive or struggling infant is even more 

challenging. However, the ability to perform this task in an 

expeditious manner is essential to resuscitation. 

Routine Access

Careful consideration should be given to the routine sites 

for peripheral intravenous (IV) access before more emergent 

techniques are employed. 

• Often access can be obtained via the peripheral veins on the 

back of the hand, in the antecubital space, or in the greater 

saphenous vein at the ankle. 

• Common pitfalls in pediatric IV placement include attempting 

placement without sufficient assistance to adequately 

restrain the child, especially the involved extremity, and an 

inexperienced provider attempting to insert a catheter of 

insufficient size.

° Infants can usually accept 22- and 24-gauge IV catheters, 

while toddlers’ and young children’s veins can accommodate 

20- and 22-gauge catheters. 

° As an older child’s size approaches adult size, the child is 

more likely to tolerate 16- and 18-gauge catheters.

• When timely attempts at routine peripheral access fail, 

consider external jugular venous cannulation or intraosseous 

(IO) needle placement. In an emergency, these alternatives, 

especially IO needle placement, should be performed within 

2 minutes.
28

Pediatric Surgery and Medicine for Hostile Environments

External Jugular Vein Cannulation

• The external jugular vein is a large peripheral vein that offers 

quick access to central circulation and is relatively easy to 

cannulate.

• It lies superficially along the lateral aspect of the neck, 

extending from the angle of the mandible downward until 

it pierces the deep fascia of the neck, just above the middle 

of the clavicle, ending in the subclavian vein. Because it is a 

very superficial vein, it tends to “roll” and be positional. Slight 

movement of the head may affect the flow of fluid.

• Technique

° Position the patient in the supine, Trendelenburg position 

and rotate the head to the contralateral side. Position an 

infant at the edge of an examination table with the child’s 

head lowered further (this is a 3-person technique).

° Prepare the skin using an aseptic technique and position a 

sterile drape.

° Apply digital pressure to the vein distally (just above the

clavicle), which will often distend the vein (applying slight 

traction with the thumb at the proximal portion of the vein 

may prevent the vein from rolling).

° Insert an IV catheter with an attached empty syringe 

into the center of the vein, keeping in mind its superficial 

position.

° After puncturing the skin, aspirate on the syringe and,

immediately upon seeing a flashback, advance the catheter 

into the lumen of the vein; stop if you meet resistance.

° Secure the catheter to the skin using tape or a sterile 

adhesive dressing.

° Maintaining the head in a neutral position will often 

optimize IV flow.

• Complications

° Manipulation of the head in trauma patients with 

potential cervical spine injuries should be performed with 

appropriate caution.

° Reduce the risk of air embolism by using a syringe attached 

to the angiocatheter during insertion.

° Pneumothorax is a remote possibility.

° Hematoma and vascular laceration are possible.
29

Vascular Access

° If the carotid artery is punctured, remove the catheter and 

apply direct finger pressure.

Intraosseous Needle Placement

• IO needle placement can provide emergency vascular access 

in a child when peripheral access is unobtainable. 

• When treating patients with cardiac arrest, IO placement 

should be considered the initial vascular access route. 

• This technique can be used on patients of all ages and is 

preferred over the endotracheal route for administering 

emergency medications. 

• The only emergency medication that cannot be administered 

via the IO route is Intralipid (Fresenius Kabi AG, Bad Homburg, 

Germany; indicated for local anesthetic cardiotoxicity [eg, 

lidocaine]). 

• The bone marrow, a noncollapsible structure with a rich 

marrow venous plexus, can provide a rapid and reliable route 

for administering crystalloids, blood and blood products, 

vasopressors, and other drugs into the central circulation 

within seconds from the time of injection.

• Although products specifically designed for IO access are 

ideal, a styletted needle used for bone marrow aspiration or 

a large adult spinal needle can be used in an emergency.

• Technique

° Common insertion sites (Figure 3-1):

▶ Tibial plateau: the flat medial surface of the proximal 

tibia 1 to 2 cm below the tibial tuberosity.

▶ Distal femur: 3 cm above the superior aspect of the 

patella.

▶ Distal tibia, radius, and ulna; iliac crests; or sternum (use 

extreme caution if attempting insertion at this site in a 

young child).

° Place the knee in approximately 30 degrees of flexion.

° Apply rigid support to the posterior aspect of the insertion

site (do not place your hand directly posterior to where the 

needle will be driven).

° Using an aseptic technique, prepare the selected site with

topical povidone iodine and chlorhexidine gluconate.
30

Pediatric Surgery and Medicine for Hostile Environments

primary

insertion

site

alternate

insertion

site

alternate

insertion

site

Figure 3-1. Preferred sites for intraosseous 

needle placement.
31

Vascular Access

° In an awake patient, infiltrate the skin and subcutaneous 

tissue with local anesthetic.

° If using a product designed specifically for IO access, follow

the manufacturer’s directions.

° If using a bone marrow aspiration needle, after penetrating

the skin, direct the IO needle at a slight angle (10°–15°) 

caudad (in the femur, angle it cephalad) and apply pressure 

with a to-and-fro rotary motion. Avoid “wobbling” the 

needle during insertion, which may result in needle 

fracture.

▶ As the needle passes from the cortex of the bone into the 

marrow, resistance will diminish.

▶ Remove the stylet and check needle placement by 

attaching tubing connected to a saline-filled, 10-mL 

syringe. The needle should stand securely in the bone 

without support.

▶ Bone marrow can be aspirated and fluid should be easily 

infused.

° Blood withdrawn from the needle may be sent to the 

laboratory for basic testing, including a complete blood 

count, electrolytes, glucose, and the like.

° Observe for fluid infiltration of the calf; if this occurs, repeat

the attempt in the opposite leg. If placement is unsuccessful, 

do not attempt again in the same extremity.

° Apply antibiotic ointment and a sterile dressing to the site 

and secure the tubing to the leg with sterile gauze. 

° Minimize needle manipulation by attaching syringes or a

stopcock to the tubing.

° Maintain vigilant care and observation of the insertion site;

accidental dislodgement of an IO needle will manifest as 

fluid extravasation into a swollen calf, or the needle will 

be mobile at the site.

° Once the emergent condition has been addressed and the

child has been resuscitated, attempt peripheral or central IV 

access, as IO lines are notoriously short lived (< 24 hours).

• Complications include:

° osteomyelitis,

° fracture (of bone or needle),

° injury to the epiphyseal plate,
32

Pediatric Surgery and Medicine for Hostile Environments

° extravasation,

° compartment syndrome,

° hematoma, and

° pressure necrosis of the skin.

• Contraindications include:

° fractures or crush injuries near the insertion site,

° fragile bone syndromes (eg, osteogenesis imperfecta), and

° unsuccessful attempts in the same bone.

Percutaneous Central Venous Catheters 

• Percutaneous central venous lines (see Table 3-1) may be 

required when peripheral venous access is either unavailable 

or insufficient. Central venous lines last longer (days to 

weeks), allow for central venous pressure monitoring and 

phlebotomy, and can safely tolerate vasoactive medication 

drips and hyperosmolar therapies. 

• The preferred site for central vein access in children is the 

femoral vein.

° It is easier and safer to access the femoral than the internal 

jugular or subclavian veins, especially during resuscitation. 

° Unlike in adults, there are no pediatric data suggesting a 

higher risk of infection at the femoral site. 

• Lines placed under suboptimal conditions should be changed 

when the patient’s condition warrants. 

• Like adults, debilitated pediatric patients with indwelling 

central lines are at risk for catheter-related bloodstream 

infections and thrombosis. The risk of deep venous thrombosis 

is lower in children than in adults. 

• The standard aseptic Seldinger technique is used for line 

placement. Remember the lateral to medial groin anatomy: 

NAVEL (nerve, artery, vein, empty space, lymphatics).

Peripheral Venous Cutdowns

• With increased use of the IO route, it is rarely necessary to cut 

down on a peripheral vein to obtain IV access. 

• The preferred site is the long saphenous vein, just superior 

and anterior to the medial malleolus. 
33

Vascular Access

• Make a transverse skin incision, carry a blunt dissection down 

through the subcutaneous tissue, and directly cannulate the 

vein.

Intraarterial Catheters

• Arterial lines are placed in clinical situations when arterial 

blood pressure must be continuously measured (eg, when 

vasopressor agents are being administered), when frequent 

arterial blood gas or other blood sampling is necessary, 

and when cerebral perfusion pressure must be measured in 

patients with traumatic brain injury (see Table 3-1).

• The radial, dorsalis pedis, and posterior tibial arteries are the 

safest to use for an arterial line.

Table 3-1. Pediatric Central and Arterial Venous Line Sizes 

Age/Size of Child Central Line Sizes Arterial Line Sizes

Infants < 5 kg 3 Fr 5–8 cm single lumen; 24-gauge IV catheter; 

 4 Fr 8-cm double lumen; 2.5 Fr 2.5 cm for peripheral

 OR (radial) access

20-gauge 12-cm pediatric 2.5 Fr 5 cm for central 

jugular vein kit (femoral) access

Larger infants/ 4 Fr 8-cm double lumen; 22- or 24-gauge IV catheter;

toddlers < 10 kg OR 2.5 Fr 2.5 cm for peripheral

20-gauge 12-cm pediatric (radial) access;

jugular vein kit 2.5 Fr 5 cm for central 

(femoral) access;

 OR

20-gauge 12–cm pediatric 

jugular vein kit for femoral 

 access

Preschool children 5 Fr 8–12-cm double or 20- or 22-gauge IV catheter

< 20–25 kg triple lumen

Older children 7 Fr adult triple lumen 20- or 22-gauge IV catheter

line

Fr: French size
34

Pediatric Surgery and Medicine for Hostile Environments

• Prior to placing a radial artery catheter, consider confirming 

that there is adequate collateral circulation to the hand via the 

ulnar artery by performing an Allen test.

• Complications (more commonly associated with axillary, 

brachial, and femoral sites) include:

° distal ischemia,

° thromboembolism, and

° local infection.
35

Mechanical Ventilation

Chapter 4

Mechanical Ventilation

Noninvasive Oxygen Delivery

• Practitioners need to be familiar with the benefits, limitations, 

and caveats of pediatric noninvasive and invasive oxygen 

delivery strategies.

• The choice of oxygen delivery device is based on the patient’s 

needs, tolerance, and efficacy (Table 4-1).

• A nonrebreather mask must have at least 10 liters per minute 

(LPM) flow to prevent carbon dioxide (CO2) retention and 

difficulty breathing with a tight mask.

• Blow-by oxygen is extremely imprecise and may lead to false 

reassurance of patient stability due to a potentially higher 

fraction of inspired oxygen (FiO2) delivery than expected 

based on proximity of the patient to the delivery device.

Table 4-1. Oxygen Therapy Device Requirements 

Device FiO2 Required Flow

Nasal cannula (low flow) 25%–40% 1–4 LPM

Nasal cannula (high flow)* Variable Infants: up 8 LPM

Children: up to 40 LPM

Venturi mask 24%–40% Variable

Simple face mask 35%–50% 6–10 LPM

Partial rebreather 50%–60% 10–12 LPM

Nonrebreather 90%–95% 10–15 LPM 

FiO2 = fraction of inspired oxygen

*Standard high-flow nasal cannula set-ups are both heated and 

humidified with titratable flow and FiO2

.

• Providers practicing in austere environments or on transports 

may be using oxygen supplied from a tank.
36

Pediatric Surgery and Medicine for Hostile Environments

• Attention should be paid to available oxygen supply based 

on tank size, flow rates, and time requirements (Table 4-2).

• Available duration of flow can be calculated using the 

following formula:

D = k × (P – R) 

 F

where D = duration of flow (min); k = conversion factor; P = 

tank pressure (PSI); R = safe residual pressure, usually 200 

PSI; F = flow rate (LPM).

• For example, an E cylinder with 1,000 PSI running at 15 LPM 

will run out of oxygen in 33 minutes:

D = 0.28 × (2000 – 200) = 33.6 min 15

Bag-Valve-Mask Ventilation

• A bag-valve mask (BVM), ideally with a positive endexpiratory pressure (PEEP) valve, should be used for the 

acutely decompensating patient.

• The appropriately sized mask will cover the child’s mouth 

and nose and will sit below the eyes, across the bridge of the 

nose (Table 4-3).

• Excessive tidal volume delivery is very common in the manual 

ventilation of pediatric patients and care should be taken to 

use appropriately sized bags and limit compression volumes 

to appropriate chest rise (Table 4-4).

• A self-inflating bag:

° Can be used without an oxygen source to deliver room air 

and up to 100% FiO2 if an oxygen source and reservoir are 

used.

Table 4-2. Oxygen Tank Capacities

Tank Max Volume Conversion Factor

D 350 Liters 0.16

E 625 Liters 0.28

M 3,000 Liters 1.56

G 5,300 Liters 2.41

H/K 6,900 Liters 3.14
37

Mechanical Ventilation

° Can be used to achieve PEEP only if a PEEP valve is attached.

° Will not provide passive oxygen flow (ie, blow-by oxygen) 

with most device types.

• A flow-inflating or anesthesia bag:

° Requires an oxygen source to remain inflated and provide 

ventilation; it cannot be used without an oxygen source or 

if the oxygen source fails.

° Provides PEEP by maintaining residual pressure in the bag 

during exhalation by manipulating the outlet control valve.

° Is more complicated than the self-inflating bag and requires 

additional training and experience to use effectively.

Preparation for Mechanical Ventilation

• Prior to placing a pediatric patient on mechanical ventilation, 

ensure all equipment is available and appropriate for 

pediatrics. See Table 4-5 and Appendix C for a list of intubating 

equipment based on age and weight. 

Table 4-4. Bag-Valve Sizes

Age Size

Infant 500 cc

1–3 y 1 L

> 3 y 3 L

Table 4-3. Mask Sizes

Age Size

Newborn 0–1

Infant 1

1–3 y 2

3–6 y 3

6–12 y 4

> 12 y 5

Table 4-5. Artificial Airways

Endotracheal

Age Tube Size Tracheostomy Tube Size*

Newborn 3.0–3.5 3.0–3.5

6 mo 3.5 4.0

18 mo 3.5–4.0 4.0

24 mo 4.0–4.5 5.0

2–4 y 4.5–5.0 5.5

4–7 y 5.0–6.0 6.0

7–10 y 6.0–6.5 6–8

10–12 y 7.0 8.0

*Tracheostomy tube should typically be a half size larger than the appropriately sized ET tube.
38

Pediatric Surgery and Medicine for Hostile Environments

• See Chapter 1, Basic Approach to Pediatric Trauma, for review 

of rapid sequence intubation procedures.

• Adequate BVM ventilation is much safer than attempting 

intubation and mechanical ventilation without appropriate 

equipment.

• Ensure that the available ventilator can deliver tidal volumes 

small enough for the patient’s size (5–7 mL/kg) and ensure 

that a pediatric circuit is available, as inappropriately large 

volumes are lost in adult circuits.

Safety

• All ventilated patients should have an appropriately sized 

bag, mask, replacement endotracheal (ET) tube and stylet, or 

tracheostomy tube available at the bedside.

• Wall suction and a Yankauer airway suction device should 

also be available and functional at the bedside at all times.

• Most modern ventilators are capable of safely and effectively 

mechanically ventilating infants and small children, but 

providers should be aware of the lower limits of effective tidal 

volume delivery prior to connecting the patient to the circuit.

• A knowledgeable respiratory therapist should be able to adjust 

for these patients’ special needs during setup.

Simplified Ventilation Modes

• All ventilator modes deliver either a set pressure (pressure 

control [PC]) or a set volume (volume control [VC]) for a set 

number of times per minute (R) to deliver a mandatory minute 

ventilation.

• The patient can take additional breaths that are either the same 

as the mandatory breaths (continuous mandatory ventilation 

[CMV]) or are size-controlled by the patient (intermittent 

mandatory ventilation [IMV]).

• In continuous spontaneous ventilation, no mandatory breaths 

are delivered and patients trigger and cycle all of their own 

breaths.

• Ventilator modes and equivalent terms

° PC-CMV: ventilator and spontaneous breaths are given at 

set pressure; pressure assist/control (A/C), pressure control.
39

Mechanical Ventilation

° VC-CMV: ventilator and spontaneous breaths are given at 

set volume; volume A/C, volume control.

° PC-IMV: ventilator breaths are given at set pressure, patient 

controls size of additional breaths; pressure-synchronized 

IMV.

° VC-IMV: ventilator breaths are given at set volume, patient 

controls size of additional breaths; volume-synchronized IMV. 

° Continuous spontaneous ventilation: patient controls size 

of all breaths; spontaneous mode. 

Initial Settings

• Initial ventilator settings depend on the patient’s age, size, 

ventilator type, and selected mode (Table 4-6).

Table 4-6. Initial Pediatric Ventilator Settings

Setting Level

Tidal volume 6–10 mL/kg

PIP 20–25 cm H2O

PEEP 5 cm H2O

R Infants: 25–30 bpm

Children: 15–25 bpm

Adolescents: 10–15 bpm

I-time Infant: 0.4–0.7 s

Adolescent: 0.6–1 s

PS 10 cm H2O

FiO2 Begin at 1; rapidly wean to < 0.6

PIP = peak inspiratory pressure; PEEP = positive endexpiratory pressure; R = respiratory rate; bpm = breaths 

per minute; I-time = inspiratory time; PS = pressure 

support; FiO2 = fraction of inspired oxygen

• The choice of ventilator mode is primarily based on provider 

comfort and familiarity; however, for severe or unilateral lung 

disease, consider initially using PC.

• When using PC modes:

° If the BVM has an attached manometer, make note of the 

pressure required for good chest excursion.

° Set this as the peak inspiratory pressure (PIP; remember,

PIP = PC + PEEP); titrate for return tidal volume of 6 to 10 

mL/kg.
40

Pediatric Surgery and Medicine for Hostile Environments

• If using VC, tidal volume (Vt):

° Initially, use 10 mL/kg, rounding down.

° Look at chest rise, listen for breath sounds, and check PIP.

° Decrease Vt if examination reveals excessive chest rise, large 

air entry, or higher-than-expected PIPs (< 30–35 cm H2O).

• PEEP: Start at 5 cm H2O for most patients, 10 cm H2O or higher 

for pulmonary edema or pulmonary hemorrhage. Patients 

may require higher levels for atelectasis or severe hypoxemia.

° Increase in increments of 2 cm H2

O.

° Lung volume recruitment with PEEP takes hours but can 

be lost in minutes.

• Goal minute ventilation for infants is approximately 200 mL/

kg/min and 100 mL/kg/min for adolescents.

• Measure arterial/venous blood gases to accurately assess 

oxygenation and ventilation status.

• Use chest radiographs to confirm the adequacy of ET tube 

placement and chest expansion.

• Use end-tidal CO2 monitors if they are available.

Titration

• Goal Vt for patients with acute lung injury or acute respiratory 

distress syndrome should be around 6 mL/kg, and goal PIP 

should be less than 35 cm H2O, with plateau pressure less than 

30 cm H2O, the same as for adults.

• Low Vt at high pressures are a sign of poor compliance. High 

Vt at low pressures indicate good compliance.

• FiO2 greater than 50% for prolonged periods will cause 

oxidative damage; FiO2 should be weaned to less than 60% 

as soon as possible.

• With severe lung disease, accept saturations down to 88%, 

pH levels down to 7.3, and grossly elevated partial pressure 

of carbon dioxide (pCO2) to meet the above parameters and 

prevent ventilator-associated lung injury.

• Consider switching to a PC mode of ventilation for severe 

lung disease or for large air leaks due to small ET tube size or 

ineffective ventilation (eg, secondary to adult ventilator circuit 

on infant or small child). PC ventilation modes theoretically 

offer advantages by allowing effective Vt at lower PIP, and 

they improve oxygenation for any given Vt.
41

Mechanical Ventilation

Hypercapnia

• CO2 removal is dictated by minute ventilation (Vt × R). Adjust 

these parameters to improve ventilation. The ability to increase 

minute ventilation will be limited by high peak pressure and 

inadequate time for exhalation leading to breath stacking.

• Assuming stable clinical status with a fixed metabolic state 

and stable dead space/tidal volume ratio, adjustments can be 

made by the following equation:

ParameterNew = ParameterCurrent ×

 CO2Current

CO2Goal

where the parameter can be MV, Vt, or R when the patient 

does not compete with the ventilator. 

• For example, a patient has an R set at 15 with a pCO2 of 60. 

To reach a goal CO2 of 40, the new rate should be 20 bpm:

RRNew=15bpm × 60 = 20 bpm 45

• Always check a follow-up blood gas for large ventilator 

changes.

Moderate to Severe Hypoxemia

• Minimize air leak by placing a larger ET tube, repositioning 

head, or changing to pressure mode.

• Increase PEEP in increments of 2 cm H2O to increase functional 

residual capacity (aerated lung volume); consider paralytics 

for PEEP greater than 10 cm H2O.

• Increase I-time to improve oxygenation by increasing mean 

airway pressure.

• Increase rate, especially if pCO2 is also elevated and minute 

ventilation needs to be increased.

• Changing to PC will result in improved oxygenation for the 

same volume delivered.

• Once the appropriate Vt is established, avoid changing or 

“weaning” volumes.

• In acute respiratory distress syndrome, ventilator-induced 

lung injury is associated with Vt greater than 8 to 10 mL/kg.
42

Pediatric Surgery and Medicine for Hostile Environments

Inadequate Tidal Volume Delivery

• Increase Vt if examination reveals poor chest rise, minimal air 

entry, and lower-than-expected PIP (less than 15 cm H2O).

• Adult-sized ventilator circuits may consume large amounts 

of volume each breath (2–3 mL for every cm H2O difference 

between PIP and PEEP).

• If this occurs and no pediatric-sized circuit is available, 

increase Vt or change to a PC-style breath and monitor return 

minute ventilation (goal 100–200 mL/kg/min).

High Peak Pressures

• Suction ET tube.

• Check ET tube position with chest radiograph.

• Consider administering inhaled bronchodilators, especially if 

the patient exhibits wheezing or prolonged expiratory phase, 

or develops auto-PEEP.

• Changing to PC will result in lower peak pressure for the same 

Vt.

• Consider adopting a permissive hypercapnia strategy if lung 

compliance and oxygenation are poor in the face of high peak 

pressures.

° Limit delivered Vt to roughly 6 mL/kg of ideal body weight.

° Accept higher pCO2

 and lower O2 saturations (> 88%).

° Use higher PEEP and longer I-time for recruitment and 

oxygenation.

° Most pediatric patients will tolerate a pH of up to 7.25.

° Treat or minimize metabolic acidosis.

Problem Solving

• Review the DOPE pneumonic for potential causes of acute 

decompensation: 

° Dislodged ET tube: check for equal breath sounds. Is endtidal carbon dioxide waveform present?

° Obstructed ET tube: suction mucous plug.

° Pneumothorax: check for equal breath sounds; use needle 

decompression or chest radiograph, depending on urgency.

° Equipment failure: disconnect from circuit, hand bag, and 

confirm 100% oxygen is flowing.
43

Mechanical Ventilation

Sedation Strategies for Ventilated Pediatric Patients

• Postoperative short-term ventilation. If the patient will be 

extubated in 6 to 12 hours, use:

° Intermittent opioids, because pain will be the primary 

problem.

° Intermittent benzodiazepines as needed for sedation.

° A propofol drip, which can be considered for short-term 

sedation because it is titratable. Long-term propofol use (> 

24–48 h) in pediatrics is discouraged given the concern for 

fatal metabolic acidosis.

• For postoperative long-term ventilation, use:

° Continuous opioids to treat pain.

° Intermittent or continuous-drip benzodiazepines as needed 

for sedation.

• For medical short-term ventilation, use:

° Intermittent benzodiazepines because sedation is the 

primary requirement for ET tube tolerance.

° Intermittent opioids may be needed.

• For medical long-term ventilation, use:

° Continuous midazolam.

° Continuous or intermittent opioids if needed for pain.

Remember, if the patient–ventilator synchrony is poor and 

adjustments to the ventilator are insufficient to make the 

patient comfortable, more sedation may be required.

Medications for Sedation

• Midazolam: starting dose is 0.05 to 0.1 mg/kg intravenous 

(IV); may repeat every 5 to 10 minutes until effective sedation 

is reached.

° Use this as basis for a dosing schedule of IV every 1 to 2 

hours.

° If effective intermittent regimen cannot be easily established, 

consider continuous drip at (0.05–0.1 mg/kg/h); watch for 

respiratory depression and hypotension.

• Lorazepam: starting dose is 0.05 to 0.1 mg/kg IV.

° May repeat in 5 to 10 minutes until effective sedation is 

reached.
44

Pediatric Surgery and Medicine for Hostile Environments

° Use this as a basis for an IV every 2 to 4 hours dosing 

schedule.

• Morphine: starting dose is 0.05 to 0.1 mg/kg IV.

° Repeat dosing every 5 to 10 minutes until effective analgesia 

is established.

° Use this as basis for an IV every 2 to 4 hour dosing schedule.

° If effective intermittent regimen cannot be easily established, 

consider continuous drip.

• Fentanyl: starting dose is 0.5 to 1 μg/kg IV.

° Repeat dosing every 5 to 10 minutes until effective analgesia 

is established.

° Use this as a basis for an IV every 1 to 2 hour dosing 

schedule (see Chapter 2, Anesthesia, Table 2-3).

Considerations for Extubation

• Has lung disease improved? Use SOAP memory aid:

° Secretions/sedation/spontaneous Vt (> 5 mL/kg): What is 

the minimal suction frequency? Is the patient awake enough 

to breathe and protect airway?

° Oxygenation: FiO2

 less than 35%.

° Airway: If a child has been ventilated for more than 48 hours 

or has been intubated several times, there is a significant 

risk of airway edema that may compromise a successful 

extubation. The presence of an audible air leak around the 

ET tube with the cuff deflated can be reassuring. Otherwise, 

consider starting airway dosing of dexamethasone 0.5 mg/

kg/dose at least 12 hours prior to planned extubation, and 

continue every 6 hours for 4 to 6 doses.

° Pressures: PIP less than 25 cm H2

O, PEEP less than 5 cm 

H2O.

Predictors of Extubation Failure

• If a patient displays postextubation stridor, consider nebulized 

racemic epinephrine, heliox (if available), noninvasive 

positive-pressure ventilation, and steroids (Table 4-7).
45

Mechanical Ventilation

Further Reading

1. Nichols DG, ed. Rogers’ Textbook of Pediatric Intensive Care. 4th ed. 

Philadelphia, PA: Lippincott Williams & Wilkins; 2008.

2. Randolph AG. Management of acute lung injury and acute 

respiratory distress syndrome in children. Crit Care Med. 2009 

Aug;37(8):2448–2454.

Table 4-7. Predictors of Extubation Failure

Variable Low Risk (< 10%) High Risk (> 25%)

Vt (spontaneous) ≥ 6.5 mL/kg ≤ 3.5 mL/kg

FiO2 ≤ 0.30 > 0.40

PIP ≤ 25 cm H2O ≥ 30 cm H2O

FiO2: fraction of inspired oxygen; PIP: peak inspiratory pressure; Vt: tidal volume

Data sources: (1) Venkataraman ST, Khan N, Brown A. Validation of predictors of 

extubation success and failure in mechanically ventilated infants and children. Crit Care 

Med. 2000 Aug;28(8):2991–2996. (2) Khan N, Brown A, Venkataraman ST. Predictors of 

extubation success and failure in mechanically ventilated infants and children. Crit Care 

Med. 1996 Sep;24(9):1568–1579.
46

Pediatric Surgery and Medicine for Hostile Environments
47

Transfusion Medicine

Chapter 5

Transfusion Medicine

Introduction

• Indications for transfusion in children are no different than 

for adults, though blood products should not be transfused 

on a unit basis; weight-based considerations are necessary.

• If transfusing less than a “unit” dose, consider having the 

blood bank “split” a unit and reserve the remainder to avoid 

unnecessary multiple donor exposure.

• Estimated blood product unit volumes currently in theater:

° Packed red blood cells (PRBCs): 300 to 350 mL/unit.

° Whole blood: 450 to 500 mL/unit.

° Fresh frozen plasma (FFP): 250 to 300 mL/unit.

° Platelets:

▶ Apheresis, single-donor: 250 to 300 mL/unit.

▶ Concentrate, random-donor: 50 mL/unit.

° Cryoprecipitate: 10 to 15 mL/unit.

Packed Red Blood Cell Transfusion

• Indications: hemoglobin (Hgb) less than 7 g/dL, symptomatic 

anemia with Hgb 7 to 10 g/dL or hemorrhage.

• Administer 10 to 15 mL/kg over 4 hours (≤ 2.5 mL/kg/h) for 

routine use. This will usually increase Hgb by 2 to 3 g/dL and 

hematocrit (HCT) by 6% to 9% in a stable patient.

• To estimate the volume of PRBC to transfuse:

Volume of PRBC: 

EBV × (desired HCT – present HCT)

HCT of PRBC

where EBV is the estimated blood volume (Table 5-1), and the 

approximate HCT of PRBC is 55% to 60%. 
48

Pediatric Surgery and Medicine for Hostile Environments 

• Give smaller amounts for anemia, which is suspected to be 

chronic in nature, to avoid volume overload. As a general rule, 

give X mL/kg, where X is the patient’s Hgb g/dL (eg, if Hgb 

is 5 g/dL, give 5 mL/kg PRBCs over 4 hours).

• Risks of PRBC transfusions are similar to those in adults 

and include infection, transfusion reactions (ie, febrile 

nonhemolytic, acute hemolytic, anaphylactic, delayed 

hemolytic, urticarial), volume overload (transfusion-related 

cardiac overload), and transfusion-related acute lung injury. 

See discussion on massive transfusions below for unique 

complications.

• Administration of PRBCs in storage longer than 14 days has 

been associated with increased morbidity and mortality in 

critically ill patients (eg, hyperkalemic cardiac arrest).

• Frozen blood may be available, but must first be deglycerolized 

before use. It is then administered like a standard PRBC 

transfusion. It can be considered a “fresh” unit, since it was 

frozen within 6 days of being collected. See Joint Theater 

Trauma System Clinical Practice Guidelines, Frozen and 

Deglycerolized Red Blood Cells (http://www.usaisr.amedd.army.

mil/assets/cpgs/Frozen_Blood_2_Apr_12.pdf).

Whole Blood Transfusion

• Whole blood transfusion is indicated in cases when massive 

transfusion (MT) is required and when there is a need for a 

component product that is unavailable (frequently platelets).

• Administration: initial volume of 10 to 15 mL/kg can be given 

quickly or over a 4-hour period, depending on the situation.

Table 5-1. Blood Volume by Age

Age Blood Volume (mL/kg)

Premature neonate 100

Full-term neonate 85

Older infant 75

> 12 months 70–75
49

Transfusion Medicine

Fresh Frozen Plasma

• Indications for FFP include massive transfusion, coagulopathy 

and bleeding, disseminated intravascular anticoagulation, and 

prolonged R value on thromboelastography (TEG).

• FFP contains all coagulation factors except platelets.

• Avoid using FFP in critically ill patients with simple 

coagulopathy without clinical bleeding.

• Thawed plasma can be refrigerated at 1°C to 6°C for up to 5 

days.

• Administer an initial volume of 10 to 15 mL/kg.

• Routine FFP transfusion rates should not exceed 1 mL/kg/min, 

as this may precipitate hypocalcemia, hypotension, severe 

cardiac depression, and cardiac arrest.

• Risks are the same as for PRBCs and hypocalcemia. 

Platelets

• Indications include massive transfusion, thrombocytopenia, 

and bleeding, or, prior to invasive procedure, decreased 

maximum amplitude on TEG (see Bolliger, et al, in Further 

Reading). 

• Avoid use in nonbleeding, critically ill patients with platelet 

values greater than 20,000/μL.

• Apheresis platelet units contain both plasma and platelets. 

• Administer an initial volume of 10 mL/kg; alternatively, for 

platelet concentrates, give 1 unit (or “one pack”) for every 5 kg 

body weight. Infuse over 30 minutes, no longer than 2 hours. 

For infants and children, these estimates should increase the 

platelet count by approximately 50,000/μL.

• Risks: same as for PRBCs, though there is an approximately 

15-fold higher risk of infection than for PRBCs given from 

room temperature storage.

Cryoprecipitate

• Indications include MT, coagulopathy and bleeding, and 

decreased alpha-angle on TEG.

• Cryoprecipitate is a source of fibrinogen, factor VIII, factor XIII, 

and von Willebrand’s factor; each unit contains a minimum 

of approximately 250 mg of fibrinogen and 80 international 

units of factor VIII.
50

Pediatric Surgery and Medicine for Hostile Environments 

• Administering 1 unit for every 5 kg body weight should raise 

the fibrinogen level by 60 to 100 mg/dL in a stable patient.

Special Blood Product Preparations 

• All blood products should be infused using a standard blood 

filter (170–260 μm) that removes microaggregates.

• Blood filters are not the same as leukocyte reduction filters.

• Leukocyte reduction

° Most blood products are leukoreduced at the time of 

collection to prevent febrile, nonhemolytic transfusion 

reactions.

° If not done prior to storage, leukocyte reduction may be 

done at the bedside only for PRBCs and platelets using 

product-specific leukocyte filters during the transfusion.

° Leukocyte reduction can decrease the risk of cytomegalovirus 

(CMV) transmission and human leukocyte antigen

alloimmunization.

° Leukocyte reduction will dramatically slow the rate 

of a transfusion and may not be appropriate during a 

transfusion for hemorrhagic shock because of active 

bleeding.

• Irradiation

° Leukocyte reduction does not eliminate all donor 

lymphocytes. Irradiation of blood products stops 

proliferation of donor lymphocytes that may otherwise 

trigger transfusion-associated graft-versus-host disease.

° Irradiation does not kill viruses.

° Irradiation is recommended for transfusions in premature 

infants and children with either congenital or acquired 

immunodeficiency.

• CMV-safe products

° For premature infants and children with congenital or 

acquired immunodeficiency, CMV-seronegative blood 

products are preferred.

° Leukocyte reduction reduces the risk of viral transmission. 

If CMV-negative products are unavailable, leukocyte 

reduction is a safe alternative.
51

Transfusion Medicine

Massive Transfusion in Children

• The same principles of “damage control resuscitation” or 

“hemostatic resuscitation” that apply to adults can be applied 

to children.

• Transfusion in a pediatric patient can be considered an MT 

when half or more of the circulating blood volume, or 40 mL/

kg or more, is replaced in under 24 hours.

• The following clinical parameters may predict the need for a 

bleeding child receiving an MT:

° severe tachycardia or hypotension for age,

° base deficit greater than 5 mEq/L,

° lactate greater than 4 mmol/L,

° international normalized ratio greater than 1.5, and

° hemoglobin at admission less than 9 g/dL.

• Use of a rapid infuser (eg, Belmont [Belmont Instrument 

Corporation, Billerica, MA]) should be avoided in small 

children. 

° Instead, use multiple smaller syringes, or set up a “pullpush” system with a 3-way stopcock.

° Smaller syringes are also more useful in pushing blood 

through small IVs (eg, 22- and 24-gauge).

• See Sample Massive Transfusion Protocol (Table 5-2) for a 

suggested strategy of administering blood products (also see 

Edwards, et al, and Diab, et al, in Further Reading).

Massive Transfusion Adjuncts

• Tranexamic acid (TXA) is an antifibrinolytic that has some 

mortality benefit in adult and pediatric trauma patients with 

documented hyperfibrinolysis.

° Indicated when the injury is less than 3 hours old or LY30 

is greater than 7.5% on TEG.

° Adult dose: 1 g IV load followed by 1 g IV infusion over 8 h.

° Optimal dosing and timing have not been established in 

pediatrics due to limited data. The literature supports a 

loading dose of 10 to 15 mg/kg (max 1 g) diluted in normal 

saline and given over 10 minutes.

° Follow up with a maintenance infusion of 1 mg/kg/h for 8 

hours.
52

Pediatric Surgery and Medicine for Hostile Environments 

Table 5-2. Sample Massive Transfusion Protocol 

Packages to 10–24 kg 25–49 kg

Transfuse	 0–4 kg	 5–9 kg	 Young	 Older	 ≥ 50 kg

in Order Neonate Infant Child Child Adult

Emergency RBC 1 RBC 2 RBC 3 RBC 5 RBC

Release (A)

B 1/2 RBC 1 RBC 2 RBC 3 RBC 5 RBC

1/2 FFP 1 FFP 2 FFP 3 FFP 5 FFP

1/2 aPlt 1/2 aPlt 1 aPlt 1 aPlt 1 aPlt

C 1/2 RBC 1 RBC 2 RBC 3 RBC 5 RBC

1/2 FFP 1 FFP 2 FFP 3 FFP 5 FFP

2 Cryo 3 Cryo 4 Cryo 6 Cryo 8 Cryo

B 1/2 RBC 1 RBC 2 RBC 3 RBC 5 RBC

1/2 FFP 1 FFP 2 FFP 3 FFP 5 FFP

1/2 aPlt 1/2 aPlt 1 aPlt 1 aPlt 1 aPlt

C 1/2 RBC 1 RBC 2 RBC 3 RBC 5 RBC

1/2 FFP 1 FFP 2 FFP 3 FFP 5 FFP

2 Cryo 3 Cryo 4 Cryo 6 Cryo 8 Cryo

B 1/2 RBC 1 RBC 2 RBC 3 RBC 5 RBC

1/2 FFP 1 FFP 2 FFP 3 FFP 5 FFP

1/2 aPlt 1/2 aPlt 1 aPlt 1 aPlt 1 aPlt

C 1/2 RBC 1 RBC 2 RBC 3 RBC 5 RBC

1/2 FFP 1 FFP 2 FFP 3 FFP 5 FFP

2 Cryo 3 Cryo 4 Cryo 6 Cryo 8 Cryo

aPlt: apheresed platelets

Cryo: cryoprecipitate

FFP: fresh frozen plasma

RBC: red blood cells 

Adapted with permission from Naomi Luban and Children’s National Medical 

Center. Literature review and protocol developed by Wong E, Criss V, Pary P, 

and Luban N. June 2, 2014.

° TXA may cause thrombotic complications; it is not 

recommended if there is renal impairment or upper urinary 

tract bleeding. Discontinue treatment if changes in vision 

occur. See Napolitano LM, et al; Eckert MJ, et al; and Royal 

College of Paediatrics and Child Health, in Further Reading.

° TXA is contraindicated with subarachnoid hemorrhage 

and active thromboembolic disease (pulmonary embolism, 

deep vein thrombosis, cerebral thrombosis). 
53

Transfusion Medicine

• Recombinant factor VIIa has not shown a clear benefit in adult 

trauma; its current use is controversial.

° Recombinant factor VIIa will NOT be effective if the patient 

has low fibrinogen (< 100 g/dL), has thrombocytopenia 

(< 100 K/mm3), or is acidotic (pH < 7.2).

° Dosing: 90 μg/kg IV.

Risks of Massive Transfusion

• Hyperkalemia

° Cardiac arrest due to hyperkalemia has been reported 

secondary to pediatric MT; risk factors include:

▶ younger age (more common in neonates and infants);

▶ faster rate of infusion, more so than total volume; and 

▶ central venous administration, likely due to dilution 

effect of potassium when given peripherally.

° During pediatric MT, monitor telemetry and measure serial 

electrolytes (particularly for acidosis and hypocalcemia), 

which may exacerbate intravascular hyperkalemia. 

° Risk may be reduced by using “fresh” PRBCs less than 7 

days old and by transfusing through a large-bore peripheral 

IV (> 23 gauge) rather than a central line.

° See Chapter 25, Basic Fluid and Electrolytes, for 

hyperkalemia management.

• Hypocalcemia

° Citrate-containing blood products (especially FFP) 

decrease the ionized calcium level and can cause significant 

hypotension in children, especially infants.

° Treat with IV calcium chloride (10–20 mg/kg) or calcium 

gluconate (60–100 mg/kg) for ionized calcium level less 

than 1 mmol/L. Consider empiric treatment if giving the 

patient large amounts for MT or rapid plasma infusion.

• Hypomagnesemia

° Hypomagnesemia is caused by same mechanism as in 

hypocalcemia; it also directly contributes to secondary 

hypocalcemia.

° Treat with magnesium sulfate 25 to 50 mg/kg IV; give 

slowly, no faster than 20 to 30 minutes, watching for 

hypotension. Maximum dose is 2 g.
54

Pediatric Surgery and Medicine for Hostile Environments 

• Hypothermia

° There is higher risk of hypothermia in children given their 

larger body-surface-area-to-weight ratio.

° Hypothermia exacerbates the acute coagulopathy of 

trauma.

° It is mitigated by use of blood warmer as in adults.

• Transfusion-Associated Volume Overload 

° Transfusion-associated volume overload is caused by 

overshooting resuscitation or by transfusions in stable 

patients with chronic anemia.

° It is manifested by pulmonary edema, gallop rhythm, 

hepatomegaly, and jugular venous distention.

° Use slow transfusion rates for patients with chronic anemia.

° Consider using furosemide (0.25–0.5 mg/kg IV) 

midtransfusion or after transfusion.

Further Reading

1. Smith HM, Farrow SJ, Ackerman JD, Stubbs JR, Sprung J. Cardiac 

arrests associated with hyperkalemia during red blood cell 

transfusion: a case series. Anesth Analg. 2008;106:1062–1069.

2. Duchesne JC, Hunt JP, Wahl G, et al. Review of current blood 

transfusions strategies in a mature level 1 trauma center: were we 

wrong for the last 60 years? J Trauma. 2008:65;272–276.

3. González EA, Moore FA, Holcomb JB, et al. Fresh frozen plasma 

should be given earlier to patients requiring massive transfusion. 

J Trauma. 2007;62:112–119.

4. Al-Said K, Anderson R, Wong A, Le D. Recombinant factor VIIa for 

intraoperative bleeding in a child with hepatoblastoma and a review 

of recombinant activated factor VIIa use in children undergoing 

surgery. J Pediatr Surg. 2008;43:e15–e19.

5. Perkins JG, Schreiber MA, Wade CE, Holcomb JB. Early versus 

late recombinant factor VIIa in combat trauma patients requiring 

massive transfusion. J Trauma. 2007;62:1095–1101.

6. Spinella PC. Warm fresh whole blood transfusion for severe 

hemorrhage: US military and potential civilian applications. Crit 

Care Med. 2008;36:S340–S345.
55

Transfusion Medicine

7. Stein DM, Dutton RP. Uses of recombinant factor VIIa in trauma. 

Curr Opin Crit Care. 2004;10(6):520–528.

8. CRASH-2 Collaborators, et al. Effects of tranexamic acid on death, 

vascular occlusive events, and blood transfusion in trauma patients 

with significant haemorrhage (CRASH-2): a randomised, placebocontrolled trial. Lancet. 2010;376:23–32.

9. CRASH-2 Collaborators, et al. The importance of early treatment 

with tranexamic acid in bleeding trauma patients: an exploratory 

analysis of the CRASH-2 randomised controlled trial. Lancet. 

2011;377(9771):1096–1101. 

10. Morrison J, DuBose J, Rasmussen T, Midwinter M. Military 

Application of Tranexamic Acid in Trauma Emergency Resuscitation 

(MATTERs) Study. Arch Surg. 2012;147(2):113–119.

11. Dehmer JJ, Adamson WT. Massive transfusion and blood 

product use in the pediatric trauma patient. Semin Pediatr Surg. 

2010;19(4):286–291.

12. Joint Theater Trauma Systems Clinical Practice Guidelines. Damage 

Control Resuscitation. http://www.usaisr.amedd.army.mil/assets/

cpgs/Damage%20Control%20Resuscitation%20-%201%20Feb%20

2013.pdf. Accessed January 13, 2015. 

13. Joint Theater Trauma Systems Clinical Practice Guidelines. Frozen 

and Deglycerolized Red Blood Cells. http://www.usaisr.amedd.

army.mil/assets/cpgs/Frozen_Blood_2_Apr_12.pdf. Accessed 

January 13, 2015.

14. Joint Theater Trauma Systems Clinical Practice Guidelines. Fresh 

Whole Blood Transfusion. http://www.usaisr.amedd.army.mil/

assets/cpgs/Fresh_Whole_Blood_Transfusion_24_Oct_12.pdf. 

Accessed January 13, 2015.

15. Bolliger D, Seeberger MD, Tanaka KA. Principles and practice of 

thromboelastography in clinical coagulation management and 

transfusion practice. Transfus Med Rev. 2012;26:1–13.

16. Edwards MJ, Lustik MB, Clark ME, Creamer KM, Tuggle DJ. 

The effects of balanced blood component resuscitation and 

crystalloid administration in pediatric trauma patients requiring 

transfusion in Afghanistan and Iraq 2002 to 2012. Trauma Acute Care 

Surg. 2015;78(2):330–335.
56

Pediatric Surgery and Medicine for Hostile Environments 

17. Diab YA, Wong ECC, Luban NLC. Massive transfusion in children 

and neonates. Br J Haematol. 2013;161:15–26.

18. Eckert MJ, Wertin TM, Tyner SD, Nelson DW, Izenberg S, Martin 

MJ. Tranexamic acid administration to pediatric trauma patients in 

a combat setting: the pediatric trauma and tranexamic acid study 

(PED-TRAX). J Trauma Acute Care Surg. 2014;77(6): 852–858.

19. Royal College of Paediatrics and Child Health. Evidence statement: 

major trauma and the use of tranexamic acid in children, November 

2012. https://www.tarn.ac.uk/content/downloads/3100/121112_

TXA%20evidence%20statement_final%20v2.pdf. Accessed May 

26, 2015.
57

Hemodynamics and Shock

Chapter 6

Hemodynamics and Shock

Shock is characterized by inadequate systemic tissue perfusion 

and oxygen delivery; if left untreated, subsequent cellular and 

metabolic derangement leads to end-organ dysfunction, failure, 

and death. A basic understanding of pediatric vital signs is 

needed to accurately perform hemodynamic monitoring and 

assess for shock (see Chapter 1, Basic Approach to Pediatric 

Trauma, Table 1-1).

Recognizing Shock

According to the American Heart Association’s Pediatric 

Advanced Life Support course, the spectrum of shock is 

characterized as follows: 

• Compensated shock: physiologic compensation maintains 

blood flow to vital organs through tachycardia and 

vasoconstriction, preserving a normal blood pressure. Clinical 

signs include:

° fever or hypothermia,

° tachycardia,

° mottled or cool extremities,

° weak peripheral pulses, 

° delayed capillary refill (central longer than 2 s, peripheral 

longer than 3 s),

° irritability, 

° oliguria, and

° lactic acidosis.

• Decompensated shock: compensatory mechanisms fail, 

systemic signs of inadequate end-organ perfusion develop, 

and hypotension ensues. Clinical signs include:

° hypotension, a late finding, is defined as a systolic blood 

pressure in the different age groups as follows:
58

Pediatric Surgery and Medicine for Hostile Environments 

▶ Infants younger than 1 month old: less than 60 mmHg.

▶ Infants 1 to 12 months old: less than 70 mmHg.

▶ Children 1 to 10 years old: less than 70 mmHg + 2(age 

[in years]).

° altered mental status;

° acute respiratory distress syndrome;

° hepatic dysfunction;

° acute kidney injury; and

° coagulopathy. 

• Irreversible shock: all compensatory mechanisms are 

exhausted and multisystem organ failure ensues; tachycardia 

and tachypnea may progress to bradycardia and apnea, 

cardiac arrest, and death.

Types of Shock

There are three broad mechanisms of shock; a patient may have 

shock as a result of more than one cause.

• Hypovolemic shock is the most common cause of shock. 

It results from extravascular (eg, diarrhea, emesis, osmotic 

diuresis, burns) or intravascular (eg, hemorrhage) fluid losses 

(Table 6–1).

• Cardiogenic shock results from inadequate cardiac output.

° Cardiogenic shock is most commonly due to 

cardiomyopathies, arrhythmias, or obstructive disorders, 

such as tension pneumothorax or cardiac tamponade.

° In neonates, unrecognized ductal-dependent congenital 

heart disease (ie, coarctation of the aorta, interrupted aortic 

arch, aortic stenosis, hypoplastic left heart syndrome, 

and transposition of the great arteries) may present with 

cardiogenic shock in the first few days to weeks of life at 

the time of functional ductus arteriosus closure.

• Distributive shock results from systemic vasodilation 

and decreased systemic vascular resistance due to septic, 

neurogenic, and anaphylactic shock.

• Many other conditions can also lead to shock through these 

mechanisms, including bowel obstruction, pneumonia, 

diabetic ketoacidosis, neglect, cystic fibrosis, and inborn errors 

of metabolism.
59

Hemodynamics and Shock

Table 6-1. Assessing the Severity of Hypovolemic Shock*

Weight Lost Weight Lost

Level (Infant) (Child) Signs and Symptoms

Mild 5% 3% Decreased urinary output,

mild tachycardia, dry mucous 

membranes, decreased tearing

Moderate 10% 6% Oliguria, tachycardia, dry 

membranes and tongue, sunken 

eyes and fontanelle, poor skin 

turgor, borderline to poor 

perfusion, mild to moderate 

tachypnea, possible shock

Severe 15% 9% Oliguria or anuria, possible shock, 

poor perfusion, decreased LOC, 

tachypnea, marked metabolic 

acidosis, shock

*Percentages indicate actual weight loss from water loss or deficit.

LOC: level of consciousness

• In addition to available history (eg, infection, trauma, 

toxin/allergen exposure, congenital heart disease), clinical 

examination may aid in the distinction of different shock 

etiologies (Table 6-2).

° Cardiac output can be assessed by observing heart rate, 

capillary refill time, mental status, and urine output.

° Preload can be assessed by observing changes in liver span 

or by viewing heart size with a chest radiograph.

Table 6-2. Distinguishing Features of Clinical Shock States

Physical Monitoring

Scenario WOB CRT Liver Skin CVP* SVR CI

Hypovolemic nl > 2 nl Cool 	 	 

Cardiogenic +++ > 2 +++ Cool 	 	 

Distributive +/++ +/– nl +/- 	 	 

*Normal CVP for infants and children is 5–8 mmHg. 

CI: cardiac index; CRT: capillary refill time; CVP: central venous pressure; nl: normal; 

SVR: systemic vascular resistance; WOB: work of breathing
60

Pediatric Surgery and Medicine for Hostile Environments 

° Systemic vascular resistance can be assessed by capillary 

refill time, pulse pressure, and by comparing differential 

skin temperatures (peripheral to central).

Goal-Directed Therapies

The treatment of shock in pediatric patients is time-based, goaldirected (Figure 6-1), and targets the initial therapeutic outcomes 

as recommended by the Surviving Sepsis Campaign 2012 (see 

Further Reading), including:

° capillary refill: 2 seconds or less;

° normal blood pressure for age;

° normalized pulses, with peripheral pulses equal to central 

pulses;

° warm extremities;

° urinary output greater than 1 mL/kg/h; and

° normalized mental status.

• After the initial resuscitation, if central vascular pressure 

monitoring is available, target:

° central venous oxygen saturation greater than 70%, and

° cardiac index of 3.3 to 6.0 L/min/m2

.

• For respiratory distress and hypoxemia, apply supplemental 

oxygen via facemask. If available, consider initiating high-flow 

nasal cannula or nasopharyngeal continuous positive airway 

pressure. 

• If respiratory failure is imminent, early intubation and 

mechanical ventilation may be indicated (see Chapter 1, Basic 

Approach to Pediatric Trauma, and Chapter 4, Mechanical 

Ventilation, for further information).

• Early establishment of vascular access, fluid resuscitation, and 

inotropic support prior to intubation may blunt hemodynamic 

collapse during initiation of positive pressure ventilation.

• During rapid sequence intubation of the pediatric shock 

patient, it is critical to avoid sedation with medications that 

may worsen hemodynamics.

° Ketamine is preferred for induction in septic shock, as long 

as it is not contraindicated (suspected increased ICP).

° Etomidate is an acceptable choice for hypovolemic or 

cardiogenic shock, though it should be avoided in septic 

shock.
61

Hemodynamics and Shock

Figure 6-1. Goal-directed algorithm for hemodynamic support of infants and 

children.

CVP: central venous pressure

Hgb: hemoglobin

ICU: intensive care unit

IM: intramuscular

IO: intraosseous

IV: intravenous

MAP: mean arterial pressure

ScvO2: central venous oxygen saturation

0–15 minutes

Fluid Refractory Shock

For cold shock, initiate dopamine (5 μ/kg/min) or 

epinephrine (0.05 μ/kg/min)

For warm shock, begin norepinephrine (0.05 μ/kg/min)

Use atropine/ketamine IV/IO/IM to establish airway and 

central access if needed

Ensure administration of broad-spectrum antibiotics 

Recognition of Shock or Shock-Like State

Signs: altered mental status, tachycardia, and poor perfusion

Airway + Breathing + Circulation

Continuously monitor vital signs and pulse oximetry

Administer high-flow oxygen

Establish IV/IO access

Initial Resuscitation

Push 20 mL/kg isotonic saline or colloid boluses up to 60 mL/kg

Check blood glucose and correct hypoglycemia

Catecholamine-Resistant Shock

Begin hydrocortisone if at risk for absolute relative adrenal insufficiency

(50 mg/m2 IV every 8 hours)

Ongoing Care

Admit to ICU, monitor CVP, lactate, ScvO2

, and distal perfusion

Target age-appropriate MAP and CVP

Primary goals: ScvO2 ≥ 70% and Hgb ≥ 10 g/dL

2nd-tier therapies: volume loading, 2nd vasopressor, 

and/or vasodilators (milrinone)

0–5 minutes 15–60 minutes

Recognition of Shock or Shock-Like State

Signs: altered mental status, tachycardia, and poor perfusion

Airway + Breathing + Circulation

Continuously monitor vital signs and pulse oximetry

Administer high-flow oxygen

Establish IV/IO access
62

Pediatric Surgery and Medicine for Hostile Environments 

° If etomidate is used, adrenal insufficiency should be 

considered and evaluated by measuring serum cortisol 

levels if available.

• Establish intravenous access, ideally in two locations; if 

vascular access is insufficient, early placement of intraosseous 

access is recommended (see Chapter 3, Vascular Access). 

Intraosseous access is functionally equivalent to central venous 

access; all drugs and products given via a central line can be 

given via an intraosseous line.

• Administer rapid volume expansion with normal saline or 

lactated Ringer’s solution in boluses of 20 mL/kg over 5 to 10 

minutes, then reassess.

° Reassessment includes evaluating level of consciousness 

and ensuring tachycardia and hypotension have reversed, 

urine output has increased, and capillary refill and 

peripheral pulses have normalized.

° Evidence of rales or hepatomegaly on examination suggests 

that inotropes be used if further resuscitation is necessary.

° If anemia is evident at presentation due to hemorrhage or 

hemolysis, early initiation of transfusion is recommended. 

° During acute resuscitation of septic shock, a hemoglobin 

of 10 g/dL or more is targeted; once stabilized, a restrictive 

transfusion threshold target of 7 g/dL or more should be 

followed.

• If there is no improvement after the initial bolus, repeat boluses 

as indicated, up to 60 mL/kg total within the first 15 to 30 

minutes.

• In septic shock, broad-spectrum antibiotics against endemic 

and epidemic pathogens should be administered within an 

hour of presentation (see Chapter 29, Infectious Diseases, and 

Table 29-1 specifically for empiric antibiotic choices by age). 

° Blood cultures should be obtained prior to administering 

antibiotics if possible, though antibiotics should not be 

delayed to do so. 

° Clindamycin should be added for toxic shock syndrome 

with unresponsive hypotension to inhibit toxin production. 

° Antibiotics may be given orally or intramuscularly if 

parenteral access is not available (see Chapter 29, Infectious 

Diseases, Tables 29-2 and 29-3). 
63

Hemodynamics and Shock

Table 6-3. Vasoactive SupportDrug/Indication	 Dosing	 Effects	 Action	 CommentsDopamine

Septic shockCardiogenic shock

Dobutamine

Cardiogenic shock

Epinephrine 

Postarrest shock Cold “septic” shock 

Norepinephrine

Warm septic shock

Phenylephrine 

Spinal shock Septic shock

Milrinone

 PVR or SVR with cardiac dysfunction

Nitroprusside

Hypertension or SVR states

BP: blood pressure; cAMP: cyclic adenosine monophosphate; NE: norepinephrine; NO: nitric oxide; PVR: pulmonary vascular resistance; SVR: systemic vascular resistance

Give centrally if possible; 

not as effective in neonates who have limited NE stores

May result in peripheral 

vasorelaxation and tachycardia

Give centrally if possible; 

may cause organ ischemia at high doses

Give centrally if possible; 

may cause organ ischemia

Give centrally (burns)Thrombocytopenia, T1/2 h 

vs min

Dose adjustment needed 

in renal impairment

Need arterial line to 

watch BP; cyanide toxicity

Acts indirectly via NE 

release; inotrope, chronotrope, vasopressor

Direct-acting pure 

inotrope, lusitrope (diastolic relaxation)

Direct-acting inotrope, 

chronotrope, and potent vasopressor

Direct-acting potent 

vasopressor

Direct-acting potent 

vasopressor

Inotrope and vasodilator, 

lusitrope (diastolic relaxation)

Potent arteriolar 

vasodilator

β 5–10 mg/kg/minα > 15 mg/kg/minββ at low dosesα at higher dosesα:β3:1Pure αPhosphodiesterase 

inhibition (cAMP)

Exogenous NO 

donor

Start at 5 mg/kg/min; range 2–20 mg/kg/minStart at 5 mg/kg/min; range 2–20 mg/kg/ minStart at 0.05 mg/kg/ min; range 0.05–1 mg/kg/min0.05–2 mg/kg/min0.05–2 mg/kg/min0.2–1 mg/kg/min;Loading dose 50 mg/kg 

over 10–60 minutes

0.5–5 mg/kg/min
64

Pediatric Surgery and Medicine for Hostile Environments 

• Peripheral inotropic support with dopamine should be added 

until central venous access is obtained if fluid resuscitation 

fails to reverse septic shock within the first hour (Table 6-3).

° Add epinephrine for cold shock (myocardial depression, 

capillary leak, metabolic acidosis, cool and mottled 

extremities).

° Add norepinephrine for warm shock (increased carbon 

dioxide, bounding pulses, decreased systemic vascular 

resistance, warm extremities, normal or extremely fast 

capillary refill time, wide pulse pressures). 

• For patients with low cardiac output, elevated systemic 

vascular resistance, and normal blood pressure, consider 

adding vasodilator therapies, such as milrinone, as well as 

inotropes. 

• Correct metabolic and electrolyte disturbances, such as 

hypoglycemia and hypocalcemia.

• For patients with fluid and catecholamine-resistant shock or 

documented absolute adrenal insufficiency, give stress-dose 

steroids (hydrocortisone, 50 mg/m2/day).

• For neonates (less than 1 month old) presenting in shock, 

begin prostaglandin infusion until a ductal-dependent cardiac 

lesion is ruled out (see Chapter 26, Respiratory Emergencies, 

and Chapter 27, Cardiology, for more information).

• Once perfusion has been normalized, continue to treat 

hypovolemic shock by calculating replacement fluids based 

on the estimated deficit (percent dehydration, see Table 6-1), 

ongoing losses, maintenance needs, and special situations (eg, 

hypernatremia or hyponatremia).

Further Reading

1. Dellinger RP, Levy MM, Rhodes A, et al. Surviving sepsis campaign:

international guidelines for management of severe sepsis and septic 

shock: 2012. Crit Care Med. 2013 Feb;41(2):580–637.
65

Managing Intracranial Pressure

Chapter 7

Managing Intracranial Pressure

Elevated intracranial pressure (ICP) may be difficult to 

diagnose and is associated with both poor neurologic outcome 

and increased mortality in infants and young children. Early 

recognition of elevated ICP and rapid intervention are key in 

maximizing positive outcomes in pediatric trauma.

Etiologies of Increased Intracranial Pressure

• Encephalitis

• Head trauma (accidental or abusive)

• Hydrocephalus

• Hemorrhage

• Intracranial mass lesion

• Meningitis

• Status epilepticus

• Stroke

• Shock leading to hypoxic-ischemic encephalopathy

Initial Evaluation

• Evaluate airway, breathing, and circulation (ABCs). 

° Ensure adequate ventilation and oxygenation.

° Rapid sequence induction/intubation therapy may be 

necessary if airway protection is needed (eg, Glasgow Coma 

Scale score ≤ 8).

° Blood pressure (BP) management depends on etiology, but 

if the patient is hypertensive due to elevated ICP, do not 

lower the patient’s BP; doing so may reduce the cerebral 

perfusion pressure (CPP).

▶ CPP is calculated as:

CPP = MAP – ICP
66

Pediatric Surgery and Medicine for Hostile Environments 

Where mean arterial pressure (MAP) is defined as:

MAP = systolic BP + 2(diastolic BP)

3

• Perform a neurological assessment.

° Use a modified Glasgow Coma Scale (see Chapter 1, Basic 

Approach to Pediatric Trauma, Table 1-3) for infants and 

children.

° Assess for signs of elevated ICP and herniation (Table 7-1).

• Treat critical elevations in ICP (Figure 7-1).

• Obtain head imaging with computed tomography or magnetic 

resonance imaging, if available.

• Consider ICP monitoring.

Table 7-1. Signs of Increased Intracranial Pressure 

Acute Increased ICP Chronic Increased ICP

Infants Irritability Irritability

Poor feeding/vomiting Poor feeding/vomiting

Split sutures Increased head circumference

Bulging fontanelle Bulging fontanelle

Altered mental status Developmental arrest or

Upgaze paresis regression

 Upgaze paresis

Children Severe, acute headache Chronic, progressive headache

Seizures Seizures

Vomiting Early morning vomiting

Rapidly deteriorating Change in school performance

 mental status Altered mental status

Posturing 6th cranial nerve palsy

Focal neurologic deficits Focal neurologic deficits

Papilledema Papilledema

Pupillary abnormalities Visual changes

Cushing’s triad*

ICP: intracranial pressure

*Hypertension, bradycardia, deep and slow respirations (occurs shortly before 

herniation).

Data source: Point-of-Care Quick Reference: Increased Intracranial Pressure. 

Elk Grove Village, IL: American Academy of Pediatrics, 2014. http:// www.

pediatriccareonline.org/pco/ub/view/Point-of-Care-Quick-Reference. Accessed 

June 10, 2014.
67

Managing Intracranial Pressure

Figure 7-1. Algorithm for managing acute intracranial hypertension.

CPP: cerebral perfusion pressure

EVD: extraventricular drain

GCS: Glasgow Coma Scale

ICP: intracranial pressure

PaCO2: partial pressure of carbon dioxide in blood

Surgery as

indicated

Correct:

 -Hypotension

 -Hypoxia

 -Hypothermia

 -Hyperthermia

 -Seizure

Carefully 

withdraw

ICP treatment

YES

YES

YES

NO

NO

NO

 Ensure:

-Airway/ventilation OK

-Head position optimal

-Ensure adequately sedated

 (Fentanyl 1–2 mcg/kg)

Persistent ICP

> 20 mmHg

-Administer osmotic

 agent, repeat as

 necessary

-PaCO2 30–35 mmHG

-Notify Neurosurgery

Osmotic Agents*:

 - Hypertonic saline (3%)

 1–5 mL/kg (can follow

 with drip) and/or

 - Mannitol 0.25–1 g/kg

*Only give if: Serum 

osmolality <320 for Mannitol 

and <360 for 3% NaCl and 

patient normovolemic

Does patient

have an EVD?

 Drain CSF

- Recheck ICP q15min

- Stop draining when

 ICP<15 mmHg

(1) Paralyze (Vecuronium 0.1 

(1) mg/kg)

(2) Barbiturate Coma

(2) (Pentobarbital drip)*

(3) Decompressive craniectomy

*Requires use of arterial line 

*blood pressure monitoring and 

*cardiovascular support to

*maintain adequate CPP
68

Pediatric Surgery and Medicine for Hostile Environments 

Indications for Monitoring Intracranial Pressure

• Monitoring ICP in infants and children with severe traumatic 

brain injury and Glasgow Coma Scale scores greater than or 

equal to 8 is recommended.

• ICP monitoring may also be considered in children who are 

at risk for neurologic deterioration as a result of traumatic 

mass lesions or in whom serial neurologic examinations 

are precluded by sedation, neuromuscular blockade, or 

anesthesia.

Neurologic Intensive Care Monitoring

• In addition to ICP monitoring (see Chapter 13, Neurosurgery), 

brain-injured patients should also be monitored for:

° ventilation, including capnography (avoid hyper/

hypoventilation);

° oxygenation, including pulse oximetry (avoid hypoxia);

° electrocardiogram;

° vitals (heart rate, BP, temperature; avoid hyperthermia);

° blood glucose (avoid hypoglycemia); and

° fluid intake and output (with a central venous catheter 

to evaluate volume status and a Foley catheter for urine 

output).

Treatment

• Assess and maintain ABCs.

° Rapid sequence induction/intubation therapy may be 

necessary if airway protection is needed (eg, Glasgow Coma 

Scale score ≤ 8).

• Maintain age-appropriate CPP goal:

° Age 0–5: CPP 40 mmHg or greater.

° Age 6–17: CPP 50 mmHg or greater.

° Adults: CPP 60 mmHg or greater.

• CPP can be reduced as a result of increased ICP, decreased 

BP, or both.

• Autoregulation usually maintains normal cerebral blood flow 

and CPP, but this process can be impaired in brain injury such 

that cerebral blood flow passively follows changes in CPP. 

• Overall goals (Table 7-2): 

° Maintain ICP less than 20 mmHg.

° Maintain CPP above goal according to age. 
69

Managing Intracranial Pressure

Table 7-2. Pediatric Traumatic Brain Injury Management Goals

Systems Management Goals

Respiratory • Early tracheal intubation if GCS ≤ 8

• Avoid hypoxemia, maintain SaO2 > 97%, PaO2 > 80 mmHg

• Maintain PaCO2 35–40 mmHg

• Hyperventilation (PaCO2 30–35 mmHg) if impending 

herniation 

° Avoid prophylactic severe hyperventilation (PaCO2

< 30 mmHg)

CV • Avoid hypotension: maintain SBP > [(2 × age) + 70 

mmHg] 

• Replace intravascular volume

° Avoid hypotonic and glucose-containing solutions

• Vasopressor agents as needed to maintain CPP

CNS • Monitor ICP and avoid ICP > 20 mmHg

• Maintain CPP appropriate for age

• Adequate sedation and analgesia

°Avoid continuous infusion of propofol

• Hyperosmolar therapy 

° Maintain Na+ 140–155 and Posm < 360 mOsm/L

• Establish therapeutic CSF drainage (EVD)

• Treat seizures

° Consider prophylactic fosphenytoin for severe TBI 

• Barbiturate coma and decompressive craniectomy 

are reserved for elevated ICP refractory to standard 

medical care

Metabolic • Prevent hypoglycemia and severe hyperglycemia

° Monitor blood glucose q4h 

° Avoid exogenous glucose × 48 h unless glucose < 70 

mg/dL

• Avoid hyperthermia and maintain normothermia

• Control shivering in intubated patients with 

neuromuscular blockade (eg, vecuronium)

CNS: central nervous system

CPP: cerebral perfusion pressure

CSF: cerebrospinal fluid

CV: cardiovascular

EVD: extraventricular drain

GCS: Glasgow Coma Scale

ICP: intracranial pressure

PaCO2: partial pressure of carbon 

dioxide in blood

PaO2: partial pressure of oxygen in blood

Posm: plasma osmolality

SaO2: oxygen saturation

SBP: systolic blood pressure

TBI: traumatic brain injury

Data source: Dinsmore J. Traumatic brain injury: an evidence-based review of 

management. Contin Educ Anaesth Crit Care Pain. 2013:13(6):189–195.
70

Pediatric Surgery and Medicine for Hostile Environments 

° Avoid factors that aggravate or precipitate elevated ICP, 

such as:

▶ obstruction of venous return (keep head midline, elevate 

the head of bed to 30°, and avoid agitation),

▶ respiratory problems (hypoxemia, hypercapnia),

▶ fever,

▶ severe hypertension,

▶ hyponatremia,

▶ anemia, and

▶ seizures.

Further Reading

1. Kochanek PM, Carney N, Adelson PD, et al. Guidelines for the acute 

medical management of severe traumatic brain injury in infants, 

children, and adolescents—second edition. Pediatr Crit Care Med. 

2012 Jan;13 Suppl1:S1– S82.
71

Status Epilepticus 

Chapter 8

Status Epilepticus

Status Epilepticus

• Impending or early status epilepticus (SE) is defined as 

protracted or recurrent seizures without complete recovery 

of consciousness lasting at least 5 minutes.

• Established SE occurs when the protracted or recurrent 

seizures persist for at least 30 minutes without cessation.

• SE can also be generalized convulsive SE or nonconvulsive 

SE.

° Generalized convulsive SE accounts for 73% to 98% of 

pediatric SE.

° Nonconvulsive SE is characterized by continuous seizures 

on electroencephalogram (EEG) without clinical seizures.

• Refractory status epilepticus (RSE) is defined as persistence of 

seizures despite the appropriate dosing of two antiepileptic 

agents, typically a benzodiazepine and fosphenytoin, 

regardless of time elapsed. RSE:

° accounts for 1.6% to 4% of all pediatric intensive care unit 

admissions, and 

° develops in 10% to 25% of uncontrolled seizure patients.

• Common etiologies of SE depend on age, but include: 

° Febrile (30%–50%).

° Remote symptomatic (24%–28%), with known prior 

neurological injury (eg, stroke, traumatic brain injury).

° Acute symptomatic (8%–28%), due to acute neurological 

injury (eg, meningitis, acute traumatic brain injury) or 

metabolic abnormality (eg, hypoglycemia, hypocalcemia, 

hyponatremia).

° Idiopathic (15%).

° Progressive encephalopathies (1%–5%), including 

progressive neurodegenerative disease, malignancies, and 

neurocutaneous syndromes.
72

Pediatric Surgery and Medicine for Hostile Environments 

• Missed medication dosing or medication tapering are common 

causes of SE in older children.

• Seizures within the first week of trauma need to be treated 

acutely; however, there is a low risk of long-term epilepsy.

• Patients who develop seizures after the first week following 

trauma are more likely to have posttraumatic epilepsy.

Complications

• Overall mortality for pediatric SE is 3% to 7%, but varies 

depending on type and age; mortality for RSE is 20%–30%.

• Mortality from idiopathic or febrile SE is low (0–2%), but for 

acute symptomatic SE, mortality is high (12.5%–16%).

• Early in SE, autonomic and metabolic changes include 

tachycardia, hypertension, hyperglycemia, and increased 

cerebral blood flow; lactic acidosis may develop from 

myoclonic contracture and hypermetabolism.

• In late SE, autonomic and metabolic reserves are depleted 

and hypoglycemia, hypotension, marked hyperthermia, and 

rhabdomyolysis result; hypoxia, hypercarbia, and cerebral 

edema may all also develop. Myoglobinuria and hypovolemia 

may lead to acute kidney injury; hepatic dysfunction and 

coagulopathy rarely also occur.

• Emergency management can be simplified into a series of 

sequential interventions (Table 8-1).

• Computed tomography scan of the head is indicated if there 

is:

° head trauma,

° evidence of increased intracranial pressure,

° focal neurologic deficit, or

° focal seizure activity.

• Lumbar puncture is contraindicated in the following cases:

° suspected increased intracranial pressure,

° focal neurologic deficits,

° cardiopulmonary instability, and

° severe coagulopathy or thrombocytopenia.

• If SE persists, consider inducing coma with EEG monitoring. 

Titrate sedation to seizure suppression, burst suppression 

pattern, or flat line on EEG.
73

Status Epilepticus 

Table 8-1. Status Epilepticus Emergency Management

Stage Intervention

Out of the hospital, consider buccal or intranasal 

midazolam (0.3 mg/kg, max 10 mg) or rectal 

diazepam (0.2–0.5 mg/kg, max 20 mg)

Stabilize the patient

• assess airway, breathing, and circulation

• apply oxygen

• obtain IV or IO access

• gather “AMPLE” history: allergies, medications, 

past medical history, last meal, events preceding

Diagnostics: glucose, sodium, calcium, ABG, CBC, 

PT/PTT, LFTs, anticonvulsant levels, toxicology 

screen, head CT

Administer benzodiazepines:

• lorazepam, 0.1 mg/kg IV (max 4 mg) over 1 min, 

OR

• diazepam, 0.2 mg/kg IV (max 10 mg) over 1 min

Consider pyridoxine 100 mg IV push if < 2 years old

Repeat benzodiazepine and administer either:

• fosphenytoin 20 mg/kg IV at 2–3 mg PE/kg/min 

(max 150 mg PE/min), or

• phenytoin 20 mg/kg IV at 1 mg/kg/min (max 50 

mg/min)

Support airway, breathing, and hemodynamics

Continuously monitor vital signs, EKG, and pulse 

oximetry 

Consult neurology service

Administer either:

• levetiracetam 20–30 mg/kg IV at 5 mg/kg/min 

(max 3 g), 

OR

• valproate 20 mg/kg IV at 5 mg/kg/min

Impending SE 

(seizures 

persist < 5 min)

Established 

SE (seizures 

persist 5–10 

min)

Initial refractory 

SE (seizures 

persist > 10 

min)

(Table 8-1 continues)
74

Pediatric Surgery and Medicine for Hostile Environments 

Further Reading

1. Tschudy MM, Arcara KM, eds. The Harriet Lane Handbook. 19th ed. 

New York, NY: Mosby; 2012.

2. Nichols DG, ed. Rogers’ Textbook of Pediatric Intensive Care. 4th ed. 

Philadelphia, PA: Lippincott Williams & Wilkins; 2008.

3. Abend NS, Dlugos DJ. Treatment of refractory status epilepticus: 

literature review and a proposed protocol. Pediatr Neurol. 

2008;38(6):377–390.

4. Wilkes R, Tasker RC. Intensive care treatment of uncontrolled status 

epilepticus in children: systematic literature search of midazolam 

and anesthetic therapies. Pediatr Crit Care Med. 2014;15(7):632–639.

ABG: arterial blood gas; CBC: complete blood count; CT: computed tomography; 

EEG: electroencephalogram; EKG: electrocardiogram; IO: intraosseous; 

IV: intravenous; LFTs: liver function tests; PE: phenytoin equivalents; PICU: 

pediatric intensive care unit; PT: prothrombin time; PTT: partial thromboplastin 

time; SE: status epilepticus

Coma induction 

(seizures 

persist > 25 min)

Administer phenobarbital 20 mg/kg IV not to 

exceed 1 mg/kg/min

Admit to PICU; anticipate intubation, mechanical 

ventilation, arterial pressure monitoring, and 

central venous access for fluids and vasopressors 

Consider continuous EEG

Initiate coma with midazolam 0.2 mg/kg bolus 

(max 10 mg) over 2 min, then initiate infusion at 

0.1 mg/kg/h

Repeat bolus every 5 minutes and titrate infusion 

up to max 2 mg/kg/h

If refractory SE, consider pentobarbital, ketamine, 

propofol, or isoflurane

(Table 8-1 continued)

Late refractory 

SE (seizures 

persist > 15 

min)
75

Care of the Newborn

Chapter 9

Care of the Newborn

Routine Resuscitation

• When called to the delivery of a newborn, first learn the basic 

maternal history (time permitting), including the following:

° the infant’s gestational age (term or preterm).

° if prenatal care was obtained. If possible, gather laboratory 

information, including ultrasound, estimated fetal weight, 

etc.

° complications, if any, leading to delivery (eg, bleeding, 

change in fetal movements, etc).

° maternal medications (during pregnancy and in the last 24 

hours of pregnancy).

° maternal health status (eg, medical conditions, 

immunizations, etc).

• Gather the proper equipment needed for resuscitating a 

newborn, including:

° Warm towels. Skin-to-skin contact with the mother can 

be used to keep the baby warm if the infant is vigorous 

at delivery. Cover the baby and the mother with a warm 

towel.

° A heat source to keep the infant warm. Use radiant warmers 

if they are available and the infant needs to be separated 

from the mother for resuscitation.

° A bulb syringe.

° A suction device, such as wall suction, that can be used 

with a suction catheter.

° An oxygen source.

° A self-inflating bag or flow-inflating bag that can provide 

positive-pressure ventilation.

° A mask, size 0 or 1, that can fit over the mouth and nose of 

an infant.
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Pediatric Surgery and Medicine for Hostile Environments 

° A minute–second timer (though not essential, this helps 

mark 1 and 5 min and is useful if positive-pressure 

ventilation is needed).

° Attempt to have a neonatal resuscitation provider available. 

Larger medical commands should identify people with this 

experience, even in the deployed environment.

• In the first 60 seconds following birth:

° Ensure the obstetrical provider securely clamps the 

umbilical cord before passing the infant to the pediatric 

team; start the minute–second timer.

° All infants need to be warm, dry, suctioned, and stimulated; 

in the delivery room, this takes place within a period of 30 

seconds.

▶ Dry the infant with the warm towels, discarding damp 

ones; it is typical to use two or three towels within the 

first 30 seconds.

▶ Rubbing the infant’s back and chest while drying is 

stimulating; if further stimulation is necessary, flicking 

or slapping the soles of the infant’s feet may help.

▶ Position the infant’s head at the foot of the bed or radiant 

warmer.

▶ Manage the airway and position the infant’s head in the 

sniffing position, allowing for slight hyperextension of 

the neck (this is usually done by the person closest to 

the infant’s head).

▶ Suction the mouth first, and then the nares, with the bulb 

syringe or suction catheter to clear amniotic fluid that 

could occlude the airway.

▶ Monitor the infant’s heart rate by gently palpating 

the base of the umbilical cord to feel for a pulse, or by 

listening to the heart with a stethoscope.

▶ Heart rate should be above 100 beats per minute (bpm) 

if the newborn is active and crying.

▷ A “vigorous” infant has good muscle tone, has a heart 

rate greater than 100 bpm, and is crying.

▷ If the baby is vigorous, stop resuscitation and allow 

the infant to transition (transitioning from the 

intrauterine environment to the outside world takes 

2–4 h). 
77

Care of the Newborn

▷ Skin-to-skin contact with the mother is important at 

this point, if both the mother and infant are doing 

well, to keep the infant warm and encourage bonding/

feeding.

° All infants are born with a hue ranging from blue to pink; if 

healthy, newborns will transition to pink with an adequate 

heart rate and ventilation.

▶ Sometimes an infant’s hands and feet stay blue even 

when the rest of the body is pink (acrocyanosis). Assess 

for central cyanosis by examining the color of the lips, 

gums, and central trunk; if infant is cyanotic, place a 

pulse oximeter (if available) on the right hand. 

▶ A brief period of free-flowing oxygen is beneficial to 

infants with adequate ventilation and heart rate who 

remain centrally blue or with a saturation of less than 

80% beyond 5 minutes of life. An infant requiring 

persistent oxygen needs more than typical resuscitation.

° Every infant is assigned an Apgar score (activity, pulse, 

grimace, appearance, and respiration; Table 9-1) at 1 minute 

and 5 minutes of life.

Table 9-1. Apgar Evaluation of Newborn Infants

Sign 0 1 2

Heart rate Absent Below 100 Over 100

Respiratory effort Absent Slow, irregular Good, crying

Muscle tone Limp Some flexion of Active motion

extremities

Response to No response Grimace Cough or sneeze

catheter in 

nostril*

Color Blue, pale Body pink, Completely pink

extremities 

blue

*Tested after oropharynx is clear.

▶ The score ranges from 0 to 10, with 10 being given to 

healthy, vigorous infants.
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Pediatric Surgery and Medicine for Hostile Environments 

▶ Properly assigning an Apgar score requires training, 

but knowledge of the components will help providers 

unfamiliar with scoring know what is important when 

assessing a newborn during resuscitation and will 

facilitate communication with a consulting specialist.

Special Circumstances Requiring Advanced Resuscitation 

• Advanced resuscitation is required when a term infant is not 

vigorous after warming, drying, suctioning, and stimulating.

• When an infant is apneic, has a heart rate less than 100 bpm, 

or has persistent central cyanosis despite free-flowing oxygen, 

further intervention is required.

° Ventilation is the most important step in the resuscitation 

of infants that are not vigorous.

° The two standard ways of providing ventilation are the 

self-inflating bag and flow-inflating bag.

° Various mask sizes are needed, depending on the 

gestational age of the infant.

▶ The mask should cover the infant’s mouth and nose and 

provide a good seal.

▶ Most term newborns will use a size 1 infant mask.

▶ Preterm infants or infants that are small for their 

gestational age may need a size 0 newborn mask.

° Initiate positive-pressure ventilation with 21% fraction 

of inspired oxygen (FiO2) in a term infant. If the infant is 

preterm, start with 40% FiO2 if a blender is available.

° Suction the infant’s mouth and nose again.

° Place the mask over the infant’s face.

° Hold the mask with your thumb and index finger; use your 

other three fingers to lift the jaw into the mask.

° Ensure there is an airtight seal.

° Begin delivering breaths at a rate of 40 to 60 breaths per 

minute; use a manometer if one is available.

° Pressures should be sufficient to provide adequate chest 

rise and fall.

▶ The first few breaths can require pressures in excess of 

25 cm H2O, but it is rare to need pressures in excess of 

40 cm H2O.

▶ Most infants will require pressures of 20 to 25 cm H2O.
79

Care of the Newborn

▶ Using excessive pressure can cause a pneumothorax.

▶ It takes experience to achieve the correct balance of 

pressure.

▷ Novices typically make one of two mistakes: they do 

not use sufficient pressure to provide adequate chest 

rise and fall, or they give breaths at a rate exceeding 

60 breaths per minute.

▷ Using the minute–second timer can alleviate the 

frequency problem (give a breath every second).

° If positive-pressure ventilation is adequate, heart rate will 

improve to over 100 bpm, color will improve, and the infant 

will start spontaneous respiration; gradually stop giving 

positive-pressure ventilation.

° If there is no improvement after 30 seconds, check that the 

facemask is sealed adequately, reposition the head, and 

suction out the mouth. At this point, increase the FiO2 to 

100%. 

° If problems persist, reevaluate the pressure being 

administered; if it is adequate but there is still no 

improvement, the infant needs to be intubated.

• Intervention is needed when the term infant needs to be 

intubated.

° Depending on the location and resources, intubating and 

ventilating a newborn infant may be impossible. 

° When working in austere environments, it is reasonable and 

ethical to decide ahead of time the limits of the providers’ 

resuscitative efforts.

° There are five main differences between the neonatal and 

adult airway:

▶ The infant’s head and tongue are proportionally larger 

than the adult’s.

▶ The infant’s larynx is more anterior and cephalad. 

▶ The infant’s epiglottis is long, narrow, and floppy 

(making it easier to use a Miller [straight] blade instead 

of a Macintosh blade).

▶ The infant’s vocal cords are slanted anteriorly.

▶ The cricoid cartilage is the narrowest part of an infant’s 

larynx, not the vocal cords.
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Pediatric Surgery and Medicine for Hostile Environments 

° A term infant is generally intubated with a 3.5 or 4.0 

uncuffed endotracheal tube (ETT), using a Miller size 1 

blade. 

° Depth of the ETT should be the approximate weight of in 

the infant in kilograms plus 6 (term infants can be estimated 

at 3–3.5 kg).

° Confirm ETT placement by observing one or more of the 

following:

▶ equal chest rise,

▶ breath sounds over the lungs and not the stomach,

▶ misting inside the ETT,

▶ positive color change using a pediatric-size disposable 

colorimetric carbon dioxide detector (fast, accurate),

▶ chest radiograph, and

▶ clinical improvement in ventilation and perfusion.

° Upon successful intubation, continue providing positivepressure ventilation with enough pressure to ensure 

adequate chest rise at a rate of 40 to 60 breaths per minute.

° In the rare case when an infant does not improve after 

establishing an airway and providing adequate ventilation, 

start chest compressions and establish intravenous access 

to give epinephrine and volume resuscitation, if necessary.

• For emergency vascular access, consider umbilical vein 

catheter (UVC) placement. 

° Equipment needed for placing a UVC includes:

▶ UVC placement kit, if available; 

▶ 3.5 F or 5.0 F single-lumen umbilical catheter;

▶ scalpel (usually in UVC kit);

▶ three-way stopcock;

▶ normal saline syringes;

▶ 5 to 10 mL syringes (usually in UVC kit);

▶ Betadine (Purdue Products, LP, Stamford, Conn; usually 

in UVC kit);

▶ umbilical tape (usually in UVC kit);

▶ small mosquito forceps; and

▶ sterile gloves.

° Technique

▶ Use aseptic technique. Assemble the needed equipment 

and prepare the line. 
81

Care of the Newborn

▶ Attach the three-way stopcock to the end of the line. 

Attach a normal saline syringe to the stopcock and flush 

the line. The other opening on the stopcock can be used 

for medication administration. 

▶ Ensure the stopcock is always in the “off to baby” 

position when it is not being used.

▶ Lift the umbilical cord by the clamp and clean the cord 

and surrounding skin with Betadine. 

▶ Tie the umbilical tape around the skin portion base of 

the cord rather than directly on the cord with a single 

tie. It should be just tight enough to prevent bleeding 

but still allow passage of the catheter. 

▶ Use a scalpel to cut across the umbilical cord about 1 to 

2 cm above the base of the stump. There will be three 

vessels, two arteries (tortuous with thicker walls), and 

a vein (thinner walled and larger). 

▶ If necessary, use small forceps to open the vessel enough 

to place the catheter (Figure 9-1). 

Figure 9-1. The cartoon depicts a typical three-vessel cord; the two smaller 

umbilical arteries and single larger vein are highlighted. The photo shows the 

insertion of an umbilical catheter into a previously dilated umbilical vein. Both 

images demonstrate the application of umbilical tape around the umbilical 

stump for hemostasis. 

Artery Artery

Umbilical tape

Vein

Note umbilical tape for hemostasis

Vein with catheter inserted
82

Pediatric Surgery and Medicine for Hostile Environments 

▶ Place the catheter in the vessel and advance to about 3 

to 4 cm while drawing back on the syringe. Stop when 

you get blood return. At this point, you are in the vessel 

and may administer fluids and medications. 

▶ An emergent UVC is not meant to be a permanent line, 

so it is usually not sutured in place but rather held by 

the provider or temporarily taped in place until a more 

stable line can be placed.

▶ For more information on emergentUVC placement, see 

https://www.youtube.com/watch?v=JjBJONanCYU.

Emergency UVC Placement 

https://www.youtube.com/watch?v=JjBJONanCYU

Scan QR code for video.

• If the infant develops a tension pneumothorax, intervention 

is required.

° Pneumothorax occurs in a small percentage of all newborns, 

rarely causing respiratory distress and need for rapid 

evacuation.

° There are cases when an infant develops a tension 

pneumothorax, especially those infants receiving excessive 

positive-pressure ventilation.

▶ The infant will be in respiratory distress (with grunting 

or nasal flaring or retracting).

▶ There are decreased breath sounds on the ipsilateral side.
83

Care of the Newborn

▶ Transilluminating the chest with a light source 

may show lucency over the side with the tension 

pneumothorax (chest radiograph confirms the presence 

of a pneumothorax, but is not usually available before 

intervention is required). To transilluminate the chest, 

turn the room lights down and place a light source in 

the infant’s axilla. If pneumothorax is present, light will 

be seen throughout that side of the chest cavity.

° Pneumothorax in infants is treated with the same technique 

used in any age group, except that providers use a smallergauge needle and the volume of air evacuated will be less 

in an infant.

▶ Use a needle (23-gauge butterfly works well) attached 

to a three-way stopcock, with one end closed to air and 

the other open to a syringe. 

▶ Insert the needle in the second intercostal space, at the 

midclavicular line.

▷ While inserting the needle, apply gentle retraction to 

the syringe.

▷ When the tip of the needle is in the correct place, 

you may hear a “whoosh” sound and will be able to 

rapidly pull back on the syringe.

▶ Draw off the air, turning the stopcock off to the patient 

and on to evacuate the air in the syringe, and repeat until 

no further air is evacuated from the lungs. Remove the 

needle and cover with occlusive dressing.

° Infants with rapidly reaccumulating air require placement 

of a chest tube, which is beyond the scope of this chapter.

• Intervention is required when the amniotic fluid is meconium 

stained.

° Infants who are stressed prior to birth or are late in gestation 

(more than 41 weeks) are at increased risk to pass stool in 

the amniotic fluid prior to birth.

° When the mother’s membranes rupture, the amniotic fluid 

is stained various shades of dark green.

° This places the infant at risk for aspiration of meconium 

fluid, which can lead to respiratory compromise (called 

meconium aspiration syndrome).
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Pediatric Surgery and Medicine for Hostile Environments 

° Obstetrical interventions reduce the risk of aspiration and 

include a transcervical amnioinfusion, bulb suctioning of 

the nares and mouth on presentation of the head (prior 

to delivery of the body), and not stimulating the infant at 

birth.

° The infant should not be stimulated when passed to the 

neonatal resuscitation team.

▶ If the infant is not vigorous, a provider experienced in 

intubating newborns should place an appropriately 

sized ETT, attach a meconium aspirator, and suction any 

meconium from below the vocal cords.

▶ This attempt should only last 30 to 60 seconds. If unable 

to place ETT in this time, abort attempt and proceed with 

next steps of resuscitation (warming, drying, stimulation, 

and suctioning the oral pharynx).

▶ The vigorous infant requires only routine resuscitation.

° Infants who develop signs of respiratory distress following 

delivery in meconium-stained fluid may have aspirated 

meconium.

▶ These infants need to be cared for in a facility equipped 

to care for sick newborns.

▶ Consultation with a neonatologist is indicated.

• A preterm infant may require advanced resuscitation.

° An infant born at less than 37 weeks is preterm (the age of 

viability is 23 gestational weeks; however, this may differ 

outside the United States depending on local neonatal 

resuscitation resources).

° Know the available hospital resources in the local area and 

consult a pediatrician or neonatologist when delivering and 

resuscitating a preterm infant.

° Remember the basics.

▶ For infants born in the third trimester (> 28 wk), basic 

resuscitation (see Routine Resuscitation, above) may be 

all that is needed.

▶ If positive-pressure ventilation is indicated, a size 0 

neonatal mask is typically used.

▶ Intubation is achieved using 2.5 to 3.5 ETT to a depth of 

7 to 10 cm, depending on the age and size of the infant 

(Table 9-2).
85

Care of the Newborn

▶ Intubation of the preterm infant requires prior experience 

in the intubation of children and newborns. 

° Following successful resuscitation, infants born at less 

than 35 weeks or weighing less than 2 kg will typically be 

admitted to a neonatal intensive care unit. Infants older 

than 35 weeks may be allowed to stay with their mothers, 

provided they can be watched closely.

▶ Resuscitated infants need to be kept warm and are easily 

susceptible to cold intolerance.

▶ Blood glucose levels should be checked shortly after birth 

and then every 3 to 5 hours before feeds until feeding 

is well established, especially in newborns that weigh 

10% (or more) below normal predicted weight for their 

gestational age (Table 9-3). Infants who are too young 

to begin oral feeds should be started on dextrose 10% 

in water (D10W) at 2.5 to 5 mL/kg/h (60–120 mL/kg/day; 

consult a pediatric provider to determine exact rates).

▶ Vital signs should be checked at least every 4 hours (Table 

9-4).

▷ Abnormal vital signs, temperature intolerance, 

hypoglycemia (blood glucose < 40), or poor feeding, 

regardless of gestational age, should prompt 

consultation with a neonatologist and transport to a 

hospital equipped to care for a sick neonate.

▷ Consultation with a neonatologist regarding a 

preterm newborn is always strongly encouraged.

• An infant that does not appear normal may require advanced 

resuscitation.

Table 9-2. Infant Endotracheal Tube Sizes

Tube Size Depth (cm) Birth Weight (g) Gestational Age (wk)

2.5 7 < 1,000 25–29

3.0 7–8 1,000–2,000 30–34

3.5 8–9 2,000–3,000 35–37

3.5–4.0 9–10 > 3,000 > 37
86

Pediatric Surgery and Medicine for Hostile Environments 

° Few abnormalities require urgent recognition and 

management in the delivery room (see below). In austere 

environments, management may be limited to recognition 

and supportive care without the ability to refer to a neonatal 

center.

Table 9-3. Expected Newborn Weight by Gestational Age

Gestational Age (wk) Mass (g)

25 650

26 750

27 880

28 1,000

29 1,150

30 1,325

31 1,500

32 1,700

33 1,900

34 2,150

35 2,375

36 2,600

37 2,860

38 3,075

39 3,300

40 3,460

41 3,600

42 3,690

Table 9-4. Normal Infant Vital Signs

Sign Normal Ranges

Respiratory rate 30–60 breaths/min

Heart rate* 120–160 beats/min

Temperature (axillary) 36.1°C–37°C

*Some healthy, term infants may have a resting heart rate as low as 90 beats 

per minute while asleep. A heart rate that remains this low in an awake, 

crying infant is not normal. 
87

Care of the Newborn

▶ Rarely, an abdominal wall defect may occur and an 

infant’s abdominal contents will develop outside the 

abdomen. In gastroschisis, the abdominal wall defect 

is typically to the right side of the umbilical cord. In 

omphalocele, the defect is through the umbilical cord 

insertion. In either case, the same steps should be 

followed.

▷ Immediately place the infant in a clear, sterile, plastic 

bag up to the neck to reduce insensible water losses 

and minimize exposure of the open bowel; if this 

is impossible, consider using plastic wrap or warm 

saturated gauze.

▷ Use an oral gastric tube to decompress the intestine 

(a Replogle tube is preferred); if the infant requires 

advanced resuscitation, limit positive-pressure 

ventilation delivered using a bag-valve mask.

▷ Place the infant on its side to take pressure off of the 

bowel.

▷ Contact a surgeon.

▶ Rarely, dusky blue to black bowel requires urgent 

reduction to prevent ischemia and bowel death. These 

patients may require initial intense fluid management 

and attention to acidosis status.

▷ Begin D10W at 3.3 to 5 mL/kg/h (80–120 mL/kg/day).

▷ Hypotension, poor perfusion, or acidosis should 

prompt a fluid bolus of 10 mL/kg given over 20 to 30 

minutes.

▷ Transport infant to a tertiary care facility.

▶ A neural tube defect, or a protrusion of the spinal cord 

or the meninges outside the spinal canal, also rarely 

occurs. 

▷ Place the infant prone on the infant warmer. 

▷ Place the infant in a clear, sterile, plastic bag covering 

the entire defect up to the infant’s axilla. In addition, 

you may cover the protruding mass in warm, sterile 

gauze soaked in sterile water. 

▷ Contact a neurosurgeon and arrange for the infant’s 

transport to a tertiary care facility.
88

Pediatric Surgery and Medicine for Hostile Environments 

▶ An upper airway anomaly may rarely occur. Infants are 

obligate nose breathers. Infants with small jaws, large 

tongues, and cleft lip or palate may have Pierre-Robin 

sequence and difficulty keeping their upper airway 

open. These patients may benefit from being placed in 

the prone position, and some require placement of an 

oral airway. Severe cases need bag-mask ventilation and 

intubation.

▷ Infants born with upper airway stenosis, such as 

choanal atresia, may also need an oral airway to 

breathe.

▷ Typically infants with only cleft lips or palates do 

not have respiratory issues, but may have difficulty 

feeding, which can be addressed by a pediatric care 

provider.

° Most other cases of infants appearing abnormal can wait 

for further evaluation until after initial stabilization.

• When a term infant appears ill, advanced resuscitation may 

be necessary.

° When an infant appears ill, it is important to ensure that 

the infant is not septic. Infection in infants can present with 

soft signs and progress to death within hours. Maternal risk 

factors for neonatal infection include:

▶ intrapartum temperature equal to or exceeding 100.4°F 

(38°C),

▶ amniotic membrane rupture more than 18 hours before 

delivery,

▶ chorioamnionitis, and 

▶ maternal group B streptococcus status (positive or 

unknown) and without maternal intrapartum antibiotic 

prophylaxis.

° Draw a complete blood count with differential and blood 

culture.

▶ An experienced provider should perform a lumbar 

puncture to obtain cultures and Gram stain, cell count, 

and glucose and protein levels.

▶ For infants less than 48 hours old, a urine culture is 

typically not helpful.
89

Care of the Newborn

° Empiric antibiotic treatment often consists of administering 

ampicillin and an aminoglycoside (usually gentamicin) 

or ampicillin and a broad-spectrum, third-generation 

cephalosporin, such as cefotaxime.

° Ampicillin dose is 100 mg/kg, the interval changes with 

the degree of prematurity and age in days; use a standard 

reference, like The Harriet Lane Handbook, to confirm dose.

° An ill-appearing infant needs transfer to a tertiary care 

facility.

▶ Consult a pediatric provider.

▶ If the term infant is less than 48 hours old, start D10W at 

2.5 mL/kg/h (60 mL/kg/day).

▶ Infants more than 2 days old require some electrolytes; 

consult a pediatric provider to determine the appropriate 

fluids (see recommendations in Chapter 25, Basic Fluid 

and Electrolytes).

° Observe vital signs.

▶ Warm hypothermic infants under a radiant warmer.

▶ Check blood glucose.

▶ Hypoglycemia can mimic infection; infants who appear 

ill and are hypoglycemic (blood glucose less than 40 

mg/dL) should receive a D10W bolus (2 mL/kg), then be 

started on intravenous fluids.

° Infants with evidence of respiratory distress or persistent 

cyanosis require evaluation by a specialist.

▶ Obtain an arterial blood gas reading by drawing blood 

from the radial artery.

▶ Place a pulse oximeter on the infant’s right hand and 

left foot to help monitor preductal and postductal 

saturations.

▶ If possible, deliver either positive pressure ventilation via 

bag mask or intubation, or continuous positive pressure 

using 100% oxygen.

▶ Obtain a chest radiograph and discuss the results with 

a specialist.

▶ Begin a sepsis evaluation (see previous information on 

evaluating for sepsis).

• If the infant is large or small for gestational age, intervention 

may be required.
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Pediatric Surgery and Medicine for Hostile Environments 

° Infants that are large or small for their gestational age are 

at risk for hypoglycemia. Check blood glucose once every 

few hours before feeds (for a total of three times) until the 

patient is stable.

Routine Care of the Newborn

• Feeding

° Breast-feeding is the recommended method for feeding a 

newborn, and may be all that is available.

▶ Breast-feeding should occur on demand (ie, when the 

infant is showing interest in feeding), 8 to 10 times in a 

24-hour period, for 10 to 20 minutes on each breast.

▶ In the stable, vigorous newborn, initiate breast-feeding 

immediately after birth; it takes priority over the 

newborn examination, delivery of vitamin K, and 

administration of eye drops.

▶ Most medications are safe to use during breast-feeding. 

▷ Exceptions include chemotherapeutic agents, 

radioactive isotopes, antimetabolites, and drugs of 

abuse.

▷ LactMed (http://toxnet.nlm.nih.gov/newtoxnet/

lactmed.htm) is an online website that can be used 

to determine a medication’s safety during breastfeeding; it is available through the National Library 

of Medicine. 

° Infants fed formula may start with only a half of an ounce 

per feed, but quickly increase to 2 ounces or more per feed 

over the next few days.

• Newborn prophylaxis

° After the first breast-feeding attempt has been accomplished, 

give 1 mg of vitamin K (phytonadione), if available, 

intramuscularly in the thigh to prevent hemorrhagic 

disease. 

° Administer erythromycin (0.5%) ointment or 1% silver 

nitrate eye drops if available for prevention of gonococcal 

eye infection.

• General care

° Infants should be dressed or blanketed in one or two layers 

more than what everyone else is wearing.
91

Care of the Newborn

▶ Excessive wrapping and layering can lead to 

hyperthermia.

▶ Place wrapped infants in a crib in the supine position. 

° Infants are typically given a sponge bath at birth to remove 

the vernix.

° Infants typically void once the first day, twice the second 

day, then more frequently after that.

▶ Most infants will pass stool at least once in the first 24 

to 48 hours.

▶ The stool will be meconium (dark and tarry) for the first 

few days.

▶ If voiding or passing stool is delayed, consultation is 

recommended.

° Most infants stay 2 days in the hospital.

▶ A weight loss of up to 10% of the birth weight can be 

expected, especially in breast-fed infants.

▶ Weight loss in excess of 10% should prompt further 

evaluation and consultation with a specialist.

▶ During this time, vital signs should be checked at least 

every 8 to 12 hours.

▶ The newborn should be assessed for jaundice.

▷ If possible, all infants should be evaluated for 

hyperbilirubinemia within the first 24 to 48 hours 

of life. Infants with yellowing skin should definitely 

be evaluated for hyperbilirubinemia or an elevated 

indirect bilirubin.

▷ Normal values for a newborn are significantly higher 

than adult values and vary based on the age (in 

hours) of the infant. For further information, see the 

American Academy of Pediatrics article in Further 

Reading, below . An indirect bilirubin of more than 

10 mg/dL after the first week of life in a term infant 

or persistent elevation of the direct bilirubin fraction 

require further diagnostic investigation.

• Screening for critical congenital heart disease

° Pulse oximetry screening can substantially increase the 

detection of a critical congenital heart defect in infants 

prior to discharge home (see Kemper, Mahle, Martin, et al 

in Further Reading).
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° Targeted heart defects include: hypoplastic left heart 

syndrome, pulmonary atresia (with intact septum), 

Tetralogy of Fallot, total anomalous pulmonary venous 

return, transposition of the great arteries, tricuspid atresia, 

and truncus arteriosus. 

° All “well” newborns should have pulse oximetry screening 

between 24 and 48 hours of life.

° A pulse oximeter probe should be placed on the infant’s 

right hand and a foot.

° A screen is positive if:

▶ oxygen saturation is less than 90% saturation of oxygen 

(SpO2);

▶ oxygen saturation is less than 95% SpO2 in both the right 

hand and foot on three measures separated by 1 hour; 

or

▶ a greater than 3% SpO2 difference is noted in oxygen 

saturation between the right hand and the foot on three 

measures separated by an hour. 

° If a screen is positive, immediately consult a pediatrician, 

neonatologist, or pediatric cardiologist.

° Depending on location and available resources, further 

evaluation with echocardiogram is recommended.

° The consulting provider may suggest starting a 

prostaglandin drip to maintain patency of the ductus 

arteriosus while transport to definitive care is being 

arranged. 

Further Reading

1. American Academy of Pediatrics Subcommittee on 

Hyperbilirubinemia. Management of hyperbilirubinemia in 

the newborn infant 35 or more weeks of gestation. Pediatrics. 

2004;114:297–316. http://pediatrics.aappublications.org/

content/114/1/297.full. Accessed April 30, 2015.

2. Kemper AR, Mahle WT, Martin GR, et al. Strategies for 

implementing screening for critical congenital heart disease. 

Pediatrics. 2011;128:e1–e8. http://pediatrics.aappublications.org/

content/128/5/e1259.full. Accessed April 30, 2015.
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Chapter 10

Clinician-Operated Ultrasound

Ultrasound (US) is a rapidly emerging complementary tool for 

diagnosis and management at the bedside that can help augment 

medical decision-making. US is ideally suited for austere 

environments, such as forward deployments and humanitarian 

assistance missions. In resource-limited settings, US may be the 

only imaging modality available.

Although no single book chapter can result in clinical US skill 

proficiency, it can highlight the clinical possibilities. Providers 

are encouraged to use US-skilled personnel (eg, emergency 

department physicians, anesthesia providers, radiologists, and 

personnel certified in peripherally inserted central catheter 

placement) and the “knobology” primer below to facilitate the 

clinical applications. Practicing image acquisition on colleagues 

is also recommended prior to using US on patients.

Supplementary links to additional online US tutorials are found 

in the chapter references and at the end of each section. 

FUNDAMENTALS

Transducer Types 

• Linear array (Figure 10-1a): higher frequency probes that 

generate high-resolution images with a wide area of view at 

the skin surface. 

° Excellent for procedures such as vascular access, but not 

as good for assessing deep structures.

° For infants and small children, the linear array may 

occasionally be useful for abdominal applications.

• Curvilinear (Figure 10-1b): a lower frequency transducer that 

penetrates deep tissues with a wide near-field view that makes 

it well suited for focused abdominal sonography for trauma 
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Figure 10-1. Transducer types. (a) Linear array. (b) Curvilinear array. 

(c) Phased array.
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(FAST) and abdominal imaging. Limited use for procedures 

because of lower resolution; the large probe footprint may 

also limit utility in children.

• Phased array (Figure 10-1c): can visualize more depth of field 

with a smaller footprint than a curvilinear probe and view 

deep structures though a small acoustic window. Good for 

FAST or chest examination, but the narrow near field makes 

it difficult to identify structures close to the probe or perform 

procedures.

Depth 

• The depth of view is displayed as a measurement scale 

traditionally aligned on the right side of the screen.

• Depth should be set deeper than the structure being examined 

so that underlying structures are imaged.

Gain 

• Increasing gain increases the sensitivity of the probe, thereby 

increasing image contrast and brightness.

• If the image is too dark, increase the gain. If it is too bright 

and fluid-filled structures have shadows, reduce the gain.

• Many machines are equipped with an “Auto Gain” button, 

which automatically optimizes the gain.

Probe Orientation 

• Each probe is equipped with a marker on the side that 

corresponds with the marker on the screen.

• All images in this text appear in noncardiac convention with 

the marker pointed to the patient’s right side or head.

Scanning Modes 

• Most US imaging is performed using two-dimensional B-mode 

(“brightness” mode; Figure 10-2a). 

• M-mode (“motion” mode) examines a small area over time to 

evaluate movement. This is especially useful for cardiac and 

pulmonary scanning (see Figure 10-2b).
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Figure 10-2. Imaging modes. (a) B-mode 2-dimensional image of the heart. 

(b) M-mode image with the cursor placed through the mitral valve apparatus.

a

b
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Online introductory US tutorial: 

• Turner L. Bedside Physics, Knobology and Artifacts [Video]. 

YouTube. http://youtu.be/jLNNdc1LaxI. Published August 17, 

2013. Accessed January 2, 2015. 

http://youtu.be/jLNNdc1LaxI

Scan QR code for video.

FOCUSED ASSESSMENT WITH SONOGRAPHY FOR TRAUMA 

• FAST (Figure 10-3) is used to detect hemopericardium and 

hemoperitoneum and has replaced diagnostic peritoneal 

lavage in trauma patients. It can help guide management.

• The examination is positive when fluid is detected on any of 

the three abdominal windows or on the cardiac window; the 

examination is negative when no fluid is detected.

• Sensitivity of FAST in children is much lower than in 

adults due to smaller structures and a higher frequency of 

nonbleeding solid organ injury; sensitivity may be increased 

by performing serial FAST examinations over time.

• A positive FAST examination is meaningful for a bleeding 

injury; a negative FAST examination should be followed by 

computed tomography or laparotomy if there is a high index 

of suspicion for bleeding injury.

• A positive FAST examination alone is not an absolute 

indication; but in the hypotensive patient, surgery is often 

indicated.

Bedside Ultrasound Physics, Knobology and Artifacts
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Figure 10-3. Focused assessment with sonography in trauma (FAST) examination windows: (a) Subcostal long-axis cardiac, (b) Perihepatic/Morison’s 

pouch, (c) Splenorenal recess, (d) Pelvic, (e) Parasternal long-axis cardiac.

Subcostal Long-Axis Cardiac 

• Use a curvilinear or phased array probe (Figure 10-4). Do not 

use a linear probe. Set the machine to the “abdominal” preset.

• Place the patient supine, with the probe below the xiphoid 

process directed toward the left shoulder and indicator toward 

the patient’s right side; apply downward and forward pressure 

in a scooping motion. 

• Observe a four-chamber view of the inverted heart with the 

apex to the right of the screen. The liver appears superficial, 

with the right ventricle located beneath it. A small amount of 

fluid around the heart can be normal.
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Figure 10-4. Subcostal long axis. (a) Normal view demonstrating (A) liver, (B) 

right ventricle, and (C) left ventricle. (b) Subcostal view with circumferential 

pericardial effusion (*).

a

b
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• Acute blood will appear anechoic (black); a clot may be echoic

(bright). Only one bright line surrounding the heart should 

be seen; effusion will appear as an envelope of fluid and will 

split this line into two.

• Pericardial tamponade can be demonstrated with diastolic 

collapse of the right atrium and/or ventricle.

Perihepatic

• The right upper quadrant is the most sensitive location in 

which to detect free intraperitoneal fluid.

• Align probe parallel to the midaxillary line between ribs 

8 and 11 to visualize liver, right kidney, Morison’s pouch, 

subphrenic space, and right pleural space.

• Free fluid appears dark and in the margins surrounding solid 

structures; it is most commonly noted in Morison’s pouch, but 

it can also be seen in the subphrenic space or at the inferior 

margin of the liver (Figure 10-5).

Perisplenic (left upper quadrant)

• Align probe parallel to the midaxillary line between ribs 9 and 

11; the ideal view contains the left hemidiaphragm, spleen, 

and left kidney.

• Free intraperitoneal fluid can be seen between the spleen 

and left kidney, surrounding the spleen, or in the subphrenic 

space (Figure 10-6); injury is easier to visualize with computed 

tomography scan than FAST. 

Pelvic

• This region is best observed in the longitudinal and transverse 

views (Figure 10-7) when the bladder is full—before inserting 

a Foley catheter—with the probe above the pubic symphysis 

and the probe indicator toward the patient’s head.

• In females, fluid will be present in the pouch of Douglas 

posterior to the uterus; in males, fluid appears in the 

rectovesicular pouch dorsal to the bladder.

Parasternal Long-Axis Cardiac

• Provides the optimal cardiac view and allows for estimation 

of cardiac function (Figure 10-8).
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Figure 10-5. Right upper quadrant focused assessment with sonography in 

trauma (FAST). (a) Normal FAST examination in the perihepatic region demonstrating (A) liver, (B) kidney, (C) diaphragm. (b) Positive FAST finding indicated by (D) free fluid.
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Figure 10-6. Left upper quadrant focused assessment with sonography in 

trauma (FAST). (a) Normal FAST findings in the perisplenic region demonstrating (A) spleen, (B) kidney, (C) diaphragm. (b) Positive FAST finding indicated by (D) free fluid.

a

b
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Figure 10-7. Pelvic focused assessment with sonography in trauma (FAST). 

(a) Normal pelvic FAST, longitudinal view, demonstrating (A) bladder. (b) 

Positive FAST finding in the pelvic region, indicated by (B) free fluid.

a

b
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Figure 10-8. Parasternal long-axis view. (a) Normal heart demonstrating (A) 

left ventricular outflow tract, (B) mitral valve apparatus, (C) pericardium, (D) 

left atrium, (E) left ventricle, and (F) right ventricle. (b) Large pericardial effusion in parasternal long-axis view, (G) pericardial effusion.
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• Use the phased array probe. Position probe at left sternal edge 

between 2nd and 4th intercostal space, with the probe marker 

pointing to patient’s left hip if in the abdominal preset.

• Tilt the probe so the view shows the left ventricular (LV) cavity 

as widely as possible while still showing the left atrium, the 

mitral valve apparatus, and the LV outflow tract with the aortic 

valve leaflets moving. 

• Assess cardiac contractility by measuring or estimating 

the fractional shortening (FS) of the LV in M-mode across 

its diameter at the level of the open mitral valve leaflets, 

perpendicular to the main axis of the LV; normal FS ranges 

between 28% and 44%. It is easy to be positioned off-axis 

and accidentally measure a higher FS than normal; therefore 

take time to adjust the probe position so the diameter of the 

chamber is as large as possible before assessing FS of the 

chamber at the level of the tips of the mitral valve.

• The equation for FS is: 

LVd-LVs FS = 

LVd

× 100

• If the anterior leaflet of the mitral valve (closest to the 

interventricular septum) comes within a few millimeters of 

the septum as the LV fills in diastole, this typically indicates 

LV function is not diminished. 

• A low FS estimate associated with little change in LV diameter 

suggests reduced cardiac function.

• If the patient is tachycardic with a large FS and significant 

obliteration of the LV cavity, this suggests hypovolemia.

• Correlate with inferior vena cava observation (below).

• Online FAST tutorials:

° Hoffmann B. Ultrasound Guide for Emergency Physicians. 

American College of Emergency Physicians. http://www.

sonoguide.com/FAST.html. Published 2008. Accessed 

January 2, 2015.

° Zwanck M. eFAST: extended Focused Assessment with 

Sonography in Trauma [Video]. YouTube. http://youtu.

be/Yg78aU93SZE. Published September 5, 2013. Accessed 

January 2, 2015.
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• Online echocardiography tutorial: 

° Turner L. FATE: Focused Assessed Transthoracic Echo 

[Video]. YouTube. http://youtu.be/dsg1CgPdL30. Published 

March 3, 2013. Accessed January 2, 2015.

http://youtu.be/Yg78aU93SZE

Scan QR code for video.

eFAST : extended Focused Assessment with Sonography in Trauma 

http://youtu.be/dsg1CgPdL30

Scan QR code for video.

Focused Assessed Transthoracic Echo, FATE exam 
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Figure 10-9. Large left-sided pleural effusion. (A) Effusion, (B) spleen, (C) 

kidney, note also (D) ascites.

PLEURAL EFFUSION AND HEMOTHORAX

• The right upper quadrant and left upper quadrant views 

obtained for the FAST examination also provide information 

about the presence or absence of fluid in the thorax, such as 

pleural effusion or hemothorax.

• Normal hemidiaphragm appears as a bright (hyperechoic) 

line just above the liver and spleen.

• Normal lung appears as a bright echogenic surface beyond 

the diaphragm and is often a normal “mirror image” of liver 

or spleen.

• If a hemothorax or pleural effusion is present, the effusion will 

appear anechoic above the hemidiaphragm (Figure 10-9).
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Figure 10-10. B-lines in lung US (white arrows); pleural line (gray arrow).

• Thoracic fluid can also be visualized directly through the 

chest wall using the linear or curvilinear array by positioning 

the probe in the intercostal spaces with the marker directed 

toward the head and the patient in an upright or semi-upright 

position. 

• Acoustic windows are easier to obtain in neonates/infants due 

to incomplete ossification of bone.

• Each lung should be assessed systematically in both transverse 

and longitudinal views, scanning from the apex to the 

hemidiaphragm in the midclavicular line, midaxillary line, 

and posteriorly medial to the scapula.
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Clinician-Operated Ultrasound

Figure 10-11. Pleural effusion. (A) Effusion, (B) lung, (C) diaphragm.

• The interface of the pleura with the lung produces a strong 

reflective surface with comet-tail artifacts called B-lines (Figure 

10-10).

• Movement of the visceral pleura against the parietal pleura 

will create the appearance of lung sliding; absence of this sign 

can be indicative of separation of the pleural interface from 

effusion or pneumothorax.

° US is very sensitive for the detection of pleural fluid, able 

to detect as little at 3 to 5 mL in pleural space.

° In a simple pleural effusion, anechoic (dark) nonloculated 

pleural fluid will change in shape and position with the 

patient’s breathing or movement (Figure 10-11).

° In a complicated pleural effusion, findings may vary, but 

fluid will likely be echogenic or anechoic, with mobile 

echogenic debris and septations within the effusion.
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THORACENTESIS/TUBE THORACOSTOMY PLACEMENT

• Once an effusion has been identified, US is useful in selecting 

a site for thoracentesis.

• With the patient in a flat or slightly recumbent position, scan 

for an appropriate pocket for insertion; for thoracentesis, 

consider a sitting position leaning forward onto a table.

• A large, dark, anechoic area away from adjacent lung 

structures and the hemidiaphragm is the ideal insertion site.

• Once the ideal location is chosen, either mark the spot and 

proceed with thoracentesis or chest tube placement in the 

usual blind manner, or refer to the below vascular access 

discussion for details about dynamic needle guidance. 

• Online chest tube insertion tutorial:

° Elbeery, J. Ultrasound Guided Chest Tube Insertion 

for Pleural Effusion [Video]. YouTube. http://youtu.be/

xVEfyXOC-mg. Published January 15, 2014. Accessed 

October 8, 2014.

http://youtu.be/ebCbewLBNGM

Scan QR code for video.

Ultrasound Guided Chest Tube Insertion for Pleural Effusion

PNEUMOTHORAX

• Pneumothorax is characterized by obliteration of normal US 

lung artifact, as air does not transmit US.
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• To identify pneumothorax, look for an absence of signs seen 

with normal lung: (1) no lung sliding at the normal pleural 

line, (2) absent B-lines, and (3) no concurrent effusion.

• Finding a “lung point” is highly suggestive of a pneumothorax. 

This is an area where you see a normal lung (lung sliding, 

B-lines, etc) moving in and out of an area without lung sliding 

or B-lines. 

• US for significant pneumothorax has a high negative

predictive value. Pleural movement suggests pneumothorax 

is unlikely. Factors such as pleural adhesions and poor 

windows may decrease the sensitivity of absent lung sliding 

for pneumothorax.

• If there are questionable findings on B-mode US, the lungs 

can also be examined using M-mode (Figure 10-12).

° Normal pleural sliding will appear as a grainy “seashore” 

sign below the pleural line.

° Pneumothorax has no movement beneath the pleural line, 

known as the “barcode” or “stratosphere” sign.

• Online pneumothorax tutorial: 

° Cook J. Critical points: beside ultrasound for pneumothorax 

[Video]. YouTube. http://youtu.be/ebCbewLBNGM. 

Published February 20, 2011. Accessed January 2, 2015.

http://youtu.be/ebCbewLBNGM

Scan QR code for video.

Critical Points: Bedside Ultrasound for Pneumothorax
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Figure 10-12. M-mode tracings of the lung. In both images, the transducer 

is sagittally oriented and the cursor placed between rib spaces through the 

pleural line. With normal lung (a), normal sliding movement between the visceral and parietal pleura leads to a grainy appearance deep to the pleural line, 

described as the “sand on a seashore” sign. With pneumothorax (b), there is no 

respiratory variation or pleural sliding; the straight lines deep to the parietal 

pleura are described as a “barcode” or “stratosphere cloud” sign.

VOLUME STATUS

• The diameter of the inferior vena cava (IVC) is suggestive of 

intravascular volume status in many conditions.
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• Place a curvilinear or phased array probe below the xiphoid 

process, with the indicator oriented toward the patient’s head, 

and tilt the tail of the probe toward the patient’s left so the 

IVC is seen sagittally where it lays to the right and anterior of 

the patient’s spine. The IVC enters the heart as it crosses the 

diaphragm, differentiating it from the aorta.

• Respiratory variation in IVC diameter suggests lower 

intravascular volume when a patient’s symptoms are 

consistent with shock (Figure 10-13). 

• Finding a full IVC with no respiratory variation may be more 

meaningful in pediatric shock management, as it suggests 

robust right heart filling pressures.

• Positive pressure ventilation, cardiac tamponade, tension 

pneumothorax, right heart failure, arrhythmia, and increased 

intraabdominal pressure can interfere with measurement.

VASCULAR ACCESS

• US using a linear transducer provides real-time visualization 

to help with placement of both peripheral IV and central 

venous catheter (CVC) lines, allowing greater first-pass 

success, faster time to insertion, and fewer complications.

• Short-axis approach: the probe is oriented perpendicular to 

the axis of the vessel such that the vein will appear circular 

(Figure 10-14a); often the preferred view for initial insertion.

• Long-axis approach: the probe is oriented parallel to the

axis of the vessel so the vein will appear as an anechoic dark 

horizontal stripe across the screen (Figure 10-14b); can be used 

to check if the wire or catheter is in the vessel.

• In addition to standard CVC supplies, a sterile plastic probe 

cover and sterile gel are necessary. 

• Short-axis technique for CVC insertion:

° Choose an insertion site and use US to delineate anatomy. 

Femoral and internal jugular are the easiest sites for US 

guidance; subclavian is much more difficult.

° Distinguish the vein from the artery. Veins will appear 

anechoic (dark), be compressible, have thinner walls, and 

be less pulsatile. Arteries will appear more pulsatile, have 

thicker walls, and will not be as easily compressible. 
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Figure 10-13. (a) M-mode view of the IVC with respiratory variation. The 

cursor is placed below the diaphragm and confluence of the hepatic veins. IVC 

variation in the vessel diameter through the respiratory cycle. (b) A full IVC 

that does not vary over time is seen. (c) The IVC can also be measured in Bmode, comparing maximum and minimum diameters on separate images in 

a video loop.
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Figure 10-14. (a) Short-axis view and (b) long-axis view of the internal jugular 

vein.
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° Prepare and drape insertion site; open the sterile probe 

cover and place US gel inside the plastic sleeve. Have an 

assistant help place the transducer into the sterile sleeve. 

° Place sterile US gel over the insertion site.

° Start in the short-axis view (Figure 10-14a), holding the 

probe perpendicular to the skin. 

° Maneuver the probe so the target vein is in the center of 

the screen.

° Enter the skin within 1 to 2 mm from the transducer such 

that the finder needle enters directly under the transducer. 

° Identify the needle tip on the screen, then move the 

transducer forward about 2 to 3 mm ahead of the needle 

tip. Advance the needle until the tip is just visible.

° Continue this “leap-frog” approach until the tip of the 

needle has entered the target vessel. As the needle pushes 

against the vein wall, you should see the wall indent.

° Small forward and backward movements (“bouncing”) of 

the needle as it advances may help identify the tip.

° Once in the target vessel, rotate the transducer into the 

long-axis plane to verify needle position prior to advancing 

the guidewire.

• Long-axis technique (Figure 10-14b): Position the transducer 

overlying and centered on the vessel onscreen.

° Advance the needle in the plane of the US beam until it 

enters the wall of vessel, at which point either blind or 

US-guided wire insertion is performed.

° After threading the guidewire but before dilating, confirm 

that the wire is inside the lumen of the vein using both the 

short-axis and long-axis views (Figure 10-15).

• After you have confirmed the wire is in the correct location, 

complete the rest of the CVC procedure.

• Online US assisted central venous access tutorial: 

° Ortega R, Song M, Hansen CJ, Barash P. Ultrasoundguided internal jugular vein cannulation. N Engl J Med.

2010;362:e57-e57. http://www.nejm.org/doi/full/10.1056/

NEJMvcm0810156. Accessed January 2, 2015. 
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PERIPHERAL INTRAVENOUS CATHETER INSERTION

• Linear US probes set to a very shallow depth can help identify 

suitable peripheral veins. 

• The basilic vein in the proximal arm and the saphenous vein 

in the leg are good locations for peripheral venous access.

• Steps are similar to US-guided CVC access without the need 

for sterile preparation and use of a wire. 

• Scan peripheral veins proximally and distally from the 

insertion site for 2 to 3 cm to ensure that the vein is relatively 

straight and has no valves. Ideally the vessel will be less than 

1 cm deep from the skin surface, and at least 2 to 3 mm in 

diameter.

• The probe should be placed with minimal pressure on the site 

because veins are easily collapsible.

• When inserting the IV, use a shallow entry angle (< 20 degrees); 

sharper angles may kink the catheter.

Figure 10-15. Long-axis needle approach in right internal jugular vein, arrow 

points to needle shadow within the vessel.
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• After insertion, US can confirm that enough catheter (1–1.5 

cm) is in the lumen to prevent extravasation.

• Online US assisted peripheral IV insertion tutorial:

° Joing S, Strote S, Caroon L, Wall C, Hess J, et al. Videos 

in clinical medicine. Ultrasound-guided peripheral IV 

placement. N Engl J Med. 2012 Jun 21;366(25):e38. http://

www.nejm.org/doi/full/10.1056/NEJMvcm1005951. 

Accessed January 2, 2015. 

OTHER APPLICATIONS

• US can help identify lung consolidation consistent with

pneumonia. Consolidation causes a loss of B-lines, and the 

lung may appear similar to liver, or an irregular geographic 

pattern of bright and dark areas.

• A wide variety of musculoskeletal applications are useful, 

such as identification of bony fracture, tendon injuries, foreign 

bodies, and differentiation of abscess from cellulitis.

• Other common abdominal applications include evaluation for 

appendicitis, intussusception, bowel obstruction, hypertrophic 

pyloric stenosis, cholecystitis, hydronephrosis, and urinary 

bladder volume prior to catheterization. 

• US can assist in procedural guidance for vascular access, 

thoracentesis, paracentesis, pericardiocentesis, nerve blocks, 

arthrocentesis, and lumbar puncture.

• The reader is referred to the host of medical literature, US 

textbooks, and online resources for more information about 

these (and other) additional applications.

FURTHER READING

1. Leeson K, Leeson B. Pediatric ultrasound: applications 

in the emergency department. Emerg Med Clin N Am

2013;31:809–829.

2. Levy JA, Noble VE. Bedside ultrasound in pediatric 

emergency medicine. Pediatrics. 2008;121:e1404–1412.

3. Nicolaou S, Talsky A, Khashoggi K, et al. Ultrasoundguided interventional radiology in critical care. Crit Care 

Med. 2007;35:S186–S197.
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4. Rozycki GS, Feliciano DV, Davis TP. Ultrasound as 

used in thoracoabdominal trauma. Surg Clin North Am. 

1998;78:295–310.

5. Schindler E, Schears GJ, Hall SR, et al. Ultrasound for

vascular access in pediatric patients. Paediatr Anaesth

2012;22:1002–1007.

6. Supakul N, Karmazyn B. Ultrasound of the pediatric 

chest—the ins and outs. Semin Ultrasound CT MR

2013;4:274–285.

Additional Online Ultrasound References

1. Beraud AS. Echocardiography in the ICU. Stanford University. 

2012. https://web.stanford.edu/group/ccm_echocardio. 

Accessed January 2, 2015. 

2. Hoffmann B. Ultrasound Guide for Emergency Physicians. 

American College of Emergency Physicians. 2008. http://

www.sonoguide.com. Accessed January 2, 2015.
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121

Aeromedical Evacuation

Chapter 11

Aeromedical Evacuation

Aeromedical evacuation (AE) is the armed forces’ system of 

evacuating patients via aircraft, usually from hostile or austere 

environments, to safer or more medically capable facilities. AE 

systems differ based on several variables, such as aircraft type 

(ie, rotary wing, tilt-rotor, or fixed wing), whether a location has 

dedicated evacuation aircraft or uses a vehicle of opportunity, 

the simplicity of arranging movement, the scale of distances 

involved, and en route capabilities. 

The US Army uses dedicated rotary-wing aircraft to support 

the AE mission and provides medical AE for all categories of 

patients, as well as support to other services. In the Army, these 

assets are located in the medical company (air ambulance), 

which falls under the general support aviation battalion, combat 

aviation brigade. In addition, triservice aircraft (eg, C-130 

Hercules, C-17 Globemaster fixed-wing platforms, V-22 Osprey, 

UH-60 Blackhawk, and CH-47 Chinook rotary-wing aircraft) may 

also be configured for patient transport. 

The evacuation and en route medical care of combat wounded 

is the most recognized mission of all medical evacuation assets. 

However, the vital functions of medical evacuation resources 

encompass many additional missions and tasks that support the 

military health system, including transferring patients between 

medical treatment facilities (MTFs) within the joint operations 

area and from MTFs to US Air Force aeromedical staging 

facilities, as well as emergency movement of class VIII medical 

supplies, blood and blood products, and medical personnel and 

equipment.
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Transport Structure

United States Transportation Command (TRANSCOM) and 

the Air Force’s Air Mobility Command operate a sophisticated 

worldwide AE system capable of safely transporting patients 

of all ages and at all levels of care across intercontinental 

distances between MTFs. Crews are composed of flight nurses 

and technicians, augmented by critical care air transport teams 

(CCATTs) when medically indicated. These expert teams are 

composed of a critical care qualified physician, intensive care 

unit nurse, and respiratory therapist. They have the expertise 

and equipment to provide in-flight intensive medical care.

Because pediatric patients are more vulnerable than adults 

to the hazards of flight, evacuating children and neonates by 

air presents unique challenges. Urgent treatment focused on 

life-threatening or organ-threatening problems must precede 

a definitive diagnosis. The impact of flight physiology and the 

need for specialized transport teams should be factored into 

mission planning.

Hazards of Flight

Hypoxia

• Routine cruising altitude for fixed-wing AE flights is 30,000 to 

40,000 feet above mean sea level. The cabin altitude routinely 

varies between 6,000 and 10,000 feet (average 8,000 feet) above 

mean sea level, maintained by pressurization of the aircraft. 

• In a child without cardiopulmonary disease, this results in a 

corresponding decrease in the oxygen saturation from near 

100% at sea level to 90% at altitude. 

• Administering 2 L/min oxygen by nasal cannula increases the 

oxygen saturation to approximately 100%.

° In patients with cardiopulmonary disease, anemia, or 

increased metabolic demands due to burns, sepsis, or recent 

operative procedures, a higher flow rate may be required 

to maintain tissue oxygenation.

° Pulse oximetry is required when administering 

supplemental oxygen.
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Aeromedical Evacuation

Decreased Cabin Air Pressure

• With the climb from sea level to cruising cabin altitude, the 

volume of a trapped gas increases as the ambient barometric 

pressure decreases, causing trapped gases within body cavities 

(pleura, skull, viscera, etc) to expand (Boyle’s Law). At a 

cabin altitude of 8,000 feet, volume increase approaches 40% 

compared to mean sea level.

• Nasogastric tubes, gastrostomy tubes, and ostomy bags must 

be vented.

• The pressure of ballooned devices (eg, endotracheal tube 

cuffs, Foley catheters) should be adjusted during the climb 

and descent phases of flight.

• Strongly consider leaving drains (including chest tubes) in 

place for flight. Patients who have had chest tubes removed 

generally must wait 24 hours before flying and must be cleared 

radiographically to confirm pneumothorax resolution. 

• When gas in cavities is not readily accessible to decompress 

(eg, pneumocephalus) and urgent AE is required, a cabin 

altitude restriction (CAR) can be requested (see CAR, below).

Thermal Stress/Humidity

• Temperature fluctuations can adversely affect infants because 

of their high surface-area-to-body-mass ratio and immature 

thermoregulatory systems.

• The Joint Theater Trauma System maintains a Clinical 

Practice Guideline on Hypothermia Prevention (http://usaisr.

amedd.army.mil/cpgs.html) that should be reviewed prior 

to transporting patients. It discusses specific blankets and 

requirements for temperature monitoring and regulation.

• Prior to and during transport from the point of injury, patients 

should be wrapped in multiple layers (wool and space 

blankets) to conserve heat. 

• Temperature should be monitored and documented prior to 

and during evacuation. Although not as accurate as a core body 

temperature measure, skin temperature devices (eg, TempaDots [3M Co, St. Paul, Minnesota]) provide an easy way to 

regularly monitor and document the patient’s temperature in 

flight.
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Pediatric Surgery and Medicine for Hostile Environments 

• Decreased cabin humidity (~ 1%) promotes dehydration.

° An incubator or other flight-approved isolette can provide 

a neutral thermal and humid environment for infants.

° At cruise altitude, increased fluid flux occurs into the 

extravascular space, and increased insensible fluid losses 

exacerbate dehydration.

° Standard maintenance fluid calculations must be adjusted.

Environmental Factors

• Vibration, acceleration and maneuvering forces, subdued 

lighting (due to combat conditions), noise (auscultation is 

almost impossible), multiple patient handoffs, and limited 

space, equipment, and supplies all impose additional risk.

• This is a difficult environment in which to evaluate or 

manage pediatric patients; the above factors promote 

equipment disconnections or malfunctions and cause patient 

disorientation and fatigue.

• These factors are especially significant in tactical evacuation 

missions using rotary-wing aircraft, where space limitation 

severely impedes the ability of a medical crew to monitor and 

perform intervention maneuvers in flight; fortunately, these 

flights are usually of shorter duration.

° All lines and tubes must be carefully secured prior to 

transfer to the aircraft and frequently checked en route to 

prevent dislodgment during the requisite multiple patient 

movements.

° Orthopedic casts must be bivalved for swelling if placed 

less than 72 hours before flight.

° Consider fasciotomy in patients at high risk of developing 

a compartment syndrome.

° Intubate patients at risk for airway compromise or with 

borderline respiratory status; establishing an emergent 

airway may be difficult or even impossible in a child while 

in flight.

• Prolonged mission duration

° Strategic AE between major command areas of responsibility 

can exceed 10 hours and entail unanticipated delays due 

to operational considerations, equipment failure, weather, 

and other factors.
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Aeromedical Evacuation

° Ensure patients have sufficient medication, blood products 

(if indicated), and pediatric age-appropriate equipment 

available; this is especially important with infant and 

toddler transports because most AE supplies are sized for 

adults.

• CAR 

° Rotary-wing and tilt-rotor aircraft cannot restrict the cabin 

altitude.

° Patients with severe pulmonary disease and marginal 

oxygenation who cannot be further optimized by increasing 

fraction of inspired oxygen, positive end-expiratory 

pressure, circulating hemoglobin, or inotropes/pressors 

require a CAR to maintain the cabin air pressure near 

that of the origination altitude and thus increase the cabin 

atmosphere’s partial pressure of oxygen to normal.

° A CAR forces the aircraft to fly lower, slower (prolonging 

the mission), less efficiently (possibly adding a fuel stop), 

and through more turbulent air.

° A CAR may place the aircraft at risk in the combat 

environment.

° Other conditions warranting a CAR include penetrating eye 

injuries with intraocular air and trapped air that cannot be 

evacuated before flight (eg, pneumoencephalus), or a small 

bowel obstruction.

• Noncertified equipment

° Approved AE equipment has been extensively tested to 

ensure that it is safe for the aircraft to operate in flight (the 

equipment will not interfere with the aircraft) and safe for the 

patient (aircraft systems will not alter equipment function).

° A waiver must be granted for noncertified or nonstandard 

medical equipment.

° Local AE support staff can identify what equipment is not 

certified.

Special Considerations

• AEs of intubated, pressor-supported, or otherwise unstable 

neonatal and pediatric intensive care patients demand special 

care and planning. Every effort should be made to create a 

transport team with the prerequisite pediatric skills.
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Pediatric Surgery and Medicine for Hostile Environments 

° Adding a physician or nurse anesthetist skilled in pediatric 

intubation, a respiratory therapist, or a pediatric-skilled 

registered nurse to the transport team may have a huge 

impact on patient safety.

° Physiological deterioration is common during pediatric 

critical care transport and should be anticipated; 

unrecognized asphyxia is the primary cause of deterioration.

° The transport team must be prepared for emergencies 

such as airway-related events, hypotension, loss of crucial 

intravenous access, and cardiopulmonary arrest.

° Although pediatric and neonatal CCATTs exist, they are 

unlikely to be quickly available in hostile environments.

• Neonatal teams typically transport patients from birth to 3 

months of age; pediatric teams generally transport critically 

ill patients ages 3 months to 14 years of age.

• Requests are coordinated between the originating physician, 

the validating flight surgeon at the patient movement 

requirements center (PMRC), and the destination/accepting 

physician.

• Close coordination between the sending facility and the PMRC 

is necessary to consider factors as such as the patient’s weight, 

transport isolette size, in-flight care requirements, acuity, and 

team composition.

Humanitarian Transport Requests

• The process of arranging pediatric humanitarian evacuations 

out of theater can take between 6 and 12 months.

• Appropriate patient selection is critical; the ideal patient will 

have only a single, fixable, stable problem.

• The lack of suitable host-nation care must be confirmed and 

documented; regional care is preferred over transport to the 

continental United States.

• Individual cases for humanitarian evacuation out of theater 

are unlikely to be successful without a passionate advocate; 

personalizing the case with photos and compelling narrative 

is crucial for success.

• These complex requests often require coordination with the 

local US embassy or State Department, host-nation medical 

officials, and transit nations’ ministries of foreign affairs (or 

equivalent).
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Aeromedical Evacuation

• Identify partners within the country of origin and within 

international nongovernmental organizations (eg, using 

resources within the US consulate and Shriners International 

for a child who needs reconstructive plastic surgery long after 

a disfiguring burn).

• For Southwest Asia, military approvals are required from local 

command through Central Command.

• All evacuated children must have an attendant; those needing 

military transport require “Secretary of Defense Designee” 

status.

• Coordination also includes travel to a receiving medical center 

once in the continental United States, obtaining diplomatic 

transit clearance during wait for ongoing flights, and return 

transport.

• Contact the servicing PMRC for guidance.

Key Steps for an Aeromedical Evacuation Request

• Contact the local flight surgeon or AE liaison to assist with 

an en route care plan and timing/precedence of evacuation; a 

patient movement request is generated by the sending MTF.

• Include equipment and support requirements, nonmedical 

attendants (parent, guardian), movement precedence, litter or 

ambulatory (or both), and services required at the accepting 

facility, including an accepting physician with a contact number.

• The servicing PMRC receives the patient movement request 

through the TRANSCOM Regulating and Command and 

Control Evacuation System (TRAC2ES) via the Internet. 

Facsimile, telephone, and Secure Internet Protocol Router 

Network (SIPRNet) messages are acceptable if TRAC2ES is 

unavailable.

• PMRC reviews the patient movement request, validates the 

request, and establishes an AE requirement. The validating 

flight surgeon, a senior physician assigned to the PMRC, is 

primarily responsible for this action.

• Determine the need for a CCATT (see “Special Considerations,” 

above).

• Patient clearance

° The local flight surgeon, working with the referring 

physician, determines that the patient is medically stable for 
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Pediatric Surgery and Medicine for Hostile Environments 

transport with the appropriate equipment and medication 

available for transport, then clears the patient for flight.

° For CCATT patients, the transporting CCATT physician 

makes the final determination, considering the patient’s 

ability to tolerate transport and operational issues.

• Patient movement precedence:

° Urgent: Immediate evacuation is necessary to save life, 

limb, or eyesight (transport as soon as possible).

° Priority: Prompt medical care is required and not available 

locally; use when condition can deteriorate and patient 

cannot wait for routine evacuation (transport within 24 

hours).

° Routine: Requires evacuation, but condition is not 

anticipated to deteriorate significantly (transport within 

72 hours).

PMRC Contact Information

TRANSCOM Patient Movement Requirements Center-Americas

Scott Air Force Base, Illinois

CONUS, US Southern Command

Commercial (COMM) Telephone: (618) 256-8728 (staffed all 

hours, 365 days a year)

Defense Switched Network (DSN): 576-8728

TRANSCOM Patient Movement Requirements Center–West 

Joint Base Pearl Harbor-Hickam, Hawaii 

US Pacific Command, East Asia 

COMM Telephone: (808) 448-1602/1609

DSN: (315) 448-1602/1609

Fax (DSN): (315) 448-1606

E-Mail: tpmrcp.ustranscom@us.af.mil

TRANSCOM Patient Movement Requirements Center–East 

Ramstein Air Base, Germany

US European Command, US Central Command, US Africa 

Command

COMM Telephone: 011-49-6371-47-8040 or 2264

DSN: (314) 480-8040 or 2264

Fax (DSN): (314) 480-2345

E-Mail: tpmrc-e.3afsgz @us.af.mil
129

Burns

Surgery
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Pediatric Surgery and Medicine for Hostile Environments 
131

Burns

Chapter 12

Burns

Introduction

Natural childhood curiosity and lack of supervision frequently 

combine to make thermal injuries a major cause of morbidity 

and mortality in the pediatric patient. In hostile environments, 

these dangers are magnified and may be accompanied by 

injuries secondary to blast, fragmentation, and blunt forces, 

resulting in visceral, neurological, and orthopedic injuries. 

Whether accidental or intentional, the most frequent etiologies 

of childhood burns are flame and scalding. Many factors 

contribute to the significant differences in the pathophysiology 

and treatment of burn injuries in children, including diminished 

thickness of skin and subcutaneous tissue, immaturity of immune 

and organ systems, difficulty establishing and maintaining 

intravenous (IV) access, pain management, and the psychological 

ramifications of hospitalization, parental separation, physical 

disability, and disfigurement.

General Considerations

• Most burns occur in the home.

• Scalding is the most common etiology.

• Flame burns cause the highest incidence of full-thickness 

injuries and are associated with the highest morbidity and 

mortality.

• Metabolic responses include:

° increased protein and muscle catabolism,

° gluconeogenesis and hyperglycemia,

° decreased insulin responsiveness,

° increased plasma catecholamines (especially norepinephrine), and

° increased heat production (basal metabolic rate).
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Pediatric Surgery and Medicine for Hostile Environments 

Pathophysiological Considerations

• Children’s increased surface-area-to-body-weight ratio results 

in increased evaporative water loss.

• Decreased skin thickness and decreased insulating fat result 

in increased heat loss.

• Children have a narrower airway than adults, and because 

resistance is inversely proportional to the fourth power of 

the radius, critical airway compromise may result from even 

minimal edema. 

Point-of-Injury Care

• Key steps in first aid for pediatric burn patients are as follows.

° Fire: stop the burning process.

° Chemical: remove contaminated clothing; lavage with 

copious quantities of water.

° Electrical: remove the patient from contact with the 

electrical current.

• Ensure airway patency.

• Prevent hypothermia by covering the patient with a clean, dry 

sheet or thermal blanket, increasing room temperature, and 

providing warm IV fluids.

• Establish IV or intraosseous access and begin fluid resuscitation 

with Ringer’s lactate.

• Conduct a primary (“ABCDE”) survey, assessing the following:

° airway,

° breathing,

° circulation,

° disability, and

° exposure/environmental control.

• Conduct a secondary survey to uncover coexistent injuries. 

History

• Use the mnemonic “AMPLE” when taking history.

° Allergies

° Medications

° Past illnesses

° Last meal

° Events/Environment
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Burns

Head-to-Toe Physical Examination

• Examine every orifice.

• Conduct a complete neurological examination.

• Run special diagnostic tests as needed.

• Reevaluate.

Initial Treatment

• Administer supplemental oxygen.

• Place a nasogastric tube in patients with burns over more than 

20% total body surface area (TBSA) due to the high incidence 

of ileus. 

• Place a Foley catheter.

• Monitor with electrocardiogram and pulse oximeter.

• Check hourly vital signs; monitor fluid input and output.

• Obtain chest radiographs of all intubated patients and those 

with suspected inhalation injury.

• Initial laboratory tests include the following:

° complete blood count,

° electrolytes,

° blood urea nitrogen/creatinine,

° blood glucose,

° urinalysis, and

° blood type and screen.

• Consider checking arterial blood gases and carboxyhemoglobin 

levels, if available (inhalation injury should be suspected in 

all burns incurred in closed spaces).

• Keep the patient warm by infusing warm IV fluids, elevating 

room temperature, and minimizing patient exposure to lower 

environmental temperature. 

• Administer tetanus immunization. If immunization status is in 

doubt, give both tetanus toxoid and tetanus immune globulin.

• Encourage ulcer prophylaxis.

• Systemic antibiotics are not indicated except for treating 

proven infection.
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Pediatric Surgery and Medicine for Hostile Environments 

Determining Burn Depth 

First Degree 

• First-degree burns involve the epidermis only (eg, sunburn; 

Figure 12-1).

• They are erythematous, painful, and do not blister.

• They are not included in TBSA calculation. 

Second Degree (“Partial Thickness”)

• Superficial partial-thickness burns involve injury to the 

epidermis and superficial dermis; are erythematous, painful, 

and characterized by intact or ruptured blisters; and heal 

spontaneously within 1 to 2 weeks, usually with minimal 

scarring (Figure 12-2).

• Deep partial-thickness burns involve injury to the epidermis 

and deeper layers of the dermis (with some remaining viable 

dermis) and are whiter and less erythematous. As the depth 

into the dermis increases, deep partial-thickness burns may 

appear mottled. Epidermal appendages (hair follicles, sweat, 

and sebaceous glands) serve as the source of regenerating 

epidermal cells following a burn, as well as a source of 

bacterial contamination.

Third Degree (“Full Thickness”)

• Third-degree burns involve epidermis and full thickness of 

the dermis (Figure 12-3). 

• These burns always require skin grafting. 

• They are painless because nerve endings are destroyed.

• They are whitish-gray or waxy to black and leathery in 

appearance; dermal elements (hair, capillaries, nerves) are 

destroyed.

• Distinguishing between deep partial-thickness burns and 

full-thickness burns may initially be difficult.

• Deep partial-thickness burns often require 3 to 4 weeks to 

heal.

• The degree of scarring is related to the length of time needed 

for reepithelialization; deep partial-thickness burns that take 
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Burns

Figure 12-1. First-degree burn.

longer than 3 weeks to heal should be excised and grafted to 

mitigate against hypertrophic scarring and improve long-term 

cosmesis.
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Pediatric Surgery and Medicine for Hostile Environments 

Figure 12-2. Second-degree burn.

Fourth Degree 

• Fourth-degree burns involve the destruction of epidermis, 

full-thickness of the dermis, and subdermal structures (eg, 

muscle, bone, or tendon; Figure 12-4).
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Burns

Figure 12-3. Third-degree burn.

Figure 12-4. Forth-degree burn.
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Pediatric Surgery and Medicine for Hostile Environments 

• Fourth-degree burns are typically associated with electrical 

burns.

Estimating Burn Surface Area 

• The pediatric modification of the adult “rule of nines” takes 

into consideration that a child’s head size is relatively larger, 

compared to the torso and extremities, than an adult’s; 

the increased ratio of the surface area of the head to TBSA 

decreases as age increases.

• A child’s palm approximates 1% TBSA; this estimation can be 

useful for calculating splotchy patterned burns.

• A modified Lund and Browder chart can be used for 

calculations in infants (Figure 12-5) and children less than 10 

years old (Figure 12-6).

Figure 12-5. Infant burn size. 

1% 1%

1%

3% 3%

CC

B B

1% 1%

CC

BB

2% 2%

A A

8%

8%

4%

7%

4%

0.5% 0.5%

3% 3%

2% 2%

0.5% 0.5%

Front Back

B = half of one thigh

A = half of head

C = half of one leg

1y 5y 10y 15y
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Burns

Figure 12-6. Older child burn size.

= half of head and neck

= half of chest

= abdomen (front)

= abdomen (back)

= perineum

= buttocks

= half of arm

= half of forearm

= half of hand

= half of thigh

= half of leg

= half of foot

Front Back

5

7

6

5

1

5

2

2

1

4

3

1

10y 

8

7

6

5

1

5

2

2

1

3

2

1

Area Age 1y

6

7

6

5

1

5

2

1

2

4

4

1

5y

4

7

6

5

1

5

2

2

1

4

3

1

15y 

A

A

B

B B

C

C

D

D

E

E

F

F

G

G G G G

H

H H H H

I

I I I I

J

J J

J J

K

K K K K

L

L L L L

A
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Pediatric Surgery and Medicine for Hostile Environments 

Inhalation Injury 

• Always suspect inhalation injury when a burn occurs in a 

closed space (Figure 12-7).

• Physical findings of inhalation injury include:

° singed nasal hair and eyebrows, 

° carbonaceous sputum, 

° increased carboxyhemoglobin, 

° hoarseness,

° wheezing,

° bronchorrhea, and

° altered mental status.

• Diagnose using bronchoscopy to determine the extent and 

severity of injury to the tracheobronchial tree.

• Indications for intubation include compromised upper airway 

patency, a need for ventilatory support as manifested by poor 

gas exchange or increased work of breathing, or compromised 

Figure 12-7. Severe facial burn showing difficult reintubation and physical 

signs of inhalation injury.
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Burns

mental status (Glasgow Coma Scale score ≤ 8). Because of the 

small diameter of the pediatric airway and the expectation 

of progressive narrowing due to edema and bronchospasm, 

it is important to establish a definitive airway early on. 

Suspected or documented pneumonia should be treated with 

appropriate antibiotics, vigorous pulmonary toilet, and toilet 

bronchoscopy, if needed. 

• Carbon monoxide toxicity is the leading cause of death in 

patients with inhalation injury. 

° Carboxyhemoglobin levels and their associated symptoms 

are as follows:

▶ Less than 20%: no symptoms.

▶ 20% to 30%: headache, nausea.

▶ 30% to 40%: altered mental status.

▶ 40% to 60%: unconsciousness.

▶ More than 60%: death.

° Carbon monoxide toxicity should be suspected when there 

is persistent metabolic acidosis, despite adequate volume 

resuscitation.

° Treatment: 100% oxygen should be administered via a 

high-flow, nonrebreathing mask to all patients suspected 

of having inhalation injury. 

Guidelines for Hospitalization or Transfer to a Burn Center

• Second- or third-degree burns over more than 10% TBSA in 

patients less than 10 years old.

• Third-degree burns over more than 5% TBSA.

• Full- or partial-thickness burns involving the face, eyes, ears, 

perineum, hands, or feet.

• Inhalation injuries.

• Electrical injuries.

• Chemical injuries (especially those involving white 

phosphorus).

Fluid Resuscitation

• Children with burns over more than 20% TBSA require formal 

IV fluid resuscitation. 

• An indwelling urinary catheter is required to accurately 

measure the adequacy of resuscitation.
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Pediatric Surgery and Medicine for Hostile Environments 

• Avoid fluid boluses unless the patient presents with 

hypotension secondary to hypovolemia.

• Calculating resuscitation requirements

° In the first 24 hours (modified Parkland formula): 

total 24-hour volume = (3 cc Ringer’s lactate) × (weight in kg) 

× (%TBSA).

Half of this volume is infused over the first 8 hours 

(calculated from the time of burning, not from when the 

patient actually arrives at the treatment facility). The 

remaining half of the calculated 24-hour volume is infused 

over the next 16 hours.

▶ These calculations are only an initial estimate; reassess 

the fluid rate every hour and titrate as appropriate to 

achieve an hourly urine output of 1 cc/kg/h in toddlers 

and 2 cc/kg/h in infants.

▶ Children weighing less than 30 kg should receive D5

Ringer’s lactate at a standard maintenance rate (4 cc/

kg/h for the first 10 kg, 2 cc/kg/h for the next 10 kg, 1 cc/

kg/h for weight over 20 kg) in addition to their calculated 

resuscitation requirement.

° 24 to 48 hours after burn:

▶ At the 24th hour, decrease IV fluid rate to approximately 

1 to 1.5 × maintenance. 

▶ For burns over more than 30% TBSA, infuse 5% albumin 

at a rate of:

▷ 30% to 40%: 0.3 cc/kg/% TBSA burn for 24 hours.

▷ 50% to 70%: 0.4 cc/kg/% TBSA burn for 24 hours.

▷ 80% to 100%: 0.5 cc/kg/% TBSA burn for 24 hours.

▶ Colloid administration may be initiated early if 

resuscitation volumes exceed estimates before 24 hours.

° After 48 hours: 

▶ Diuresis will usually commence at this time.

▶ Administer D5 Ringer’s lactate at a maintenance rate.

▶ Monitor daily body weight, daily “ins and outs,” urinespecific gravity, serum electrolytes, blood urea nitrogen/

creatinine, and complete blood count. Supplement 

electrolytes and free water as indicated.
143

Burns

▶ Note: it is critically important that intake and output 

volumes are recorded every 30 to 60 minutes on a burn 

resuscitation flow sheet.

Managing Minor Burns

• Goals of treatment are to minimize pain, superficial infections, 

wound drainage, and prolonged convalescence.

• Small burns may initially be covered by a cloth cooled with 

saline solution.

• Ice should never be applied directly to a burn.

• Intact blisters should be left unbroken unless they are at flexion 

creases; ruptured vesicles should be debrided and the area 

cleansed gently.

• Partial-thickness injuries may be treated with 1% silver 

sulfadiazine cream or by application of a fine-mesh gauze 

impregnated with petroleum jelly.

• Tetanus immunization should be given as indicated by 

immunization history.

• Nonsteroidal antiinflammatory agents may reduce pain.

• If the patient has evidence of group A streptococcal disease, 

give penicillin (50,000 units/kg/24h, divided every 6 h oral or 

IV) to prevent colonization of the burn.

Burn Wound Care

• Provide adequate IV (not intramuscular or subcutaneous) 

analgesics or conscious sedation for wound debridement and 

dressing changes.

• Devitalized skin, foreign bodies, and ruptured blisters should 

be debrided.

• Cleanse wounds with surgical soap.

• Apply topical agents twice a day, such as:

° 1% silver sulfadiazine cream (may cause neutropenia).

° 10% mafenide acetate cream (a carbonic anhydrase inhibitor 

that may cause metabolic acidosis and compensatory 

hyperventilation).

° 0.5% silver nitrate solution (may cause decreased serum 

sodium, resulting in seizures, methemoglobinemia, and 

indelible black staining).
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Pediatric Surgery and Medicine for Hostile Environments 

• Silver-impregnated dressings may be changed every 48 hours, 

rinsed, and reapplied on the same patient.

• Treat facial burns with antibiotic ointment to avoid ocular 

irritation.

• Treat burns to the external ear with mafenide acetate cream.

Circumferential Extremity Burns 

• The eschar of circumferential full-thickness and deep partialthickness burns may result in vascular compromise as 

resuscitation proceeds.

• Delta pressure = diastolic blood pressure – measured 

compartment pressure. A delta pressure less than 30 mmHg 

is indicative of a compartment syndrome.

• Extremity escharotomy is indicated for clinical symptoms 

of ischemia (five Ps: pain, pallor, paresthesias, paralysis, 

pulselessness) or for progressive firmness of an extremity.

• Treat with emergent escharotomy, preferably performed at 

the bedside using electrocautery.

° Incise the eschar longitudinally through the medial and 

lateral aspects of the extremity down to the subcutaneous 

fat, which should bulge into the wound if adequately 

incised (Figure 12-8).

° Arterial pulse should immediately return.

• Failure to adequately apply compartmental decompression 

may necessitate a fasciotomy (Figure 12-9), especially with 

high-voltage electrical burns. This procedure is generally 

performed in the operating room but can be effectively 

performed in the intensive care unit if necessary.

Circumferential Chest Wall Burns

• A child’s respiratory efforts may become rapidly exhausted 

by the edema and restriction of a circumferential chest wall 

burn.

• Decreased compliance may impair oxygenation and 

ventilation, which are indications for chest wall escharotomy 

(Figure 12-10). Perform a chest wall escharotomy by incising 

the chest along the anterior axillary lines bilaterally, extending 

onto the abdomen, with transverse bridging incisions across 

the chest. 
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Burns

Surgical Burn Treatment 

• Early excision and grafting are effective in decreasing 

morbidity and improving the mortality rate of extensive fullthickness burns. The goal should be to excise the wound within 

the first week following injury, but this is not always practical 

in an austere environment and patients should be transferred 

to a facility with burn care resources and expertise.

• Preoperatively, patients must be hemodynamically stable and 

in optimal acid–base, fluid, and electrolyte balance.

• Intraoperative hypothermia should be anticipated and 

prevented.

• Adequate blood products must be available before excision 

and grafting can be considered.

• A prophylactic dose of a first-generation cephalosporin 

antibiotic may be used.

• It is extremely important to maintain the patient’s body 

temperature at all times.

Figure 12-8. Upper extremity escharotomy.
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Pediatric Surgery and Medicine for Hostile Environments 

° Raising the temperature of the operating room is the most 

effective way to achieve this.

° On-table patient warming devices can also be used.

• Tangentially excise burn eschar in a progressive fashion down 

to viable tissue using an electric or air-driven dermatome or 

freehand knife (eg, Weck). Bleeding may be minimized by 

careful operative planning, subeschar dilute epinephrine 

clysis, or use of tourniquets.

• Harvest meshed autografts from donor sites. Graft thickness 

varies in pediatric patients.

° Infants: 0.008 to 0.010 inch.

° Children: 0.010 to 0.012 inch.

° Teenagers: up to 0.012 inch.

• Carefully apply appropriate wound dressings to prevent 

dislodgment of crucial skin grafts.

• Donor sites can be dressed with occlusive or nonocclusive 

dressings.

Figure 12-9. Fasciotomy. 
147

Burns

• Burn excision results in significant blood loss; the equivalent of 

4 units of packed red blood cells (40 cc/kg) should be available 

for each 10% TBSA excision.

Electrical Burns

• Low-voltage injuries result from sources of less than 1,000 volts 

and include oral injuries from biting electrical cords, outlet 

injuries from placing objects into wall sockets, and injuries 

from contacting live wires or indoor appliances.

• High-voltage injuries are caused by sources of more than 

1,000 volts and result from contact with a live wire outdoors 

or from being struck by lightning.

• Children who have sustained high-voltage electrical injury 

require admission to the hospital and cardiac monitoring, 

serial electrocardiography, urinalysis, and determination of 

creatine kinase and urine myoglobin levels.

Figure 12-10. Torso escharotomy.
148

Pediatric Surgery and Medicine for Hostile Environments 

• If urine is dark red, assume myoglobinuria (Figure 12-11) 

and initiate treatment to avoid renal tubular injury. Increase 

fluid administration to produce a urine output of 2 cc/kg/h. If 

pigment does not clear, administer 1 g/kg of mannitol IV and 

add mannitol to IV fluids.

• Treat metabolic acidosis in a normovolemic patient with

sodium bicarbonate to alkalize the urine and increase 

myoglobin solubility. 

• Follow renal function and serum electrolytes.

• Perform appropriate radiographic examinations to exclude 

concomitant long-bone and spine injuries.

• Myoglobinuria should be treated aggressively with IV 

hydration, osmotic diuretics, and urine alkalinization to avoid 

renal failure.

• Extremities must be monitored carefully for compartment

syndrome development, which would necessitate fasciotomy.

• The definitive treatment for myoglobinuria is surgical 

debridement of dead muscle.

Chemical Burns

• The cornerstone of initial management for chemical burns is 

copious irrigation with water.

• Alkali burns may require several hours of lavage.

• Resuscitate and manage patients with chemical burns in the 

same manner as those with thermal burns.

• White phosphorus (“WP,” “Willy Peter”) is an incendiary 

chemical used in ordnance, such as hand grenades and mortar 

rounds, and has some particularly nasty attributes.

° Incandescent particles of white phosphorus cast off by the 

initial explosion can produce extensive, deep, second- and 

third-degree burns. It adheres to the skin and continues to 

burn at extremely high temperatures unless deprived of 

oxygen or until it is completely consumed. 

° Terminate further white phosphorus oxidation by irrigation 

or by placing saline-soaked or water-soaked pads on areas 

of exposure. Remove contaminated clothing because it may 

reignite and cause extended and worsened burns.
149

Burns

Figure 12-11. Heavily pigmented urine.
150

Pediatric Surgery and Medicine for Hostile Environments 

Pain Management

• Pain and anxiety management are critical to the care of burned 

children.

• Initially, IV morphine should be used in small amounts and 

titrated to the child’s physiological state.

• Analgesic agents are most effective when given on a regular 

schedule (rather than as needed).

• Generous analgesia or conscious sedation should be used 

before dressing changes and wound debridement or other 

painful procedures.

• A bowel regimen, including both a stimulant and a stool 

softener, should be maintained as long as the child is being 

administered opioid-derived analgesics.

• Benzodiazepines alleviate the many psychological stresses 

impacting injured children.

• Use diphenhydramine to treat severe pruritus in children with 

healing second-degree burns.

Nutrition

• Nutritional support should be started as soon as possible after 

injury, preferably via the enteral route.

• If patients cannot ingest adequate calories, a nasoduodenal 

feeding tube should be placed and isoosmolar feedings 

initiated.

• Estimated protein requirements are 3 g/kg/day.

• The daily caloric requirements of pediatric burn patients can 

be estimated using the Curreri formula:

° Age 0 to 1 years: basic metabolic requirements + 15 

kcal/%TBSA burn.

° Age 1 to 3 years: basic metabolic requirements + 25 

kcal/%TBSA burn.

° Age 4 to 15 years: basic metabolic requirements + 40 

kcal/%TBSA burn.

Rehabilitation

• Burns traversing joints must be treated with passive and active 

range-of-motion exercises during the healing process. 
151

Burns

• Burned extremities should be splinted with the joints in the 

position of function at night.

• Attention to occupational and physical therapy is necessary 

to ensure optimal results.

• Burns requiring more than 2 weeks to heal and all grafted 

burns should ideally be treated for 1 year with compression 

garments that apply approximately 30 mmHg of pressure, 

which decreases the formation of hypertrophic scars.
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Chapter 13

Neurosurgery

Managing pediatric neurotrauma at medical treatment facilities 

(Roles 1 to 3) requires especially close coordination by providers 

and administrators within the military healthcare system. Caring 

for pediatric neurotrauma patients is resource intensive. Patients 

frequently require prolonged mechanical ventilation, extensive 

rehabilitation, specialized nursing and medical expertise, and 

invasive physiologic monitoring. Few facilities in the developing 

world are capable of providing the requisite level of care, and 

coalition healthcare providers are often unprepared for such 

limitations. It is essential to assess facility capabilities and 

address postresuscitation and posttreatment patient flow prior

to the arrival of pediatric casualties. Patient transfer to hospitals 

within a country or to another country are often complicated by 

operational and diplomatic considerations. Failure to make these 

assessments will result in poor patient outcomes, increased stress 

on healthcare providers, and potential erosion of relationships 

with local host-nation residents.

Non-neurosurgeons assigned to Role 3 facilities should receive 

training in the basic tenets of performing emergency craniotomies 

prior to deployment. Cranial surgery should only be performed 

by non-neurosurgeons in the most dire circumstances, and 

ideally after consultation (via telephone, radio, Internet) with 

a qualified neurosurgeon, if at all feasible. Nonemergent and 

elective neurosurgical procedures should not be performed. 

All general surgeons should be familiar with the array of 

nonoperative treatment regimens for head trauma discussed in 

this and other chapters of this book. Unforeseen complications 

are potentially devastating in craniotomies performed for trauma, 

and due to the limitations of resources and surgical expertise 

in austere environments, are often accompanied by significant 

morbidity, mortality, and recurrence of the original pathology. 
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154

Considering the available tiered military medical resources, hostnation resources, and logistics, the best medical management 

with or without expedited transfer is often the optimal treatment 

solution.

Head Injury in the Pediatric Patient

• Anatomical, physiological, cognitive, and social variances 

between adult and pediatric patients influence evaluation and 

treatment.

• Accurate neurological assessment is essential for appropriate 

patient triage and guides further management.

° The validity of the Glasgow Coma Scale (GCS) is 

compromised in children because it is difficult to accurately 

categorize their verbal and motor responses. Ageappropriate modifications should be used to determine the 

GCS score (Table 13-1).

° The Infant Face Scale (Table 13-2) is a validated clinical tool 

with a high degree of interrater reliability; it is a modified 

GCS for children.

Table 13-1. Glasgow Coma Scale

Function Score

Eye Opening

Spontaneous 4

Verbal stimulation 3

Painful stimulation 2

None 1

Motor

Spontaneous and purposeful 6

Withdraws to touch 5

Withdraws to pain 4

Flexion 3

Extension 2

None 1

Verbal

Coos and babbles 5

Irritable cries 4

Cries in response to pain 3

Moans in response to pain 2

None 1
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• Triage decisions in pediatric patients in theater are difficult 

and can be emotionally charged.

° Although pediatric patients with neurological injuries are 

more likely to have favorable long-term outcomes than 

adults with similar injuries, their care is impacted by limited 

resources in theater.

° The decision to initiate treatment as opposed to provide 

palliative care for an injured child is a sobering but 

necessary aspect of neurotrauma care in an austere 

environment.

° Several factors influence whether to proceed with treatment, 

including:

▶ a facility’s capabilities,

▶ the physicians’ and nurses’ level of expertise,

▶ options for later evacuation to military facilities with 

enhanced capabilities or to a host-nation healthcare 

facility,

Table 13-2. Infant Face Scale Modifications to Glasgow Coma 

Scale

Function Score

Best Motor Response

Spontaneous, normal movements 6

Hypoactive movements 5

Nonspecific movement to deep pain 4

Abnormal, rhythmic, spontaneous movements 3

Extension, either spontaneous or to pain 2

Flexion 1

Best Verbal Response

Cries spontaneously to handling or pain, alternating 5

with quiet wakefulness

Cries spontaneously to handling or minor pain, alternating 4

with sleep

Cries to deep pain only 3

Grimaces only to pain 2

No facial expression to pain 1

Data source: Durham SR, Clancy RR, Leuthardt E, et al. CHOP Infant Coma 

Scale (“Infant Face Scale”): a novel coma scale for children less than two years 

of age. J Neurotrauma. 2000;17(9):729–737.
Pediatric Surgery and Medicine for Hostile Environments

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▶ operational factors,

▶ clinical factors, and

▶ physiologic stability. Abundant literature confirms poor 

neurological outcomes in patients following prolonged 

periods of hypotension or hypoxia; palliative care 

should be strongly considered for patients in these 

circumstances.

• GCS and Infant Face Scale scores correlate well with 

neurological outcome and are accurate in normotensive, 

nonhypoxic patients with no pharmacologic agents 

compromising their examination.

° After physiological stabilization, consider reversing 

sedation and neuromuscular blockade to facilitate a 

comprehensive neurological assessment.

▶ See Broselow tape for reversal-agent dosing.

▶ Muscle relaxation reversal should be confirmed with a 

peripheral nerve stimulator.

▶ A typical reversal regimen consists of neostigmine (50 

μg/kg), glycopyrrolate (10 μg/kg), naloxone (10–20 μg), 

and flumazenil (10 μg/kg).

° Patients with GCS scores greater than 8 will often benefit 

from treatment; when resources are available, they should 

be treated aggressively.

° Patients with GCS scores of 6 to 8 inhabit a “gray zone” and 

may proceed to treatment or palliative care, depending on 

additional clinical considerations and resource availability.

° Patients with GCS scores less than 5 will rarely benefit 

from treatment in a forward environment, and expectant 

management should be considered.

Pupillary Reactivity

• Findings of a pupillary examination convey important 

information about the function of the eye and cranial nerves 

II and III.

• Pupillary function can be impaired by several medications, 

including intravenous atropine (often used for resuscitation).

• Pupillary function is not impaired by muscle relaxants.

• In the absence of penetrating injuries to the globe, bilateral 

mydriasis (large, nonreactive pupils) is a strong predictor 
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of poor neurological outcome; treat patients with bilateral 

nonreactive pupils expectantly.

• Unilateral pupil dilation may result from direct trauma to the 

globe, orbit, or cranial nerves. Unilateral pupil dilation can 

indicate impending herniation and should be considered in 

concert with other clinical factors.

• A computed tomography (CT) scan is important when

determining the salvageability of neurological patients. The 

following two findings are the most likely to determine patient 

salvageability:

° Midline shift: easily measured by dropping a line from the 

anterior and posterior insertion of the falx cerebri.

▶ Midline shift allows for quantification of intercompartmental shift.

▶ A shift exceeding 5 mm is worrisome; a shift in excess 

of 1 cm portends a poor prognosis.

° Patency of basal cisterns (Figure 13-1): the basal cisterns, 

small-volume spinal fluid spaces at the base of the brain, 

are visible on nearly any CT scan of the head.

▶ Anteriorly, basal cisterns are shaped like pentagons, and 

posteriorly like smiles.

▶ When patent, basal cisterns indicate low intracranial

pressure (ICP) and increased likelihood of salvageability.

▶ When basal cisterns are absent, the patient’s prognosis 

is poor.

Medical Management

Hypoxia and Hypotension

Avoiding hypoxia and hypotension in the acute phases of 

traumatic brain injury (TBI) management should be the primary 

goals of the treating team.

• Using corticosteroids for ICP management in TBI patients has

not been shown to have therapeutic benefit and is not advised.

• Avoid excessive hyperventilation; maintain partial pressure 

of arterial carbon dioxide (PaCO2) at 35 to 40 mmHg. Extreme 

hypocarbia results in diminished cerebral blood flow and is 

detrimental to neurologic outcome.
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Seizure Prophylaxis

Seizure prophylaxis (Figure 13-2) is appropriate in the first week 

following injury to minimize the deleterious effects of increased 

cerebral blood flow (accompanying a generalized seizure) in 

patients with impaired intracranial compliance. 

• Phenytoin should be used prophylactically for 7 days to reduce the 

incidence of posttraumatic seizures in patients with severe TBI.

Figure 13-1. Computed tomography scans of some common injuries 

seen in pediatric neurotrauma. (a) Subdural hematoma. (b) Small intraparenchymal hematoma. (c) Small epidural hematoma in an infant. 

(d) Depressed skull fracture.
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° Loading dose: 15–20 mg/kg or an equivalent dose of 

fosphenytoin.

° Maintenance dose: 5 mg/kg/day divided twice or three 

times daily.

• Recognize that unexplained tachycardia in a paralyzed patient 

may represent seizure activity.

Intracranial Pressure Monitoring

• ICP monitoring should be strongly considered in infants and 

children with severe TBI (GCS score ≤ 8).

° Additionally, the treating physician may consider ICP 

monitoring in a less severely brain-injured child when 

reliable serial neurologic examinations may not be 

obtainable (eg, during prolonged periods of sedation or 

anesthesia).

° In situations where ICP monitoring is not achievable, 

alternative strategies are as follows.

▶ Use hyperosmolar therapy (5–6 cc/kg of 3.0% hypertonic 

saline) to treat to a predetermined level of hypernatremia 

(ie, Na 145–160 mEq/L).

▶ Use clinical cues to guide hyperosmolar therapy, such 

as 

Figure 13-2. Levels of intervention in neurological injury.

Levels of Intervention

Pentobarbital

or thiopental load

Hemicraniectomy/duraplasty

Mild hypothermia (34°C–36°C) should be considered in isolated head

injury but should be avoided in multitrauma

Cerebrospinal fluid drainage via ventriculostomy 

Mannitol/furosemide (possibly 3.0% hypertonic saline)

Moderate head elevation (30°)

Adequate sedation/analgesia (midazolam, fentanyl, morphine, propofol)
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▷ radiographic evidence of intracranial hypertension 

(effaced sulci or cisterns or midline shift),

▷ a bulging or tight fontanelle, or

▷ signs of neurologic deterioration.

• Prior to deployment, non-neurosurgeons should receive 

predeployment training for the indications, procedure, 

use, and risks of ICP monitoring devices before attempting 

placement in an austere environment. The following is a 

cursory overview for the well-trained provider.

° A patent fontanelle does not preclude elevated ICP.

° There is no accurate, noninvasive means of determining 

ICP, though military research is pursuing some promising 

technologies.

° Parenchymal monitors, available through the military 

supply system, accurately measure ICP.

° Parenchymal monitors are easier to place and carry a lower 

infection risk, but provide no means of directly treating 

ICP.

° Parenchymal monitors may be placed at a depth of 1 to 2 

cm, regardless of the patient’s age.

° Parenchymal monitors need to be zeroed before placement 

and experience a drift of up to ± 1 mmHg per day.

• Ventriculostomy catheters (Figure 13-3) also accurately 

measure ICP and are available in the military supply system. 

Placing a ventricular catheter is much more difficult than 

placing a parenchymal monitor and carries a higher risk of 

morbidity. Even the most seasoned neurosurgeon can be 

challenged with ventricular catheter placement in a patient 

with small ventricles or altered anatomy.

° Ventriculostomy catheters allow treatment of elevated ICP 

by permitting intraventricular cerebrospinal fluid (CSF) 

drainage.

° For ventricular catheters, antibiotic prophylaxis with 

a second- or third-generation cephalosporin should be 

considered, and periodic routine CSF sampling should be 

performed.

• General anatomic guidelines for placing ICP monitors are as 

follows (Figure 13-4).
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° Begin at an entrance point approximately 10 to 12 cm from 

the glabella posteriorly and 3 cm lateral to midline. This 

should correspond to a point near the coronal suture and in 

the mid-pupillary line. For infants, the anterior fontanelle 

may be used instead of a cranial trephination, provided the 

entry site is a minimum of 2 cm off the midline.

° Trephination of the calvarium should be performed in 

the same trajectory as placement of the catheter. The 

trajectory for catheter insertion is toward the ipsilateral 

medial canthus in the coronal plane and toward the tragus 

in the sagittal plane. This should approximate a trajectory 

perpendicular to the calvarium.

Figure 13-3. Schematic of ventriculostomy setup. Dashed red line represents the zero point of the system. Collection buretrol is set at desired height above the external auditory canal.

CSF: cerebrospinal fluid

Drawing courtesy of: Medtronic Neurosurgery, Goleta, California.
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162

° For parenchymal monitors, the entrance point is approximately the same, but the accuracy of the insertion point 

and trajectory are less critical.

° Ventriculostomy catheters lie within the ventricle at a depth of

▶ 3.5 cm in infants.

▶ 4 cm in toddlers.

▶ 5 to 6 cm in older children and adults.

° Depth of insertion and cranial access in infants must be 

considered when placing ventriculostomy catheters in 

children.

° Drain setup is identical to that of any fluid-coupled 

system used in the intensive care unit, with the following 

exceptions.

▶ The zero point for the system is the external auditory 

canal.

▶ The system should never be attached to a pressurized 

flush (such as that used for an arterial line).

Figure 13-4. Three-dimensional rendering of the appropriate placement 

of a ventricular catheter into the anterior horn of the lateral ventricle.
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▶ When used for drainage purposes, one method is to set 

the drain open at a certain height (eg, 10 cm H2O above 

the external auditory canal) and record hourly output.

▶ To prevent hyponatremia or hypokalemia, each milliliter 

of CSF output should be replaced in infants and toddlers 

with a milliliter of 0.9% NaCl plus 20 mEq KCl.

▶ Rapidly wean the patient from CSF drainage if 

possible. Permanent shunts have been used in austere 

environments by both the military and civilian 

humanitarian neurosurgical organizations. The 

treatment team must consider the patient’s ability 

to obtain revisions when the shunt fails to function 

properly.

• ICP and cerebral perfusion pressure (CPP) thresholds

° ICP: treat sustained values of greater than 20 mmHg, with 

the goal of reducing below this threshold.

° CPP is calculated by subtracting the ICP from the mean 

arterial pressure (MAP). 

▶ With the standard practice of zeroing the ICP monitor 

to the level of the foramen of Monro (relative to the 

MAP being zeroed to the atrium), true CPP will be 

underestimated, depending on the size of the patient 

and the angle of the head of the bed. Age-related 

variances in MAP impact CPP treatment threshold 

recommendations.

▶ A CPP threshold of 40 to 60 mmHg should be considered. 

A minimum of 40 mmHg is used for infants, and the 

minimum is increased up to 60 mmHg for adolescents 

and young adults.

Medical Adjuncts

• Avoid pain and agitation in patients with head injury as this 

will increase ICP. Sedatives and analgesics should be chosen 

by the treating physician.

° Propofol infusion is contraindicated for long-term sedation 

(> 24 h) in pediatric patients because of the risk of fatal 

metabolic acidosis (propofol infusion syndrome). 

° A single dose of etomidate (0.3 mg/kg) may be a useful 

adjunct in a patient with severe refractory elevated ICP.
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164

° Low-dose thiopental may also be considered as a sedative 

for a patient with elevated ICP.

° 3% saline has replaced mannitol/furosemide as the 

preferred hyperosmolar or diuretic therapy.

▶ 3% saline: bolus of 5 to 6 mL/kg can be used. Alternatively, 

administer an infusion ranging from 0.1 to 1 mL/

kg/h. Treatments should be titrated with the goal of 

maintaining ICP less than 20.

▶ In the absence of an ICP monitor, a target serum sodium 

of 150 to 155 mEq/L can be an effective treatment 

paradigm.

▷ Higher serum sodium targets have been reported, 

provided isovolemia is maintained without 

deleterious results.

▷ Hypertonic saline may also be considered in 

circumstances of hyponatremia caused by cerebral 

salt wasting syndrome, syndrome of inappropriate 

antidiuretic hormone (SIADH) secretion, or iatrogenic 

causes.

• Therapeutic hypothermia has not been validated for head 

injury in pediatric patients and is rarely practical in a deployed 

environment.

• Reduce the cerebral metabolic rate by avoiding or aggressively 

treating hyperthermia.

• Barbiturate coma effectively manages refractory ICP in 

children, but is impractical in a deployed environment. Do 

not use routinely.

Surgical Management

The spectrum of surgical management of pediatric head 

injury is broad. This chapter provides limited guidance for 

surgically managing head injuries; it is not a substitute for more 

conventional surgical education. Non-neurosurgeons should 

preplan and carefully consider military medical assets, transfer 

capabilities, and host-nation resources in their area of operation 

before being confronted by a surgical emergency. Ideally, 

predeployment training for the non-neurosurgeon, coupled 

with real-time remote neurosurgical consultation, is advised 

to address the atypical circumstance when cranial surgery by a 

non-neurosurgeon may be warranted.
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165

Figure 13-5. Scalp anatomy and blood supply.

supratrochlear artery

supraorbital artery

superific temporal 

artery

occipital artery

postauricular artery

periosteum

skin

skull

loose connective 

tissue

connective tissue

aponeurosis

Scalp Lacerations and Low-Velocity Penetrating Head Injuries

• Understanding the anatomy of the scalp and principles of

scalp closure is essential (Figure 13-5).

• Penetrating injuries to the scalp require watertight repair to 

stop blood loss and prevent CSF efflux and the potential for 

meningitis from retrograde infection.
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• The only surgical intervention required in the majority of 

head-injured patients with GCS scores greater than 8 may be 

as simple as the following:

° fully expose the wound by shaving the scalp,

° conservatively debride devitalized tissue, and

° perform layered closure of the galea, followed by the skin.

• Definitive treatment for many patients (particularly those with 

a GCS score ≥ 11) can be performed at facilities with limited 

surgical capabilities.

Craniotomy in the Pediatric Patient

• Positioning: a Mayfield headrest with pins is not appropriate 

for pediatric trauma patients in theater. A gel donut or 

cerebellar headrest (when available) helps avoid the potential 

for skull penetration in thinner pediatric skulls. A generous 

shoulder/hip roll can be used to maintain neutral neck 

positioning.

• Scalp incision: decreased absolute patient blood volume makes 

hemostasis imperative during scalp incision.

° Lidocaine (0.5% lidocaine with epinephrine 1:100,000) is a 

readily available, easy means of reducing blood loss at the 

time of skin incision.

° Lidocaine toxicity limits dosing to less than 7.5 mg/kg. 

▶ A maximum of 5 mg/kg of lidocaine or 7 mg/kg of 

lidocaine with epinephrine, injected intradermally, can 

be used in pediatric patients (1% lidocaine = 10 mg/mL).

▶ In children less than 2 years old with decreased scalp 

thickness, Raney clips can be applied to achieve 

hemostasis.

▶ Alternatively, apply hemostats to the galea during 

opening.

▶ Consider extending the scalp incision through the 

dermal appendages only and complete the opening with 

monopolar electrocautery.

▶ A needle-tipped Bovie on settings of 7 cut, 12 cauterize 

works well.

▶ Dural closure is rarely required and often needlessly 

prolongs anesthesia for damage-control surgery.
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167

▷ Onlay dural grafts are readily available and are the 

preferred tools in this setting for separating the brain 

from the scalp.

▷ Onlay repairs are effective in nearly all cases where 

the galea and scalp have been properly closed.

Bone Flap Preservation

• Pediatric neurotrauma patients have limited options for 

reconstructive surgery following recovery in theater (Figure 

13-6).

• In acute injury, the bone flap is rarely replaced in the head at 

the time of surgery.

• Autologous “storage” of a flap that is not grossly contaminated 

is possible. At the time of cranial surgery, prepare the abdomen 

for subcutaneous bone flap placement. The right lower 

quadrant is preferred to preserve the left upper quadrant for 

possible gastronomy tube placement.

• The bone flap must occasionally be bisected and stacked to 

accommodate an expansive hemicraniectomy flap.

• The bone flap has the potential to become infected during the 

patient’s hospitalization or following discharge.

• Bone flap replacement may be considered 3 to 6 months after 

injury if follow up is possible. If not, arrangements should 

be made for subsequent treatment at an appropriate medical 

facility to the extent feasible.

Spinal Injury in the Pediatric Patient

The pediatric spine, particularly the cervical spine, differs from 

the adult spine both anatomically and in its response to injury. 

Differences are most pronounced in patients less than 9 years 

old, after which anatomy and injury patterns tend to parallel 

those of adult patients.

Anatomical and Biomechanical Differences Between the 

Pediatric and Adult Spine

• The pediatric spine 

° contains more elastic ligaments than the adult spine,

° exhibits anterior wedging of vertebral bodies,
Pediatric Surgery and Medicine for Hostile Environments

168

Figure 13-6. (a) A typical, question-mark-shaped incision in the scalp 

commonly used in neurotrauma. (b) After scalp flap rotation, several 

burr holes are placed within the calvarium to create a bone flap that 

will allow ample access to the underlying dura and brain.

a

b
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169

° has facet joints that are oriented more horizontally than in 

adults, and

° lacks uncinate processes, making the spinal unit less stable 

in the cervical region.

• Children’s proportionately larger heads increase the force 

applied to the upper cervical spine and cause neutral 

positioning differences compared to adults.

• The relative size of the spinal canal (which achieves nearadult cross-sectional area prior to the age of 9) presents a 

proportionately larger target for penetrating fragments in the 

thoracic and lumbar regions.

Pathophysiological Differences Between the Pediatric and Adult 

Spine

• The increased elasticity and proportionately larger head of 

a pediatric patient results in profound changes in observed 

injury patterns.

• Spinal fractures are relatively uncommon in pediatric patients.

• The fulcrum of the cervical spine is shifted from C5–6 in adult 

patients to C2–3 in infants.

° Injuries most commonly occur between the occiput and C3 

levels.

° Disruptions of unfused ossification centers, such as the C2 

synchondrosis, are common (as are ligamentous injuries at 

the craniocervical junction).

• Spinal cord injury without radiographic abnormality 

(SCIWORA) is also more common in this age group.

Radiographic Differences Between the Pediatric and Adult Spine

• There are significant differences in radiographic images and 

CT scans between adult and pediatric patients.

• The large proportion of cartilage in the pediatric spine, 

coupled with primary and secondary ossification centers, are 

unfamiliar to most providers.

• Standard measurements, including the atlantodental interval 

and anterior soft tissue thickness at C2, are increased 

in pediatric patients compared to adults. The normal 

measurements for the predens space are 1 to 3 mm in the 

adult, as opposed to 3 to 5 mm in the infant.
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170

• Additional findings, such as C2–3 pseudosubluxation, also 

present challenges to inexperienced providers. Repositioning 

the head in a neutral position may help resolve the apparent 

finding of pseudosubluxation.

• Providers likely to encounter pediatric patients in theater

should familiarize themselves with these differences and if 

in doubt, avoid removing cervical immobilization devices.

Transporting Pediatric Patients With Suspected Spinal Injuries

• A pediatric patient’s proportionately large head size requires 

additional consideration at the time of transport.

• To maintain anatomical cervical lordosis and airway patency, 

the patient must be placed on a spine board with a bolster 

under the body at and distal to shoulder level, leveling the 

patient’s face and allowing for proper spinal and airway 

positioning (Figure 13-7).

Medical and Surgical Management of Spinal Injuries

• Pediatric spinal injury management in current operational 

theaters is limited. Select US facilities in theater may have 

the requisite spinal instrumentation and intraoperative 

fluoroscopy.

• The majority of closed and penetrating injuries can be

managed with resources available at facilities with less robust 

clinical and radiographic support.

Closed Injuries

• Management consists of restoring (near) normal anatomical 

alignment and immobilizing the patient.

• Gardner-Wells tongs can be used for reduction in pediatric 

patients as they are in adults. Less weight is typically required 

to achieve reduction (2 lb per level in pediatric patients, as 

opposed to 5–10 lb per level in adults).

• Commercial cervical collars or expedient structural aluminum 

malleable splints can be contoured to the patient to provide 

immobilization for cervical injuries.

• In the exceptional case that an appropriately sized halo vest 

is available, apply 6 to 8 pins at a force not to exceed 4 footpounds of torque.
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171

• Thoracolumbar fractures may be managed with 4 to 6 weeks 

of bed rest.

• Studies investigating the use of high-dose steroid therapy 

(methylprednisolone) in pediatric patients have not been 

performed; routine high-dose steroid therapy for pediatric 

spinal cord injuries is not recommended.

Figure 13-7. (top) Improper positioning of a child to maintain a patent 

airway. The disproportion between the size of a child’s cranium and 

the midface leads to a propensity for the posterior pharynx to buckle 

anteriorly. The large occiput causes passive flexion of the cervical spine. 

(bottom) Proper positioning of a child to maintain a patent airway. Avoid 

passive flexion of the cervical spine by keeping the plane of the midface 

parallel to the spine board in a neutral position, rather than in the “sniffing position.” Placement of a one-inch-thick layer of padding beneath a 

child’s entire torso will preserve neutral alignment of the spinal column.

Reproduced with permission from: American College of Surgeons. Advanced Trauma and Life Support Student Course Manual. 8th ed. Chicago, 

Ill: ACS; 2008: 230.

Plane of face is

parallel to spine board

Plane of face is not

parallel to spine board
Pediatric Surgery and Medicine for Hostile Environments

172

Penetrating Injuries

• Penetrating injuries are frequently encountered in theater.

• The absence of body armor and the proportionately large size 

of the spinal canal in children produce complex injuries, often 

traversing multiple body cavities in addition to the spinal 

canal.

• Antibiotic coverage is guided by the body cavities traversed 

and the relative cleanliness of the fragment and wound.

• Steroid therapy is inappropriate, based both on age and the 

penetrating mechanism.

• Spinal stability is rarely impacted by penetrating injuries.

• Most injuries are managed either with 6 weeks of bed rest for 

immobilization, or without positioning restrictions if upright 

radiographs demonstrate stability (in younger patients, 

sedation may be required to restrict activity).

• CSF fistula presents one of the most serious challenges in these 

patients.

° If cutaneous CSF leakage is noted, or if clear fluid is noted 

at a high output from a chest tube following a transthoracic 

gunshot wound to the chest, a spinal fluid drain must 

be placed postoperatively, either under direct vision 

intraoperatively or percutaneously at the L4–5 interspace.

° Anesthesia providers are often qualified to assist with drain 

placement in the absence of neurosurgical support.

° Height-controlled drainage of 5 to 15 mL/h is usually 

sufficient to stop drainage through the fistula.

° The fistula will often permanently close after 72 hours of 

drainage. Clamp the drain for 24 hours to ensure successful 

resolution of the fistula prior to removal.

Critical Aeromedical Considerations

The medical and nursing personnel accompanying a patient 

with a ventriculostomy catheter during air transport must have 

a thorough understanding of the system, and must ensure that 

ICP is frequently measured to preclude increases resulting from 

ambient barometric pressure changes. Failure to do so has been 

associated with catastrophic consequences. Patient positioning 

on the aircraft litter stanchions (head elevated) and location of the 
Neurosurgery

173

patient’s head (forward or aft) must also be discussed with the 

Air Force Critical Care Aeromedical Transport Team physician. 

If pneumocephaly is present, the coordinating US Air Force 

flight surgeon and transporting critical care physician must be 

made aware, so flight altitude restrictions may be considered 

and discussed with the aircraft commander.

Further Reading

1. Head injuries. In: Emergency War Surgery, Third United States 

Revision. Washington, DC: Department of the Army. Office of The 

Surgeon General, Borden Institute; 2004. Chap 15.

2. Wounds and injuries of the spinal column and cord. In: Emergency 

War Surgery, Third United States Revision. Washington, DC: 

Department of the Army. Office of The Surgeon General, Borden 

Institute; 2004. Chap 20.

3. Kochanek PM, Carney N, Adelson PD, et al. Guidelines for the acute 

medical management of severe traumatic brain injury in infants, 

children, and adolescents–second edition. Pediatr Crit Care Med. 

2012;13(Suppl):S1–S82.
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Chapter 14

Ophthalmology 

Portions of this chapter previously appeared as: Ocular Injuries. In: 

Emergency War Surgery, 3rd United States Revision. Burris DG, 

Dougherty PJ, Elliot DC, et al, eds. Washington, DC: US Department 

of the Army, Borden Institute; 2004: Chap 14.

The visual sensory system of a child less than 8 to 10 years old 

is developing and can be irreversibly damaged by a variety 

of conditions if the conditions are not detected and treated 

early. In the US military, general ophthalmologists on active 

duty provide most pediatric eye care in many locations. At 

some facilities, optometrists may also provide nonsurgical 

refractive care and evaluate the eye health of pediatric patients, 

subsequently referring cases with more serious conditions 

to an ophthalmologist. Both general ophthalmologists and 

optometrists refer more complicated pediatric eye patients to 

subspecialty trained pediatric ophthalmologists. These US Army, 

Air Force, and Navy specialists are generally located at larger 

facilities, such as regional medical centers and facilities with 

ophthalmology teaching programs, and at all military hospitals 

with neonatal intensive care units. All military facilities that have 

ophthalmology residency programs have one or more pediatric 

ophthalmologists on staff.

The Pediatric Eye Examination

• History

° Obtain a history of the present condition.

° Gather information about birth history. 

▶ Prematurity may be associated with retinopathy of 

prematurity (ROP), hypoxic ischemic encephalopathy, 

intraventricular hemorrhage with secondary 

hydrocephalus, and ventriculoperitoneal shunts; a 
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failing shunt may be responsible for abducens nerve 

palsy (“sun-setting eyes”) or papilledema.

▶ Forceps delivery is associated with corneal clouding 

(edema of the cornea from Descemet’s membrane tears). 

▶ Shoulder dystocia, difficult delivery, and neck traction 

may be associated with Horner’s syndrome (ptosis, 

miosis, anhydrosis). Anisocoria is worse in the dark and 

there is mild ipsilateral ptosis.

° General medical history should include family history 

(especially of strabismus and heritable eye and systemic 

conditions) and surgical history (ie, prior eye surgery).

• Examination

° Observe general appearance.

° Note head position. Observe for head tilts, face turns, and 

chin-up or chin-down posture. A goniometer is useful for 

quantifying abnormal head positions.

° Check facial symmetry, look for gross abnormalities and 

size or shape disparities.

° Determine visual acuity (one of the vital signs of eye 

health). Visual acuity evaluation and documentation is age 

dependent (Table 14-1).

▶ Premature infants and neonates (up to 2 mo old) should 

blink in response to a bright penlight.

▶ Infants (2–6 mo old) should fixate on and follow a near 

target, such as a human face or colorful toys.

▶ In infants and toddlers (6 mo–2 1/2 y old), vision should 

be central (eye appears properly aligned with target), 

steady (no nystagmus or searching movements), 

and maintained (eye can hold fixation for at least a 

few seconds when the other eye is covered and then 

Table 14-1. Normal Visual Acuity by Age

Age (years) Vision

3–4 20/30

5 20/25

6–12 20/20

12–18 20/15
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uncovered; this is especially useful in the presence of 

strabismus). 

▶ Preschoolers (21/2–5 y old) should be able to see 

pictograms at 20/20 (feet) or 6/6 (meters). If the child 

is shy, is unable to verbally identify the pictograms, 

or speaks a language foreign to the examiner, placing 

a photocopy of the pictograms or the letters “HOTV” 

on a clipboard permits the patient (adult or child) to 

simply point and match what they see on the screen. If 

single optotypes are used, a one-line difference in acuity 

is considered significant and warrants ophthalmology 

referral. If the targets are presented in a linear fashion, 

a two-line difference is deemed significant.

▶ Children of school age and older should be able to see 

an alphabet at 20/20 (feet) or 6/6 (meters).

° Intraocular pressure (IOP; the other vital sign of eye health) 

is always measured indirectly (through the cornea or 

through the lids and cornea). If a child is unable to cooperate 

while conscious, IOP checks may be obtained while a child 

is sedated or at the onset of general anesthesia.

▶ Digital (finger) method: eyes are palpated through the 

closed lids; annotated as normal finger tension. This 

method is acceptable for the majority of patients.

▶ Instrument method: measured through the cornea. 

▷ This method is more accurate, but more frightening to 

the patient; therefore, it is reserved for older children 

or for those in whom increased IOP is suspected.

▷ The Tonopen XL (Reichert Technologies, Buffalo, NY) 

requires a topical anesthetic, but has the advantage 

of giving a pressure reading with each successful 

tap on the cornea. The Icare Rebound Tonometer 

(Icare Finland Oy, Helsinki, Finland) does not require 

topical anesthesia, but does require several taps that 

are so light they are not typically perceived by the 

patient. Both methods require a cooperative patient. 

▷ Crying or active resistance may give falsely elevated 

IOP readings with any method. 

▷ IOP measurements on sleeping or eating infants tend 

to be very reliable.
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Pediatric Surgery and Medicine for Hostile Environments 

° Binocularity is a special vital sign of pediatric eye health. 

Binocular vision occurs in the cerebral cortex and involves 

integrating the sensory input from each eye to produce a 

single three-dimensional image.

° Stereo vision testing (often called “depth perception” 

testing) is commonly used to check binocularity.

▶ The Titmus (Titmus Optical Inc, Chester, VA) and Randot 

(Stereo Optical Company, Inc, Chicago, IL) stereoacuity 

tests use polarized glasses and slightly horizontally 

dissimilar photographs to create a three-dimensional 

illusion to detect the highest level of binocularity; these can 

be used on cooperative children as young as 2 years old.

▶ With the Worth 4 Dot Test (Richmond Products, Inc, 

Albuquerque, NM), glasses with red and green lenses 

are used to view red and green lights in an otherwise 

dark room. This test detects a lesser level of binocularity 

and is used on children around 5 years old and older.

▶ A base-out prism test calls for a low-power, clear prism 

(4–8 prism diopter power) to be brought over one eye, 

oriented apex toward the nose. The presence or absence 

of a corresponding fusional convergence movement is 

noted. This test can be used on children as young as 6 

months old.

° Extraocular motility

▶ Follow movement in lateral, medial, upward, downward, 

and diagonal directions of gaze. The examiner will need 

an assortment of fixation targets (eg, toys) to maintain 

the child’s interest.

▶ Observe for over- or under-muscle action, baseline or 

induced nystagmus, or strabismus.

▶ Examine pupils. Check size, shape, and location of the 

pupils, as well as direct and consensual response to light.

▶ Results are more reliable if the child’s attention is 

diverted toward a distant target and away from the 

examiner’s light source.

▶ A finding of afferent pupillary defect requires further 

evaluation, especially of the optic nerve. Magnetic 

resonance imaging (MRI; preferred) or a computed 

tomography (CT) scan may be indicated.
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▶ The examination for muscle balance is performed in 

primary position (face straight) at a distance and then 

near (14–16 inches), followed by other gaze positions as 

indicated (right, left, up, down, right tilt, and left tilt).

▶ Cover-uncover test: one eye is covered by an occluder 

while the examiner observes the other eye; if movement 

is detected, strabismus is manifest. 

▶ Alternate cover test: an occluder is moved back and forth 

from one eye to the other; movement represents latent 

or manifest strabismus.

▶ Simultaneous prism cover test: an occluder is placed 

over the nonfixing eye while a correcting prism is placed 

over the dominant, better-seeing eye because the prism 

itself can blur the patient’s vision. Putting a prism over a 

poorly seeing or amblyopic eye could degrade the acuity 

even further, making it difficult to accurately measure 

the angle of strabismus.

▶ Deviations in magnitude are measured with calibrated 

prisms. The endpoint is no movement on the alternate 

cover test or simultaneous prism cover test. 

° External examination

▶ Check lid position (observe for unilateral or bilateral 

ptosis).

▶ Epicanthal folds and a flat nasal bridge are frequently 

associated with pseudoesotropia. 

▶ Increased tear lake, mucoid discharge, and epiphora 

may be signs of nasolacrimal duct obstruction.

▶ Look for lid masses and lesions (eg, dermoids, 

molluscum lesions).

▶ Note telecanthus (increased distance between medial 

canthi).

▶ Check for hypertelorism, also known as telorbitism 

(increased distance between orbits; associated with 

midface abnormalities).

▶ Examine the anterior segment (cornea, conjunctiva, 

anterior chamber, and iris).

▶ Cycloplegic refraction is the most accurate method of 

determining a refractive state of the eye.
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Pediatric Surgery and Medicine for Hostile Environments 

▶ Autorefraction is often unreliable in children; use only 

in adolescents.

▶ Manifest refraction (using phoropter) is unreliable in 

young children; it is easy to overestimate the power 

required (“over minus”); however, manual cycloplegic 

refraction with free-held lenses or devices (skiascopy 

bars) is helpful.

▶ Perform a retinoscopy (if the retinoscopic reflex is 

obscured, the visual axis is likely affected enough to 

produce amblyopia).

▶ A dilated fundus examination is best performed with an 

indirect ophthalmoscope set on the dim light setting.

▶ A posterior central fundus view is usually all that is 

required.

▶ The standard eight views of the periphery per eye is 

rarely indicated or tolerated by most younger children. 

A hand-held toy (illuminated or nonilluminated) that 

the child can visually track up, down, right, and left may 

permit better views of the peripheral retina.

▶ The patient may need to be evaluated under anesthesia or 

sedation to obtain detailed views of the peripheral retina.

Pediatric Ophthalmic Disease Diagnosis and Treatment

Nonstrabismic Conditions

• Orbital dermoid cyst

° Orbital dermoid cysts are most commonly located along 

the superior-temporal orbital rim. They are occasionally 

attached by a narrow transosseous isthmus to an intraorbital 

component.

° An orbital dermoid cyst slowly enlarges; it may internally 

rupture and produce intense regional inflammation after 

minor local trauma. 

° Surgical removal is indicated after CT scan to rule out 

intraorbital portion.

• Ptosis

° Ptosis is eyelid droop that is usually unilateral. Urgent 

treatment is needed if the visual axis is obscured. Less 

urgent correction is indicated for astigmatism caused by the 

weight of the ptotic lid on the cornea or by an exaggerated 
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compensatory chin-up head position (when children 

maintain a chin-up position, they are attempting to use the 

ptotic eye; when the lid droop is such that the child is not 

even trying to use the ptotic eye, the visual axis is usually 

blocked in that eye by the lid).

° The most common form of ptosis includes poor levator 

muscle function (upper lid movement is limited), 

manifested by reversal of ptosis on down-gaze. 

▶ The levator muscle is very inelastic, much like a leather 

belt. Treat with a frontalis sling.

▶ If levator function is adequate (ie, upper lid has good 

movement), treat with levator resection.

° Prominent epicanthal folds (skin fold over medial canthus 

gives the illusion of small-angle esotropia or crossed eyes) 

are a normal variant and no treatment is needed.

• Blepharitis (erythema of the lid margin)

° Patient may have recurrent chalazia, lash loss, and scaling 

skin debris.

° Blepharitis is common in those with trisomy 21.

° It may be a sign of immunologic deficiency in severe or 

chronic cases.

° It can be treated with proper lid hygiene and a mild topical 

antibiotic ointment before sleep.

• Nasolacrimal duct obstruction

° Nasolacrimal duct obstructions are common in neonates 

and infants.

° They are usually unilateral and manifest as chronic 

mucopurulent discharge with excess tearing (epiphora).

° A nasolacrimal duct obstruction may be mistaken for 

chronic or recurrent conjunctivitis. 

° The discharge is often improved while the patient is 

using antibiotic drops or ointment, only to recur when the 

medication is discontinued. Antibiotics alone should have 

no effect on the excessive tearing.

° Most cases resolve by 1 year of age.

° Massaging the nasolacrimal sac may assist resolution. 

° Nasolacrimal duct probing and irrigation are indicated

for those cases persisting at 1 year old; if probing fails to 

resolve symptoms, temporary silicone-tube stinting may 

be required (Figure 14-1).
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Figure 14-1. (a)“00” Bowman probe introduction into right superior puncta 

and canuliculus. (b) Medial and superior rotation of probe, then inferior advancement of probe to hard palate. (Figure 14-1 continues) 

a

b
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Figure 14-1 continued. (c) Replacement of probe with a long, 23-gauge, blunttip canula, then, irrigation of a very small amount (< 1 cc or mL) of fluorescein-stained normal saline. (d) Recovery of fluorescein from ipsilateral nares 

with 8 Fr suction catheter confirms open nasolacrimal duct. Avoid airway 

compromise from excessive irrigation.

c

d
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Pediatric Surgery and Medicine for Hostile Environments 

• Conjunctivitis

° Conjunctivitis is usually viral and self-limited.

° Acute purulent conjunctivitis is usually bacterial and 

is characterized by hyperemia, edema, mucopurulent 

exudates, and ocular discomfort. 

° The most frequent organisms to blame are staphylococci, 

pneumococci, Haemophilus influenzae, and streptococci. 

Gram stain and culture are used to identify the specific 

organism, and infections usually respond to warm 

compresses and frequent instillation of topical antibiotic 

drops.

° Viral conjunctivitis is usually associated with adenovirus 

and manifested by a watery (as opposed to purulent) 

discharge. This type is usually self-limited, Gram stain and 

bacterial cultures are negative, and treatment with topical 

sulfonamides is sufficient.

° Chemical conjunctivitis may occur after prophylactic 

instillation of silver nitrate (1%), erythromycin ophthalmic 

ointment (0.5%), or azithromycin ophthalmic solution (1%) 

12 to 24 hours after birth. No pathogens are identified and 

no treatment is necessary.

° Most cases are treated by the patient’s primary physician, 

but severe, chronic, recurrent, or unusual cases are often 

referred to an ophthalmologist.

° Treat raised umbilicated lid lesions (molluscum 

contagiosum) by incision and curettage or simple scraping.

° Conjunctivitis can be recurrent and associated with

epiphora; if it always occurs on the same side, suspect 

nasolacrimal duct obstruction and arrange for probing and 

irrigation.

° If probing fails to give long-term symptom relief, the patient 

may need a stent.

° Epidemic keratoconjunctivitis manifests as small, scattered, 

superficial corneal infiltrates that are self-limited (may take 

6–10 weeks to resolve). Treat with supportive care and mild 

topical antibiotic ointment before sleep to prevent bacterial 

superinfection.

• Ophthalmia neonatorum (Figure 14-2) is caused by infection 

due to Neisseria gonorrhoeae or Chlamydia trachomatis acquired 

by passage through the infected genital tract. 
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° Ophthalmia neonatorum results in profuse discharge, 

marked eyelid edema, and conjunctival hyperemia. If 

untreated, infection can lead to corneal perforation and 

blindness. 

° Gram stain demonstrates gram-negative diplococci in 

gonorrhea infections, and intracytoplasmic inclusion bodies 

in chlamydia. Both types of infections require systemic and 

topical antibiotics.

• Periorbital cellulitis refers to inflammation of the lids and 

periorbital tissues without involvement of the orbit itself. 

° It may be associated with trauma, wound, or abscess of the 

lid or periorbital region. 

° Staphylococcus and Streptococcus species are the most 

common organisms, and prompt treatment with systemic 

antibiotics is indicated to prevent development of an orbital 

abscess, cavernous sinus thrombosis, or meningitis.

Figure 14-2. This was a newborn with gonococcal ophthalmia neonatorum

caused by a maternally transmitted gonococcal infection. Unless preventative 

measures are taken, it is estimated that gonococcal ophthalmia neonatorum 

will develop in 28% of infants born to women with gonorrhea. It affects the 

corneal epithelium causing microbial keratitis, ulceration, and perforation.

Reproduced from: Centers for Disease Control and Prevention Public Health 

Image Library Web site. Photograph courtesy of J Pledger. http://phil.cdc.gov. 

Accessed September 9, 2010. Image 3766.
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Pediatric Surgery and Medicine for Hostile Environments 

• Anterior uveitis (iritis)

° Anterior uveitis is uncommon in children; it usually follows 

blunt ocular trauma.

° Symptoms may be photophobia and conjunctival injection 

(redness).

° It is associated with juvenile idiopathic arthritis and may be 

painless in these patients; perform a baseline examination 

and periodic screening on all patients.

° Treat with topical antiinflammatory steroids and a 

cycloplegic and mydriatic agent for patient comfort and to 

avoid synechiae of the iris to the cornea or lens; systemic 

immune suppressive agents may also be required.

° Associated with sarcoidosis, especially in older children, 

children of African descent, and those with a positive family 

history.

° Treat sarcoidosis with intensive topical antiinflammatory 

steroids, followed by a tapered dose.

° Patients may require higher doses of oral steroids for a time; 

severe cases may require long-term topical or oral steroids 

to prevent rebound inflammation.

• Leukocoria (white pupil)

° Retinoblastoma is a life-threatening malignancy that must 

be ruled out first in all leukocoria cases.

° Leukocoria may be bilateral.

° Leukocoria may be familial.

° MRI scan and ultrasound are used most commonly to 

evaluate these tumors.

° CT scan will show intralesional calcification, but is used less 

commonly now in an attempt to limit the child’s exposure 

to radiation.

• A cataract is a lens opacity and is visually significant if the 

visual axis is blocked.

° May be unilateral or bilateral; all bilateral cases require 

evaluation for infectious, genetic, and metabolic causes.

° Congenital cataracts are present at birth; urgent removal is 

indicated. If left untreated by 6 to 8 weeks of age, irreversible 

nystagmus and amblyopia may occur. Congenital cataracts, 

especially in microphthalmic eyes, are highly associated 

with subsequent glaucoma.
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° Infantile cataracts are present within the first year of life; 

urgent removal is indicated, but there is a lower association 

with glaucoma.

° Acquired cataracts may be associated with trauma, steroid 

use, or less common lens defects (posterior lentiglobus or 

lenticonus; Figure 14-3).

• Amblyopia management is required for many years after 

cataract removal (at least until age 8). 

• Unilateral aphakia (absent lens) places the affected eye at 

a significant disadvantage to the “normal” eye, making 

amblyopia much more difficult to manage. 

° Patching the better eye for 2 to 6 hours a day forces vision 

development in the aphakic eye, and refractive treatment 

with a special aphakic contact lens or an intraocular lens 

is preferred over unilateral aphakic glasses for better 

binocularity development. 

° Bilateral aphakia makes amblyopia management less 

difficult. Aphakic contact lenses, aphakic glasses, or 

intraocular lenses may be used. Patching is only needed if 

a disparity in visual acuity is noted.

° Following cataract removal, up to a third of all affected eyes 

may develop glaucoma by adulthood.

Figure 14-3. Acute traumatic cataract left eye.
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° Pediatric cataracts are best managed by those experienced 

in their evaluation and treatment.

• Toxocara granuloma (from dog hookworm larvae) is an ocular 

form of visceral larva migrans characterized by severe local 

granulomatous inflammation due to dead worm larvae.

Retinal Disorders

Retinopathy of Prematurity

• ROP is an abnormal blood vessel growth with a risk of 

tractional retinal detachment.

• It is associated with prematurity (< 30 weeks gestation) and 

birth weight less than 1,500 g.

• These patients are screened while in the neonatal intensive 

care unit and screening is continued until the retina is fully 

vascularized, the ROP resolves, or the treatment threshold is met.

• Treatment consists of laser photocoagulation of the peripheral 

avascular retina or intravitreal injection of bevacizumab 

(see Mintz-Hitner, et al, in Further Reading). Evaluation 

and treatment of ROP during the acute phases should be 

performed by ophthalmologists experienced in dealing with 

this condition. Bevacizumab may prove to be as efficacious, 

more readily available, and easier to administer than laser as 

the treatment of ROP, especially in a hostile environment.

• Long-term periodic follow up is required to screen for early 

onset myopia.

Nonaccidental Trauma

• Nonaccidental trauma, such as shaken baby or shaken 

impact syndrome, may cause multiple intraretinal and 

preretinal hemorrhages in the macula, extending to the midperiphery due to disruption of venous outflow or peripheral 

hemorrhages at the vitreous base due to a shearing effect.

• When intraretinal hemorrhages are present, there is often also 

neurological depression, which may be life threatening.

• Screening examinations are usually requested by the pediatrics 

service associated with infants or toddlers presenting with 

injuries inconsistent with their history or with multiple injuries 

of various chronology.
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Ophthalmology

• Social services and law enforcement officials are required 

to be notified in all suspected nonaccidental trauma cases. 

Photo documentation of the retinal findings is becoming 

the medical-legal standard for prosecuting the responsible 

individuals (though this is not usually available in a deployed 

environment).

Optic Nerve Abnormalities

• A large cup-to-disc ratio is an indicator of possible glaucoma 

in adults, but the majority of pediatric patients with large 

cup-to-disc ratios do not have glaucoma. Check the patient’s 

IOP and central corneal thickness (pachymetry), then follow 

with baseline photos and ocular coherence tomography.

• Acute papilledema is a sign of increased intracranial pressure 

characterized by bilateral blurred disc margins, elevated discs, 

obscuration of vessels, and hemorrhages. It may indicate 

an intracranial tumor. An immediate imaging of the brain 

(CT or MRI) is indicated, and neurological or neurosurgical 

evaluation is required.

• Optic nerve coloboma (incomplete closure of embryologic 

fetal fissure) presents an increased lifetime risk of retinal 

detachment. Patients with this disorder may also have 

chorioretinal coloboma at the inferior nasal location. It may 

be associated with systemic abnormalities or syndromes 

and requires periodic observation and surgery for retinal 

detachment (as needed).

Refractive Error

• Treat a high refractive error (like one of the following) with 

eyeglasses to prevent or treat amblyopia.

° Symmetric astigmatism greater than 3 diopters.

° Myopia greater than 6 diopters.

° Hyperopia greater than 6 diopters.

• Anisometropia greater than 1.50 diopters difference requires 

refractive treatment.

• Mild to moderate levels of myopia do not need treatment; 

however, school-aged children with this level of myopia will 

need to wear eyeglasses for good distance vision. Encourage 

children to remove their glasses for prolonged near tasks.
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• Mild to moderate levels of hyperopia do not require treatment 

unless there is intermittent esotropia (see strabismus section 

below); however, school-aged children with moderate (greater 

than 3.00 diopters) hyperopia may need glasses for prolonged 

near work.

• Strabismus is defined as an eye misalignment of any type and 

is the most common reason for pediatric eye surgery.

° Comitant strabismus is an ocular misalignment in which 

there is a similar quantitative deviation in all directions of 

gaze.

° Congenital esotropia is the most common strabismus.

° There is usually a large angle of deviation, but amblyopia is 

rare and often mild because of cross-fixation (spontaneous 

alternation of eyes). Treat with strabismus surgery (bilateral 

medial rectus recessions) around 5 to 7 months of age, if 

possible.

• Accommodative esotropia is associated with high hyperopia, 

especially when actively focusing on an object (distant or near) 

or when fatigued. Onset is around 18 months to 4 years of age 

and is usually initially intermittent. The child may have greater 

esodeviation on near sight and a high ratio of accommodative 

convergence to accommodation (AC/A).

• The patient may develop amblyopia quickly in the 

nondominant (esodeviating) eye. Treat with “plus power” 

eyeglasses; give the full cycloplegic refraction. 

• Patients with a high ratio of AC/A may require bifocals. 

The bifocal segment must be 1 mm below the visual axis (at 

the level of the pupil). Surgery is reserved for patients with 

residual esodeviations while in full cycloplegic refraction.

• Use bilateral medial rectus recessions with or without 

posterior fixation sutures (preferred), or on eyes with 

refractory amblyopia, a unilateral medial rectus recession 

and lateral rectus resection (recess-resect procedure) may be 

considered.

• Intermittent exotropia often manifests when an individual 

is visually inattentive, fatigued, ill, or has taken medications 

that decrease alertness.

• There is a highly variable age of onset.
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Ophthalmology

• Individuals typically have excellent control of ocular alignment 

at near distances (divergence excess pattern), only exhibiting 

a well-controlled exophoria with near fixation, which permits 

the development of good binocularity.

• Vision is usually normal in each eye.

• Stereopsis is usually normal.

• Up to a third of patients may improve with accommodative 

exercises; daily alternate-eye patching may improve some 

cases.

• Patients not responding to the above measures may be treated 

with strabismus surgery (bilateral lateral rectus recessions).

• Consecutive strabismus is a deviation that occurs months 

to years after strabismus surgery, usually in the opposite 

direction of the initial surgery (typically exotropia after 

surgery for esotropia). Treat with either bilateral recessions 

of the lateral rectus muscles (for exotropia or a lateral 

rectus weakening [recession]/medical rectus strengthening 

[advancement/resection] procedure on the nondominant eye 

if the near deviation approximates or exceeds the distance 

deviation due to the previously recessed medial rectus 

muscles). Medial rectus muscle recessions typically work well 

for consecutive esotropia.

• Noncomitant strabismus is a condition in which ocular 

misalignment varies according to the direction of the patient’s 

gaze.

° Superior oblique, or trochlear, palsy (cranial nerve IV palsy) 

usually presents with a head tilt away from the affected 

side. 

° Longstanding cases often present with intermittent 

diplopia (rare in children). The patient may have facial 

asymmetry with contralateral facial hypoplasia (hemifacial 

microsomia). 

• Treat with strabismus surgery. The most common procedure 

is to weaken the ipsilateral inferior oblique muscle either by 

recession or myectomy. The next most common is a tuck 

(shortening) of the affected superior oblique tendon.

• Other conditions associated with strabismus include

° Duane syndrome.

° Brown syndrome.

° Monocular elevation deficiency (double elevator palsy).
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Ocular Manifestations of Systemic Disease

• Aniridia: Wilms tumor.

• Blue sclera: osteogenesis imperfecta.

• Kayser-Fleischer corneal ring: Wilson disease. 

• Congenital cataracts: intrauterine infection.

• Leukocoria (white reflex in the pupil): retinoblastoma.

• Retinal hemorrhages with white centers (Roth spots): subacute 

bacterial endocarditis.

• Chorioretinitis: toxoplasmosis, histoplasmosis, cytomegalovirus, tuberculosis, syphilis.

Pediatric Eye Injuries

General Guidance 

The examiner must have a high index of suspicion; patients 

may not self-report because they are too young, fear reprisal for 

having participated in unapproved behavior that resulted in the 

accidental injury, or are victims of nonaccidental trauma. These 

injuries are not frequently witnessed or reported by adults and 

may only be suspected after a delayed presentation for medical 

evaluation.

• Physical symptoms include

° reluctance to open an eye,

° reported or observed redness of an eye,

° photophobia,

° excessive tear production, and

° pain.

• Vision examination

° Carefully measure vision (eg, patient’s reaction to light, 

distance at which patient can count fingers, etc).

° Use any printed material (books, medication labels, etc) if 

a vision-screening card is not available.

° Compare sight in the injured eye to that in the uninjured 

eye.

° Severe vision loss is a strong indicator of serious injury.

° If there is a lid laceration, suspect and carefully check for 

signs of possible underlying globe laceration; examine the 

eyes prior to lid repair. Be sure to evaluate and repair the 

canalicular (tear duct) system.
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Ruptures and Lacerations (Open Globe)

These injuries may result from penetrating or blunt eye trauma 

and may cause vision loss from either disruption of ocular 

structures or secondary infection (endophthalmitis).

• Signs include

° Hemorrhagic chemosis (elevation of the conjunctiva from 

the sclera by dense bleeding).

° Hyphema (blood in the anterior chamber); if rupture is 

complete, an “eight ball” hyphema is present (may also be 

present in severe blunt trauma).

° Disrupted anterior chamber architecture.

° Irregular or teardrop pupil shape (peaked pupil).

° Dark iris or uveal tissue protruding through cornea.

• If there are signs of fragmentation injury (by either primary 

or secondary missiles) to the head, neck, or face, intraocular 

foreign bodies may be present.

• Proptosis may indicate a retrobulbar hemorrhage; urgent 

lateral canthotomy and cantholysis may be indicated.

• Decreased motility of one eye may be a sign of an open globe. 

Other causes of limited motility include muscle injury, orbital 

fracture, and orbital hemorrhage.

• Treating an open globe injury

° In a casualty with severe vision loss, a traumatic hyphema, a 

large subconjunctival hemorrhage, or other signs of an open 

globe injury with an intraocular foreign body, biplanar 

radiographs or a CT scan of the orbit may initially help 

identify a metallic intraocular fragment.

° Immediate treatment of an open globe injury is as follows.

▶ Tape a rigid eye shield (not a pressure patch) over the 

eye. Gauze or an eye patch under the shield may adhere 

to the underlying exposed tissues and, when removed, 

could actually worsen the injury.

▶ Do not apply pressure to or manipulate the eye (ie, no 

ultrasound).

▶ Do not apply topical medications.

▶ Start a quinolone antibiotic (oral or intravenous [IV]; 

dose for patient weight).

▶ Schedule an urgent (within 12–24 h) referral to an 

ophthalmologist.
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▶ Administer tetanus toxoid, if indicated. 

▶ Use antiemetics (dose for patient weight).

▶ The patient can expect surgical exploration and 

globe repair under general anesthesia by the initial 

ophthalmologist; further procedures may be required later.

Subconjunctival Hemorrhage

• Small subconjunctival hemorrhages (SCHs) may occur 

spontaneously or in association with blunt trauma; these 

lesions require no treatment and resolve in days to weeks. 

• SCH may also occur in association with a rupture of the 

underlying sclera.

• Warning signs for an open globe include a large SCH with 

chemosis (conjunctiva bulging away from globe) in the setting 

of blunt trauma, or any SCH in the setting of penetrating 

injury. Casualties with blast injury and normal vision do 

not require special immediate ophthalmologic care, but 

should get a complete ophthalmic examination at the earliest 

opportunity. Suspected open globe patients should be treated 

as described above (see Ruptures and Lacerations).

Chemical Injuries of the Cornea

• Initiate immediate copious irrigation (maintain for 30 min) 

with normal saline, lactated Ringer’s, or balanced salt solution 

(nonsterile water may be used if it is the only liquid available). 

A Morgan lens is often used to facilitate irrigation. Use a 

topical anesthetic prior to initiating irrigation.

• Measure tear pH to ensure that irrigation continues until the 

pH returns to normal (7.35–7.45); do not use alkaline solutions 

to neutralize acidity (or vice versa).

• Remove any retained particles.

• Use fluorescein strips or drops with a Wood’s lamp or other 

source of cobalt blue light and examine for epithelial defects.

° If none are found, treat mild chemical injuries or foreign 

bodies with artificial tears. 

° If an epithelial defect is present, use a broad-spectrum 

antibiotic ophthalmic ointment (bacitracin/polymyxin, 

erythromycin, or bacitracin) 3 to 4 times per day (same 

dosing as for adults).
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° Apply a pressure patch between drops of ointment if there 

is a large epithelial defect.

° Monitor (via daily topical fluorescein evaluation) for a 

corneal epithelial defect until epithelial healing is complete 

(as determined by a negative fluorescein evaluation).

• Noncaustic chemical injuries usually resolve without sequelae.

• Severe acid or alkali injuries of the eye (recognized 

by pronounced chemosis, limbal blanching, or corneal 

opacification) can lead to infection of the cornea, glaucoma, 

and possible loss of the eye. 

° Refer the patient to an ophthalmologist within 24 to 48 

hours. 

° These more severe chemical injuries may also require 

treatment with prednisolone 1% drops 4 to 9 times per 

day, and scopolamine 0.25% drops 2 to 4 times per day 

(these should only be started on the direction of an 

ophthalmologist).

Corneal Abrasions

• Be alert for the possibility of an associated open globe injury.

• The eye is usually symptomatic, with pain, tearing, and 

photophobia; vision may be diminished from the abrasion 

itself or from profuse tearing.

• Diagnose with topical fluorescein and cobalt blue light or 

Wood’s lamp (if available).

• A topical anesthetic may be used for diagnosis, but should 

not be used as an ongoing analgesic agent (this delays healing 

and may cause other severe complications).

• Apply broad-spectrum antibiotic ointment (polymyxin B, 

erythromycin, or bacitracin) four times a day.

• Pain relief options include

° a pressure patch or a bandage soft contact lens (usually 

sufficient for most abrasions);

° diclofenac 0.1% drops, four times a day; and

° a short-acting cycloplegic agent (1% tropicamide or 1% 

cyclopentolate) and a pressure patch for larger abrasions.

• More severe discomfort can be treated with 0.25% scopolamine 

(1 drop twice a day), but this will result in pupil dilation and 

blurred vision for 5 to 6 days.
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• Small abrasions usually heal well in 1 to 4 days without 

patching; if the eye is not patched, antibiotic drops 

(fluoroquinolone or aminoglycoside) may be used four times 

a day in lieu of ointment. Sunglasses are helpful in reducing 

photophobia.

• All corneal abrasions need to be checked once a day until 

healing is complete to ensure the abrasion has not been 

complicated by secondary infection (eg, corneal ulcer, bacterial 

keratitis).

• Thermal burns of the cornea are initially treated in the same 

manner as corneal abrasions. 

• Laser-induced injuries usually involve the retina, which is 

the most vulnerable tissue. Degree of injury depends on 

the duration of exposure and amount of energy delivered. 

A reduction in visual acuity, tearing, and pain are the main 

symptoms of laser injury.

• Nonpenetrating corneal injuries (anterior segment) should be 

treated the same way as corneal abrasions. Injury involving the 

posterior segment should be referred to an ophthalmologist 

as soon as possible.

Corneal Ulcer and Bacterial Keratitis

• Corneal ulcer and bacterial keratitis are serious conditions 

that may cause vision or eye loss.

• These conditions are associated with soft contact lens wear, 

especially if contacts are not taken out prior to sleep.

• Symptoms include increasing pain and redness, decreasing 

vision, persistent or increasing epithelial defect (positive 

fluorescein test), and a white or gray spot on the cornea (seen 

on examination with penlight or direct ophthalmoscope).

• Treatment includes quinolone drops (1 drop every 5 min for 

5 doses initially, then 1 drop every 30 min for 6 h, then 1 drop 

hourly thereafter).

° Scopolamine 0.25% (1 drop twice daily) may help relieve 

discomfort caused by pupillary spasm; patching and use 

of topical anesthetics for pain control are contraindicated.

° Expedite referral to an ophthalmologist (within 1–2 days).
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Conjunctival and Corneal Foreign Bodies

• These present with abrupt onset of discomfort or history of 

suspected foreign body.

• If an open globe injury is suspected, treat as discussed in 

Ruptures and Lacerations.

• Definitive diagnosis requires visualization of the offending 

object, which may be difficult; a hand-held magnifying lens 

or pair of reading glasses will help.

° Stain the eye with fluorescein to check for a corneal 

abrasion.

° The patient may be able to indicate the perceived location 

of the foreign body prior to instillation of topical anesthesia.

° Eyelid eversion with a cotton-tipped applicator helps the 

examiner identify foreign bodies located on the upper tarsal 

plate.

• Treatment

° Superficial conjunctival or corneal foreign bodies may be 

irrigated away or removed with a moistened sterile swab 

under topical anesthesia.

° Objects adhering to the cornea may be removed with a spud 

or the edge of a sterile 22-gauge (or larger) hypodermic 

needle mounted on a tuberculin syringe (hold the needle 

tangential to the eye to avoid iatrogenic ocular penetration 

and corneal perforation).

° If no foreign body is visualized but the index of suspicion 

is high, the foreign body may be removed by vigorous 

irrigation with artificial tears or sweeps of the conjunctival 

fornices with a moistened, cotton-tipped applicator (after 

applying topical anesthesia).

° If an epithelial defect is present after the foreign body is 

removed, treat as a corneal abrasion (see Corneal Abrasions 

section).

Hyphema (Blood in the Anterior Chamber)

• Treat to prevent permanent vision loss from increased IOP or 

corneal blood staining.

• Suspect associated significant intraocular damage (at the site 

of the hemorrhage).
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• Suspect a possible open globe and treat appropriately.

• A major goal of management is to avoid rebleeding.

° Avoid aspirin and nonsteroidal antiinflammatory drugs.

° Limit activity (require bed rest, with the patient only getting 

up to use the bathroom) for 7 to 10 days.

° Administer prednisolone 1% drops four times a day, and 

scopolamine 0.25% drops twice daily.

° Cover the eye with a protective shield.

° Elevate the head of the bed to promote settling of red blood 

cells in the anterior chamber (Figure 14-4).

° Patient should be seen by an ophthalmologist within 24 

to 48 hours to monitor for increased IOP (which may 

cause permanent injury to the optic nerve or corneal 

Figure 14-4. Blood aqueous level (arrow) indicates 5% hyphema.
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Ophthalmology

blood-staining and secondary deprivation amblyopia) and 

to evaluate for associated eye injuries. 

▶ If evaluation by an ophthalmologist is delayed (longer 

than 24 h), treat with a prostaglandin analogue, such as 

latanoprost once daily at bedtime, or a topical β-blocker 

(timolol or levobunolol) twice daily to help prevent IOP 

elevation.

▶ If IOP is found to be markedly elevated (above 30 mmHg) 

with a portable tonometry device, other options for 

lowering it include administering acetazolamide (oral 

or IV) or mannitol (IV), dosed for the patient’s weight.

Retrobulbar (Orbital) Hemorrhage

• Symptoms include severe eye pain, proptosis, vision loss, and 

decreased eye movement.

• Marked lid edema may make the proptosis difficult to 

recognize; however, failure to recognize may result in 

blindness from increased ocular pressure.

• Treatment 

° Perform an immediate lateral canthotomy and inferior 

cantholysis (see below for detailed instructions).

° Provide an urgent referral to an ophthalmologist (within 6 

to 12 h).

° If evaluation by an ophthalmologist is delayed (more than 

24 h), treat with a topical β-blocker (timolol) twice a day 

to help lower IOP elevation. 

° If IOP is found to be elevated (greater than 30 mmHg), 

follow the first two steps. 

° Perform lateral canthotomy and cantholysis.

▶ Do not perform these procedures if the eyeball structure 

has been violated; if the globe is open, apply a Fox 

shield (Bausch & Lomb, Bridgewater, New Jersey) for 

protection and seek immediate ophthalmic surgical 

support.

▶ Inject 2% lidocaine with 1:100,000 epinephrine into the 

lateral canthus to the rim.

▶ Crush the lateral canthus with a straight hemostat, 

advancing the jaws to the lateral fornix/orbital rim.
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▶ Using straight scissors, make a 1-cm long horizontal 

incision of the lateral canthal tendon, in the middle of 

the crush mark to the rim.

▶ Grasp the lower eyelid with large, toothed forceps, 

pulling the eyelid away from the face; this pulls the 

inferior crus (band of the lateral canthal tendon) tight 

so it can be easily cut loose from the orbital rim. 

▶ Use blunt-tipped scissors to cut the inferior crus; keep the 

scissors parallel (flat) to the face with the tips pointing 

toward the chin.

▶ Place the inner blade just anterior to the conjunctiva, and 

the outer blade just deep to the skin; the eyelid should 

pull freely away from the face, releasing pressure on the 

globe.

▶ Cut residual lateral attachments of the lower eyelid if it 

does not move freely. Keep in mind that this procedure 

is performed to urgently alleviate dangerously high 

retrobulbar pressure; in this situation, cosmesis is 

irrelevant. Make generous cuts, at least 1 cm vertical and 

1 cm horizontal. The lid defect can be repaired once the 

emergency has been addressed. 

▶ If the intact cornea is exposed once the lower eyelid 

is cut and orbital pressure is relieved, apply copious 

erythromycin ophthalmic ointment or ophthalmic 

lubricant ointment hourly to prevent devastating corneal 

desiccation and infection. Orbital pressure relief must 

be followed by lubricating protection of the cornea 

and urgent ophthalmic surgical support. Do not apply 

absorbent gauze dressings to the exposed cornea.

Orbital Floor (Blowout) Fractures 

• These fractures are usually the result of a blunt injury to the 

globe or orbital rim and may be associated with head and 

spine injuries.

• Blowout fractures may be suspected on the basis of 

enophthalmos, diplopia, decreased ocular motility, 

hypoesthesia of the V2 branch of the trigeminal nerve, 

associated subconjunctival hemorrhage, or hyphema.
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• Immediate treatment includes administering broad-spectrum 

antibiotics for 7 days, applying ice packs, and instructing the 

casualty to avoid nose blowing.

• Definitive diagnosis requires a CT scan of the orbits with axial 

and coronal views. 

• Indications for repair include severe enophthalmos and 

diplopia in the primary or reading-gaze positions. The surgery 

may be performed 1 to 2 weeks after the injury, but may have 

greater success in children if it is performed as soon as possible 

in trapdoor-style blowout fractures.

• Patients with an orbital floor (blowout) fracture often have a 

limited (restricted) upgaze on the affected side and may also 

have a restricted downgaze on the affected side. Early surgical 

intervention may be indicated, especially if there is a trapdoor 

fracture that results in entrapment of the inferior rectus on 

the affected side. In this circumstance, attempted upgaze may 

stimulate the oculocardiac reflex, which is associated with 

nausea, vomiting, and severe bradycardia, even to the point 

of asystole. 

• Strabismus surgery is reserved for patients with diplopia in 

the primary gaze (straight ahead) or in the reading position 

(moderate downgaze).

Lid Lacerations

• Treatment for lid lacerations not involving the lid margin is 

as follows.

° Delayed primary closure is not necessary when there is 

adequate blood supply.

° Eyelid function (protecting the globe) is the primary 

consideration.

° Begin with irrigation and antisepsis (using any topical 

solution), and check for retained foreign bodies.

° Superficial lacerations of the eyelid that do not involve the 

eyelid margin may be closed with running or interrupted 

polypropylene (preferred for adults), 6-0 silk, or nylon 

sutures. For children, consider absorbable sutures such as 

gut, fast gut, or chromic sutures.

° Horizontal lacerations should include the orbicularis 

muscle and skin in the repair.
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° If skin is missing, an advancement flap may be created 

to fill in the defect. For vertical or stellate lacerations, use 

traction sutures in the eyelid margin for 7 to 10 days.

° Apply antibiotic ointments four times a day until sutures 

are removed. Skin sutures may be removed in 5 days.

• Treatment guidelines for lid lacerations involving the lid 

margin are as follows.

° Tissue loss greater than 25% will require a flap or graft (less 

in children with little, if any, lid laxity).

° When repairing a marginal lower-eyelid laceration with 

less than 25% tissue loss, the irregular laceration edges may 

be freshened by creating a pentagonal wedge. Remove as 

little tissue as possible.

° Place a 5-0 or 6-0 silk or nylon suture in the eyelid margin 

(through the grayline, 2 mm from the wound edges and 

2 mm deep) and tie it in a slipknot; symmetric suture 

placement is critical to obtaining postoperative eyelid 

margin alignment.

° Loosen the slipknot and place two or three absorbable 5-0 

or 6-0 sutures (Vicryl [Ethicon, Somerville, New Jersey], 

not gut or chromic) internally to approximate the tarsal 

plate; the skin and conjunctiva should not be included in 

this internal closure.

° Place anterior and posterior marginal sutures (6-0 silk) in 

the eyelid margin just in front of and behind the previously 

placed suture.

° Leave all suture tails long and drape them over the lid 

margin onto the skin surface. Tape them or incorporate 

them into the skin sutures to prevent them from abrading 

the cornea.

° Close the skin with Prolene (Ethicon, Somerville, New 

Jersey), 6-0 silk, gut, or nylon sutures and place the lid on 

traction for at least 5 days.

° Remove the skin sutures at 3 to 5 days, and the marginal 

sutures at 10 to 14 days.

° If there is orbital fat in the wound or if ptosis is noted in an 

upper lid laceration, damage to the orbital septum and the 

levator aponeurosis should be suspected. Do not suture; 

immediately refer to an ophthalmologist.
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° If the eyelid is avulsed, the missing tissue should be 

retrieved, wrapped in a moistened, nonadherent dressing, 

and preserved on ice. The tissue should be soaked in a dilute 

antibiotic solution prior to reattachment. Avoid debridement 

of the lid, which is very resilient. Lid lacerations often appear 

worse than they actually are. Injured orbicularis often retracts, 

making gaps appear larger. Attempt to reapproximate the 

tissue with forceps and likely most (if not all) of the tissue 

will be found. Any avulsed tissue should be secured in the 

anatomically correct position in the manner described for 

lid margin repair. Lubricate, shield the eye, and promptly 

refer the patient to an ophthalmologist or plastic surgeon.

• Damage to the canalicular system can occur as a result of 

injuries to the medial aspect of the lid margins.

° Suspected canalicular injuries should be repaired by an 

ophthalmologist with monocanalicular (if available) or 

bicanalicular intubation to prevent subsequent problems 

with tear drainage. The tubes should remain in place for 3 

to 6 months.

° This repair can be delayed for up to 24 hours.

Enucleation 

• Whenever possible, an ophthalmologist should perform 

an enucleation; however, a general surgeon in a forward 

unit could remove a traumatized globe if it is completely 

disorganized.

• Enucleation should only be considered if the patient has a very 

severe injury, exhibits no light perception when the provider 

uses the brightest light source available, and is not able to be 

evacuated to a facility with an ophthalmologist. 

• Sympathetic ophthalmia is a condition that may result in loss 

of vision in the uninjured eye if a severely traumatized, blind 

eye is not removed, but it rarely develops prior to 14 days after 

an injury; thus, delaying the enucleation until the patient can 

see an ophthalmologist is relatively safe and advisable. 

Further Reading

1. Mintz-Hittner HA, Kennedy KA, Chuang AZ, et al. Efficacy of 

intravitreal bevacizumab for stage 3+ retinopathy of prematurity. 

N Eng J Med. 2011;364:603–615.
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Pediatric Dental Surgery

Chapter 15

Pediatric Dental Surgery

Introduction

Pediatric dentistry is defined as the diagnosis and treatment of 

oral disease in children from birth to age 18, and includes care 

of developmentally disabled patients. Dental disease (caries) is 

the most common infectious disease in children.

Primary teeth erupt at 4 to 30 months, sequentially from 

mandibular dentition to maxillary. Twenty primary teeth (10 

per arch) erupt with normal spacing. Children should have their 

first dental visit by 6 months of age. 

Of the secondary teeth, permanent molars and mandibular 

incisors erupt first, by 6 years of age. The remainder erupt by 

18 years of age, third molars included, for a total of 32 total 

permanent teeth. It is not uncommon for permanent mandibular 

incisors to erupt behind primary incisors.

Dental Caries

• Dental caries is caused by infectious disease; Streptococcus 

mutans is the most common cause. It may also be caused by 

parental microbe transmission.

• Carbohydrate, tooth surface, and microorganisms are required 

for caries to develop.

• Dental caries may be mild or severe.

• Complications include pain, inability to chew, facial abscess, 

and facial swelling.

• Treatment includes restorative dentistry and root canal or 

extraction of the offending tooth.

Preventing Tooth Decay

• Decrease refined sugar intake.
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• Do not let children use a bottle at night with sweetened fluids.

• Provide fluoride supplementation.

• Avoid bottle propping.

Toothache

• Emergency treatment may be needed for toothache, especially 

when decay is visible.

• Gently debride visible decay.

• Apply immediate restorative material into the cavity (contains 

eugenol to eliminate pain; Figure 15-1).

• Local anesthetics that temporarily relieve toothache and 

extraction pain include 

° 1% or 2% lidocaine with or without epinephrine 1:100,000 

(use a 3-cc syringe, 22-gauge 11/2-inch needle).

° 0.5% bupivacaine for long-acting local anesthesia.

° maximum 1% or 2% lidocaine with or without epinephrine 

(2 mg/pound [4.4 mg/kg] bupivacaine [1.3 mg/kg], per 

American Academy of Pediatric Dentistry guidelines).

Figure 15-1. Immediate restorative material for temporary pain relief.
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Pediatric Dental Surgery

Figure 15-2. Inferior alveolar nerve block.

Figure 15-3. Local infiltration anesthesia.

• Techniques for pain relief include

° Inferior alveolar nerve block (Figure 15-2).

° Local infiltration (Figure 15-3).

° Periodontal ligament injection.
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Pediatric Surgery and Medicine for Hostile Environments 

• Always aspirate before injecting local anesthetics. Lip and 

tongue trauma are common during the anesthetic period 

following an inferior alveolar nerve block.

Extraction 

• Extraction is indicated in cases of severe tooth pain, abscesses, 

severe gum (periodontal) disease, and traumatic injuries.

• Tooth root structure 

° Anterior teeth have single roots.

° In most instances, molars have three roots.

° Bicuspids (premolar) have one or two roots.

Equipment

• Maxillary and mandibular forceps for both maxillary and 

mandibular incisors and posterior teeth (Figure 15-4).

• Elevator to loosen teeth before extraction (Figure 15-5).

• Needle holder, #15 scalpel, 4-0 chromic suture material (Figure 

15-6).

Figure 15-4. Forceps for extraction of maxillary and mandibular dentition. 
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Pediatric Dental Surgery

Technique

• If possible, take a radiograph to look for multiple roots and 

root fracture.

• Inject sufficient local anesthetic.

• Loosen the selected tooth using a 301 elevator (see Figure 15-5).

• Firmly grasp the tooth with a forceps. Manipulate the tooth 

from front to back until the periodontal ligament breaks. 

° For anterior teeth: use a rotational motion to extract the 

tooth. 

Figure 15-5. 301 elevator.
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Pediatric Surgery and Medicine for Hostile Environments 

Figure 15-6. Needle holder, suture, and #15 scalpel.

° For posterior teeth: grasp firmly and use facial direction 

to extract molars (Figure 15-7). If the root is fractured and 

cannot be easily removed, it should be left in place.

Oral Pathology

Dentoalveolar Abscesses

• Dentoalveolar abscesses may be localized or involve facial 

spaces.

• Definitive treatment consists of extracting the offending 

tooth. If the tooth cannot be removed and intraoral swelling 

is present, use an 18-gauge needle and 5-cc syringe to aspirate 

purulent material, or incise and drain carefully with #15 

scalpel.

• Antiinfective agents should be used for mild to moderate 

infections.

° Prescribe oral clindamycin (10 mg/kg/day) every 6 hours 

for 7 days.
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Pediatric Dental Surgery

° Prescribe oral amoxicillin (50 mg/kg/day) every 6 hours for 

7 days.

• For severe infections, give clindamycin (20 mg/kg/day) IV 

every 6 hours for 7 days. Hospitalization is indicated for

° severe trismus,

° dehydration,

° swelling beneath the mandible,

° inability to protrude the tongue, and

° orbital swelling.

• Mucocele is caused by an obstruction of a salivary gland and 

is commonly located on the mucosal surface of the lower lip. 

Treat by removing the minor salivary gland. 

Eruption Hematoma

• An eruption hematoma is a blood-filled area near an erupting 

tooth.

• Bluish-red in color.

• There is no treatment for an eruption hematoma.

Figure 15-7. Extraction of posterior molar.
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Pediatric Surgery and Medicine for Hostile Environments 

Natal and Neonatal Teeth 

• Natal and neonatal teeth are teeth that are present at birth 

(natal) or within 30 days after birth (neonatal).

• They are usually mandibular incisors.

• No treatment is needed unless the tooth is very mobile or 

causes pain for the mother while breast-feeding.

Pyogenic Granuloma 

• A pyogenic granuloma is a localized mass, sometimes on 

gingiva, associated with traumatic irritation from calculus 

deposits.

• These disappear with removal of the cause.

Aphthous Ulcers

• Aphthous ulcers are painful oral lesions located on unattached 

oral mucosa (Figure 15-8).

• They appear as a red halo with a pale center.

• Causes include allergies, immunological factors, and infection 

with L-form Streptococci.

Figure 15-8. Aphthous ulcer. 
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Pediatric Dental Surgery

• Aphthous ulcers usually disappear after 10 to 14 days without 

treatment. Pain can be treated with 

° an oral paste containing benzocaine used twice daily,

° chlorhexidine gluconate 0.12% oral mouth rinse used twice 

daily, or

° amoxicillin for very large, painful lesions (50 mg/kg/day 

for 10 days).

Riga-Fede Disease

• Riga-Fede disease appears as irritation from the incisor to the 

lingual portion of tongue with ulceration.

• Treat by extracting the tooth or smooth the edges of the 

offending tooth.

Herpetic Gingivostomatitis

• Herpetic gingivostomatitis is caused by herpes simplex virus.

It may be primary or recurrent.

• Primary herpetic gingivostomatitis is very painful and 

manifests as crops of vesicles located on the lips, gingiva, and 

palate.

° The patient may become dehydrated from decreased fluid 

intake. 

° Infection may be severe.

° Infants usually require hospitalization and intravenous 

fluids.

• Treatment consists of acyclovir for severe infections and 

hydration (oral or intravenous).

• The virus can be transmitted to the digits and eyes.

Dentoalveolar Trauma

• Causes of dentoalveolar trauma include falls, motor vehicle 

accidents, and altercations. Careful neurological examination 

should be performed when assessing trauma to the head or 

facial region.

• Check the patient’s tetanus immunization status and 

administer toxoid or immunoglobulin, as appropriate.

• Assess pupillary size and reactivity and assign a Glasgow 

Coma Scale score as part of the neurological examination.
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Pediatric Surgery and Medicine for Hostile Environments 

• Always consider non-accidental injury as a possible etiology.

• Fractured teeth are classified (Ellis classifications) and treated 

as follows.

° I: enamel fracture only; smooth area with file.

° II: enamel/dentin; bonding agents and restoration.

° III: pulpal exposure; pulpal protection and restoration, root 

canal therapy.

Avulsion of Teeth

• In the case of primary teeth, do not reimplant.

• For permanent teeth, reimplantation done within 2 hours of 

the incident results in the best chance of success (Figure 15-9).

• Reimplantation technique 

° Do not scrub the tooth.

° Store the tooth in milk or a balanced salt solution.

Figure 15-10. Repositioned maxillary incisors (always check occlusion with 

mandibular teeth).

Figure 15-9. Severely displaced maxillary incisors.
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Pediatric Dental Surgery

Figure 15-11. Splint made of flexible orthodontic wire (0.018 inch) bonded 

with composite.

Figure 15-12. Maxillary incisors after splint removal. 

° Take a radiograph of the area if the tooth is fractured (soft 

tissue).

° Reimplant the tooth (Figure 15-10).

° Stabilize the implanted tooth with 0.018 stainless steel wire 

for 1 week (Figures 15-11 and 15-12).

° Root canal therapy may be required.

° Antibiotics may be needed (eg, amoxicillin, clindamycin) 

if the area is grossly contaminated or infected.

Intrusion of Teeth

• For primary teeth, obtain a radiograph to ascertain whether 

or not the root is fractured. The tooth may re-erupt.

• For permanent teeth, obtain a radiograph of the area. 

Orthodontic extrusion is needed in many cases.
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Luxation of Anterior Teeth

• If the tooth is very mobile, remove it.

• A radiograph is needed to ascertain whether the root is 

fractured.

• Manually realign the tooth within the arch.

• The tooth may need stabilization with 0.018 stainless steel 

wire and enamel bonding agents.

• Follow-up is needed for possible pulpal therapy.
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Chapter 16

Face and Neck

Ear, nose, and throat (ENT) disorders are very common in 

children in the developing world. Providing care for even 

common ENT problems (tonsillectomy, pressure equalizer tubes, 

etc) in austere or hostile environments may be associated with 

many complications.

General Principles of Pediatric Ear, Nose, and Throat Care in 

Hostile Environments

Generally, avoid procedures for which adequate follow-up 

care is unavailable, take into account the entire post-procedure 

recovery period (including the time after discharge from the 

hospital), and do not compromise the standard of care in austere 

environments. Consider the relationship of the patient to the 

person who is providing consent, the consenting individual’s 

ability to understand the procedure, and outcomes and care 

requirements.

Disorders of the Upper Airway

Choanal Atresia 

Choanal atresia is a congenital obstruction of the posterior nasal 

choana (Figure 16-1). The obstruction may be bony, membranous, 

or mixed.

• Unilateral choanal atresia presents with mild respiratory 

symptoms and rhinorrhea.

• Bilateral choanal atresia manifests as intermittent respiratory 

distress in infants (cyclical cyanosis: breathing when crying, 

cyanosis when quiet. Infants are obligate nasal breathers). 

• Diagnosis is made when a nasal catheter cannot be passed 

into the pharynx, with imaging (computed tomography 
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Figure 16-1. Choanal atresia in a neonate (a) as seen with a 120° telescope, and 

(b) following choanal atresia repair and dilation.

a

b
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Face and Neck

[CT] scan), and via direct nasopharyngoscopy. Consider 

associated syndromes when making a diagnosis (ie, CHARGE: 

coloboma of the eye, heart defects, atresia of the nasal choanae, 

retardation of growth or development, genital or urinary 

abnormalities, or ear abnormalities and deafness).

• Initial management 

° Insert an oropharyngeal airway. 

° Administer orogastric tube feedings. 

° Perform surgical repair with short-term nasal stenting.

Intraoral Obstruction 

• Mandibular hypoplasia (micrognathia). Associated with:

° Pierre Robin syndrome. Main features include:

▶ cleft palate, retrognathia (abnormal positioning of the 

jaw or maxilla), and

▶ glossoptosis (airway obstruction caused by backward 

displacement of the tongue base). 

° Treacher Collins syndrome. Typical physical features 

include:

▶ downward-slanting eyes,

▶ micrognathia (a small lower jaw),

▶ conductive hearing loss,

▶ underdeveloped zygoma,

▶ drooping part of the lateral lower eyelids, and

▶ malformed or absent ears.

° Mandibular hypoplasia occurs when a normal-sized tongue 

falls posteriorly, obstructing the supraglottic airway. 

° Treatment: place the patient in a prone position. Rarely, a 

nasopharyngeal tube is needed. 

° The mandible grows faster in children, so by 3 months of 

age, the condition is usually resolved. 

• Macroglossia 

° Associated with Beckwith-Wiedemann syndrome. 

Characteristics include: 

▶ macroglossia (large tongue),

▶ macrosomia (above-average birth weight and length),

▶ midline abdominal wall defects (omphalocele/

exomphalos, umbilical hernia, diastasis recti),

▶ ear creases or ear pits, and
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Pediatric Surgery and Medicine for Hostile Environments

▶ neonatal hypoglycemia. 

° Treat by placing the patient in the prone position to keep 

the tongue forward. A tracheostomy and a gastrostomy 

tube may be necessary. 

° Tongue reduction surgery may be performed. Reduce the 

bulk of the tongue without resection of the tip (midline 

glossectomy; Figure 16-2).

• Intraoral neoplasms 

° Types of intraoral neoplasms include lymphangioma, 

teratoma, aberrant thyroid gland tissue, and rhabdomyosarcoma (Figure 16-3).

° Treatment approaches vary but excision with or without a 

temporary tracheotomy is often indicated. 

Laryngotracheal Abnormalities

• Malformations

° Laryngomalacia is a collapse of the supraglottic tissues 

(epiglottis, arytenoids) during inspiration.

Figure 16-2. Midline partial glossectomy sparing the tip of the tongue in a 

child with macroglossia.
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Face and Neck

▶ This is the most common cause of upper airway 

obstruction in an infant. 

▶ Symptoms include inspiratory stridor, cyanosis, 

retractions and, occasionally, feeding difficulty.

▶ Laryngomalacia may not be present at birth but develops 

within the first 4 to 6 months of life.

▶ It worsens with agitation and supine positioning. 

▶ It is milder when the patient is in the prone position with 

neck extended. 

▶ Laryngomalacia is diagnosed with direct laryngoscopy 

(which will reveal an Ω-shaped epiglottis and supraglottic 

collapse with inspiration). 

▶ Treatment is usually nonsurgical; place the infant in the 

prone position with neck extended. 

▶ Temporary tracheotomy may be required for severe 

symptoms (this is necessary in fewer than 10% of 

patients).

▶ Symptoms typically resolve by 2 years of age. 

° Laryngeal clefts may be limited to the deep interarytenoid 

notch or extend through the cricoid ring.

▶ Symptoms include respiratory distress, cyanosis, and 

aspiration pneumonia. 

▶ Diagnosis is made by endoscopy. 

▶ Treat with endotracheal (ET) intubation and gastrostomy 

tube. Later, surgical repair will be needed. 

° Webs: thin, membranous, obstructing diaphragms usually 

located at the glottic level. 

▶ Symptoms include airway obstruction at birth. 

▶ Diagnosis is made by laryngoscopy. 

▶ Treat with endoscopic excision. 

° Atresia requires immediate tracheostomy. 

° Laryngeal foreign bodies. 

▶ Symptoms include sudden choking, loss of voice, 

dyspnea, inspiratory stridor, and retractions. 

▶ Initial treatment consists of providing abdominal or chest 

thrusts. 

▶ Surgical treatment involves removal of the foreign body 

by direct laryngoscopy.

▶ Cricothyroidotomy or emergent tracheotomy may also 

be necessary. 
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Figure 16-3. Oral hairy polyp in a newborn (a) and (b) coronal computed tomography scan of the mass. The lesion was soft and mobile and the infant was 

orally intubated with direct laryngoscopy. The lesion was surgically removed 

within the first 10 days of life without complications. 

a
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Cysts and Tumors 

Laryngocele

• A laryngocele is a fluid-filled cyst of the larynx. 

• Symptoms include inspiratory stridor. 

• Diagnosis is made by laryngoscopy. 

• Treatment consists of ET intubation and needle aspiration of 

the cyst and surgical unroofing (marsupialization).

Lymphangioma 

• Lymphangioma is usually multiloculated and lined with 

endothelium. 

• Airway obstruction is the only symptom. 

• Treatment consists of staged excision. 

b
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Pediatric Surgery and Medicine for Hostile Environments

Hemangioma 

• Airway hemangioma is usually seen in infants less than 1 year 

old. This is often associated with cutaneous hemangiomas in 

a beard distribution. 

• Located in the subglottic area.

• Symptoms include inspiratory stridor and respiratory distress.

• Diagnosis is made by laryngoscopy, CT scan, or magnetic 

resonance imaging.

• A hemangioma may regress spontaneously; administer oral 

or intralesional steroids if the patient is symptomatic.

• Oral propranolol is now the initial treatment of choice for 

infantile hemangiomas, including airway hemangiomas.

Papillomas

• Papillomas are benign neoplastic lesions associated with 

condyloma acuminatum in the mother at the time of birth. 

• Symptoms include hoarseness, stridor, and dyspnea. 

• Treatment consists of surgical excision; recurrence is common 

(virtually certain through puberty).

• Resection should be conservative. 

Acquired Airway Obstructions 

Acute Epiglottitis (Supraglottitis)

• Acute epiglottitis is an acute inflammatory swelling of the 

epiglottis caused by Haemophilus influenzae type B. 

• It typically occurs in children ages 2 to 6 years old but can 

occur at any age, even through the adult years.

• Symptoms include inspiratory stridor, “sniffing” head 

position, systemic illness, drooling, dyspnea, and muffled 

voice; patients appear toxic with fever, tachycardia, tachypnea, 

and increased white blood cell count. 

• Diagnosis is made with a radiograph of the lateral neck, 

which will show edema (evident as “thumb printing”) of the 

epiglottis. If the patient is unstable, avoid radiographs and 

initiating intravenous access, and go directly to the operative 

suite. If radiographs are ordered, the surgical team should 

accompany the child throughout care. 
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Face and Neck

• Treatment

° Keep the patient calm; never attempt to visualize the throat 

in the emergency department. 

° Use ET intubation (usually for 3 days) in an operating room 

under general anesthesia with a surgeon present.

° Perform tracheostomy if intubation cannot be accomplished 

(rare).

° Initiate intravenous antibiotics (cefotaxime or ceftriaxone). 

Croup (Acute Laryngotracheobronchitis)

• Croup is a viral inflammation producing subglottic edema.

• It is caused by parainfluenza viruses A and B. 

• It occurs in children ages 3 months to 3 years old. 

• Symptoms include barking cough, inspiratory and expiratory 

stridor, and substernal retractions (no drooling). 

• Laboratory findings show increased white blood cell count 

with a right shift of the differential (ie, lymphocytosis). 

• Neck radiographs show subglottic narrowing. 

• Treat with humidification (croup tent) and racemic 

epinephrine (occasionally dexamethasone for severe cases).

• Avoid intubation or airway endoscopy if possible. 

Foreign Bodies 

• Laryngeal foreign bodies may result in complete airway 

obstruction.

• The most common airway site affected is the right mainstem 

bronchus. 

• Symptoms include stridor, aphonia, cyanosis, hypoxia, 

coughing, wheezing, fever, and rhonchi. 

• Diagnosis can be made with anterior-posterior and decubitus 

chest radiographs with the obstructed side down; radiograph 

will show hyperaeration on the side with the obstruction due 

to air trapping (Figure 16-4).

• Surgical treatment consists of extraction by direct laryngoscopy 

or rigid bronchoscopy under general anesthesia. 
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Pediatric Surgery and Medicine for Hostile Environments

Figure 16-4(a–c). Chest radiographs in a child with a partial obstruction of 

the left mainstem bronchus due to a radiolucent object (vegetable matter). (a) 

Slight hyperinflation is seen on the posteroanterior. 

a

Postintubation Subglottic Tracheal Stenosis

• Postintubation subglottic tracheal stenosis occurs when the 

cricoid forms the only complete ring in the airway and the 

area of smallest tracheal diameter. Stenosis usually occurs at 

the level of the ET tube balloon cuff.

• Diagnosis is made by laryngoscopy. 

• Treatment: a tracheotomy tube will bypass the stenosis. 

Open and endoscopic repairs are used for correction 

(laryngotracheal reconstruction), but these require significant 

expertise and long-term postsurgical management.
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Figure 16-4(b). Comparison of the right and left lateral decubitus films shows 

air trapping on the left decubitus film.

b

• Prevention: ensure there is a small air leak around the ET tube 

(leak should occur in all tubes at or below 20 cm H2O and 

should be rechecked at regular intervals), stabilize ET tubes, 

and avoid reintubations if possible.
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Figure 16-4(c). Left lateral decubitus film showing trapped air.

c

Surgical Procedures for Procuring an Emergency Airway

Cricothyroidotomy

• Avoid cricothyroidotomy in children under 12 years old. 

• Needle cricothyroidotomy is a useful adjunct in children. It 

permits oxygenation and “buys time” until a definitive airway 

can be established.
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Face and Neck

• NOTE: In an emergency, needle cricothyroidotomy permits 

the patient to be oxygenated but does not permit adequate 

ventilation, so blood levels of carbon dioxide will increase, 

resulting in a worsening respiratory acidosis. Avoid use 

beyond 45 minutes.

Tracheostomy 

• Avoid tracheostomy in an emergency setting because of the 

high incidence of serious complications.

• In infants and young children, the hyoid bone, laryngeal 

cartilage, and cricoid ring are closely approximated and often 

overlap.

• Never excise cartilage from the anterior tracheal wall. 

• Make longitudinal (vertical) tracheal incisions through the 

second and third rings. 

• Suture skin edges down to the tracheostomy using half vertical 

mattress sutures to “mature” the stoma.

• Traction sutures should be placed through the cut edges of 

the trachea, and ends taped to the skin.

• Accidental decannulation in the perioperative period is a 

frequent cause of mortality in children with a tracheotomy.

Laryngoscopy 

• The most common indication for laryngoscopy is inspiratory 

stridor. 

• Unique anatomical features of the infant larynx to note before 

performing laryngoscopy are as follows: 

° The infant larynx is situated more anteriorly (and 

superiorly) at birth. 

° An infant’s epiglottis is at the level of the soft palate at birth.

° The infant’s larynx is narrowest in the subglottic region.

• Other indications for laryngoscopy include laryngomalacia, 

subglottic hemangiomas, papillomas, webs, foreign bodies, 

and cysts.

• The most common complication of laryngoscopy is laryngeal 

edema. Treat with humidification, racemic epinephrine, and 

steroids. 
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Pediatric Surgery and Medicine for Hostile Environments

Bronchoscopy (Flexible or Rigid) 

• Diagnostic uses of bronchoscopy include tracheomalacia 

and stenosis, extrinsic compression, tracheobronchial lavage 

(in cystic fibrosis patients), and foreign-body retrieval (rigid 

bronchoscopy). 

Establishing an Airway 

• Perform rapid-sequence intubation using etomidate plus 

succinylcholine (except in burns or crush injuries). 

• In patients less than 12 years old, perform a tracheostomy 

through the second tracheal ring instead of a cricothyroidotomy. 

• Estimate ET tube size using approximately the size of the 

child’s little finger or the following:

(16 + age in years)/4 

• The distance (in centimeters) from lips to midtrachea: 12 + 

(age in years/2). 

• An uncuffed ET tube is preferred in children less than 8 years 

old without conditions that may be associated with decreased 

lung compliance.

Trauma

• Fractures of the mandible (particularly subcondylar fractures) 

or maxilla (Le Fort fractures) can result in free-floating bone 

or soft tissue, which can prolapse and obstruct the airway.

• Dislocated teeth or debris may obstruct the airway. Carefully 

check a chest radiograph for displaced teeth (Figure 16-5).

• Initial maneuvers to secure an airway include jaw thrust, 

nasal trumpet (do not use if a fracture at the base of the skull 

is suspected), or oral airway. 

Facial Bone Fractures 

• In the absence of fractures leading to airway obstruction 

or severe bleeding, facial bone fractures do not need to be 

managed acutely but can be addressed up to 2 weeks after 

injury. 

• Mandibular fractures may be associated with free-floating 

segments, resulting in prolapse of the tongue and airway 

obstruction. 
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Face and Neck

° If this occurs, the mandible may be maneuvered to an 

anterior position to allow airway management and fractures 

can be addressed later. 

° Presenting symptoms include pain upon jaw opening, 

inability to open jaw (trismus due to masseter muscle 

spasm), and malocclusion (top and bottom teeth do not 

match up correctly). 

Figure 16-5. Displaced tooth in the right mainstem bronchus (black arrow).
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Pediatric Surgery and Medicine for Hostile Environments

° Most mandibular fractures involve more than one site; 

isolated fractures are uncommon. 

° Many mandibular fractures are of the greenstick 

(incomplete) type and may be managed conservatively by 

closed reduction. 

• Subcondylar fractures are generally managed with a soft diet 

and close observation. 

• Nongreenstick body, angle, ramus, and parasymphysis 

fractures are managed with open reduction and internal 

fixation, together with maxillary-mandibular fixation (MMF) 

using intraoral wiring. 

° Care must be taken to avoid injuring permanent tooth roots 

when placing fixation device screws. 

° When wiring the jaws together (with wires or elastic 

bands), consider potential airway obstruction, emesis, and 

suitable caloric intake. Wire cutters should be available at 

the bedside at all times. Do not discharge patients with 

their jaws wired shut.

° MMF duration should be brief in children, often no more 

than 2 to 3 weeks (adults undergo MMF for 4 to 6 weeks).

• Maxillofacial fractures 

° These fractures can wait up to 2 weeks for repair and are 

not urgent once bleeding is controlled and the airway is 

stable.

° Classify using Le Fort classification (Figure 16-6).

Figure 16-6. Le Fort facial fracture classifications. 
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Face and Neck

▶ Le Fort I: maxillary and alveolar fracture. 

▶ Le Fort II: pyramidal, nasal, and orbital fracture. 

▶ Le Fort III: craniofacial disassociation 

° Presenting symptoms include distorted facial appearance, 

facial swelling or bruising, malocclusion, and diplopia. 

° Significant hemorrhage often accompanies fractures of the 

maxilla and can be managed with nasal and oral packing 

after the airway has been secured. 

° Maxillofacial fractures may accompany cervical spine 

trauma and orbital or ocular trauma. 

° Use caution when placing nasal tubes (eg, nasogastric tubes, 

nasal trumpets) in patients with nasal or maxillary fractures 

due to the possible presence of a basilar skull fracture; this 

may result in inadvertent intracranial placement. 

° Assess the hard palate for fracture by palpation. 

° Management is limited to the facial support buttresses 

(medial and lateral), which are repaired with open reduction 

and internal fixation, and possibly MMF (temporary, short 

term).

• Nasal fractures 

° Nasal fractures are the most common facial fractures. 

° Diagnosis is made by manual palpation, if the nasal bones 

are mobile, fracture is present (plain films are not accurate 

as the suture is often confused for a fracture).

° The decision to repair is based primarily on cosmetic 

considerations and is not urgent (it may be delayed up to 10 

days) but should be performed by closed reduction as soon 

as the acute edema has subsided (usually within 5 days).

° Septal hematoma may be associated with any nasal trauma 

and must be identified early to prevent cartilage necrosis.

▶ Diagnose by visualizing the anterior septum either with a 

nasal speculum, otoscope, or other light source. A septal 

hematoma will appear as a dark purple mass (not subtle). 

▶ Treatment includes prompt incision and evacuation of 

the clot. Suture the mucoperichondrial flap in place over 

plastic or silicon splints or place a running septal whip 

stitch; administer systemic antibiotics while splints are 

in place (usually 5–7 days).
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Pediatric Surgery and Medicine for Hostile Environments

Base of the Skull and Temporal Bone Fractures 

• Presenting symptoms include postauricular bruising 

(Battle’s sign), orbital bruising (raccoon eyes), hearing loss or 

dizziness, facial nerve injury, hemotympanum, and leakage 

of cerebrospinal fluid (CSF), otorrhea, or rhinorrhea. 

• Determining and documenting the length of time facial nerve 

function has been absent (ie, delayed versus immediate), 

if applicable, is important to optimize future facial nerve 

function. 

° Complete immediate-onset nerve damage requires direct 

nerve repair once life-threatening injuries have been 

addressed. 

° Managing incomplete facial nerve injuries (ie, some 

movement is visible) is not of acute interest and management 

can be delayed for up to 2 weeks. 

° Facial nerve repair, when indicated, is performed after 

decompression and under magnification with 9-0 suture. 

° Hearing loss may be conductive (mechanical) or 

sensorineural (nerve) and may be distinguished with a 

tuning-fork exam.

• Treat tympanic membrane perforation by keeping the ear 

clean and dry. 

• A tympanic membrane perforation with purulent drainage 

(otorrhea) may be treated with nonototoxic antibiotic ear drops 

(eg, ofloxacin) for 7 to 10 days.

• Suspected CSF drainage from the ear should not be blocked 

(eg, with cotton balls, gauze, etc).

° CSF otorrhea and rhinorrhea in the setting of a basilar skull 

fracture may be noted by the presence of clear, salty-tasting 

drainage that is exacerbated by sitting upright and leaning 

forward. Two concentric rings will be seen when a drop is 

placed on a piece of absorbent paper. 

° Treat with bed rest. Elevate the head of the patient’s bed 

15 to 30 degrees. The patient should avoiding straining, 

sneezing, and coughing.

° Consider placing a lumbar drain if one is available. 

° Repair can be deferred until appropriate otolaryngological 

or neurosurgical expertise is available. 
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Laryngeal Trauma 

• Laryngeal trauma is uncommon in pediatric patients because 

of the elevated position of the larynx underneath the mandible 

and the cartilaginous structure of the pediatric larynx (which 

is commonly ossified in adults). 

• Presenting symptoms include hoarseness, stridor, crepitation, 

and subcutaneous emphysema. 

• Acute management consists of appropriately securing the 

airway. Orotracheal intubation is usually possible; however, 

a tracheotomy is sometimes preferred in instances of severe 

laryngeal trauma. Definitive management may then be 

performed by the appropriate specialists. 

Penetrating Neck Trauma

• Hemorrhage and airway injury are the primary concerns with 

penetrating neck trauma.

• The neck is divided into three anatomic zones to aid in 

management (Figure 16-7): 

° Zone 1 

▶ Boundaries: clavicle to cricoid membrane. 

Zone III

Zone II

Zone I

Figure 16-7. Neck zones. 
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Pediatric Surgery and Medicine for Hostile Environments

▶ Critical structures: common carotid artery, subclavian 

artery, apices of the lung, and the brachial plexus. 

° Zone 2 

▶ Boundaries: cricoid to angle of the mandible. 

▶ Critical structures: common and internal carotid arteries, 

internal jugular vein, esophagus, and trachea. 

° Zone 3 

▶ Boundaries: angle of mandible to base of the skull. 

▶ Critical structures: internal carotid artery, jugular vein. 

• If the platysma muscle is not transgressed, no surgical 

management is initially indicated and close observation 

for neurologic changes, hematoma formation, or airway 

compromise is warranted. 

• Diagnostic measures: 

° esophagoscopy, 

° bronchoscopy, 

° contrast (water-soluble) swallow study, and

° CT angiogram. 

• Zones 1 and 3 injuries 

° Management is selective based on clinical evidence of 

significant structural injury, such as significant bleeding, 

expanding hematoma, subcutaneous emphysema, 

hoarseness or stridor, hemoptysis, decreased pulses in the 

arm or neck, and mental status changes. 

° If the above are present, exploration with the appropriate 

expert (ie, vascular surgeon, otolaryngologist, neurosurgeon) 

is indicated to manage injury of involved structures. 

• Zone 2 injuries 

° Presenting symptoms 

▶ air bubbling from the wound, 

▶ subcutaneous emphysema, 

▶ stridor, 

▶ dyspnea, 

▶ hypoxia, and 

▶ expanding hematoma.

• Management includes initial neck exploration and full 

endoscopy. Perform neck exploration via an incision along the 

anterior border of the sternocleidomastoid muscle to evaluate 

vascular structures, trachea, and the esophagus; repair as 

indicated.
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Face and Neck

• Tracheal injury: after the airway is secured, repair can be 

performed using 5-0, 6-0 nylon sutures, being careful not 

to enter the lumen of the trachea (if the airway is secure, 

evacuation to a suitable expert is strongly encouraged). 

• Endoscopy should include laryngoscopy, bronchoscopy, and 

esophagoscopy.

• Esophageal injury may be difficult to diagnose because of 

delayed presentation, but should be considered in patients 

with unexplained fever or tachycardia and penetrating neck 

trauma in Zones 1 or 2. 

° Presenting symptoms include fever, tachycardia, and 

dysphagia. 

° Diagnose using chest radiograph, esophagoscopy, watersoluble contrast swallow studies, diatrizoate meglumine, 

and diatrizoate sodium solution swallow. 

° Initial management: allow nothing by mouth, explore and 

drain, give antibiotics, and refer the patient (if necessary) to 

the appropriate surgical specialty (general surgery, thoracic 

surgery, etc). 

° Definitive management consists of debridement with 

primary repair and feeding tube placement. 

Soft Tissue Trauma 

• Most injuries to the soft tissue of the face should be repaired 

primarily.

• Minimize the amount of tissue debridement, as even seemingly 

devitalized tissue may recover due to a robust blood supply.

• The cartilage should be meticulously covered with soft tissue.

• Consider antibiotics for Pseudomonas and Staphylococcus

infection.

• Prompt incision and drainage of auricular hematomas with 

application of a bolster (two dental rolls or similar material 

sutured on opposite sides of the auricle) for 5 to 7 days 

to reduce the likelihood of hematoma reoccurrence and 

permanent cartilage damage.
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Pediatric Surgery and Medicine for Hostile Environments

Figure 16-8. Cat scratch disease neck abscess in a child.

Masses

Cervical Lymphadenitis 

• Cervical lymphadenitis is the most common cause of a neck 

mass in a child.

• Etiology: usually Staphylococcus or Streptococcus infection. 

• Treatment 

° Initially, administer antibiotics (eg, third-generation 

cephalosporin) to treat the primary cause (otitis media, 

pharyngitis). 

° Incise and drain fluctuant nodes.

° Excise chronic lymphadenitis.

° In addition to the bacterial infections cited above, the 

differential diagnosis includes human immunodeficiency 

virus, Epstein Barr virus, tuberculosis, atypical mycobacteria, 

and cat scratch fever (Bartonella henselae; Figure 16-8).
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Face and Neck

Lymphoma 

• Lymphoma is the most common cause of malignant neoplasms 

of the head and neck, manifesting as firm, fixed nodes with 

generalized involvement (especially if present in the neck, 

axilla, or groin).

• Diagnosis is made by excisional lymph node biopsy. 

Thyroglossal Duct Cyst 

• Development of the thyroid gland originates at the base of 

the tongue in the foramen cecum and passes between the 

genioglossus muscles and through the hyoid bone to its 

normal anatomic position. 

• A thyroglossal duct cyst is the most common congenital cyst 

of the neck.

• Thyroglossal duct cysts are usually discovered at 2 to 4 years 

of age, when baby fat starts to diminish. 

• They are often asymptomatic, but recurrent infection is 

a characteristic problem due to communication with the 

pharynx.

• Thyroglossal duct cysts appear as a mass located in the midline 

at or below the level of the hyoid bone that moves up and 

down with swallowing.

• Differential diagnosis includes: lymphadenopathy, dermoid 

cyst, and aberrant thyroid tissue (obtain a thyroid ultrasound 

if the presence of a normal thyroid gland in is question). 

• Treatment 

° Provide antibiotics for active infection. 

° Perform needle aspiration of abscesses. 

° Definitive treatment: perform elective surgical excision of 

the cyst and tract to the pharynx, in continuity with the 

central portion of the hyoid bone and attached tract to the 

base of the tongue (Sistrunk operation), with ligation of the 

foramen cecum. 

Branchial Cleft Cysts 

• Branchial cleft cysts are congenital fistula resulting from 

malformation or persistence of the second (most common) or 

third branchial cleft; abnormalities of the first branchial arch 

are associated with facial clefts (eg, cleft palate).
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Pediatric Surgery and Medicine for Hostile Environments

• First branchial cleft sinuses communicate with the eustachian 

tube. 

• Second branchial cleft cysts extend from the anterior border of 

the lower third of the sternocleidomastoid muscle superiorly, 

then inward between the carotid bifurcation, entering the 

posterolateral pharynx just below the tonsillar fossa.

• The third branchial cleft tracks lateral to the carotid bifurcation. 

• Symptoms include:

° a painless nodule at the anterior border of the 

sternocleidomastoid muscle, 

° drainage from the external auditory canal (first cleft sinus), 

° external fistula with drainage of clear fluid from the lateral 

neck (second cleft), and

° abscess formation in the lateral neck. 

• Consider a third or fourth branchial cleft cyst in pediatric 

patients presenting with acute thyroiditis.

• Pathology: cysts are lined with squamous and columnar 

epithelium, cartilaginous remnants, and cystic dilatations.

• Treatment of second branchial cleft anomalies is as follows: 

° Initially, treat infection (if present) with antibiotics to cover 

Staphylococcus and Streptococcus organisms. 

° Perform complete surgical excision of the cyst and tract.

° A lacrimal duct probe inserted through the external opening, 

as well as injection of a small quantity of methylene blue, 

will help define and facilitate dissection of the tract.

° Use a series of small, transverse, “stair step” incisions, 

rather than a long, oblique incision. 

° The marginal branch of the facial nerve may be injured by 

intraoperative retraction. 

Lymphatic Malformations (Cystic Hygroma) 

• Cystic hygromas are congenital malformations resulting 

in sequestration or obstruction of developing lymphatic 

channels. 

• They are usually posterior to the sternocleidomastoid muscle 

of the neck (posterior triangle). Other sites include: 

° axilla, 

° groin, 

° mediastinum, and 
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Face and Neck

° retroperitoneum.

• Cysts are usually multiloculated, may “infiltrate” deep 

structures of the neck (tongue, mouth floor), and are lined by 

endothelium.

• Infected cysts may cause airway compromise by compressing 

the trachea.

• Cysts may contain nests of vascular tissue (benign lesions).

• Characteristics 

° Soft and compressible. 

° Transilluminate.

° Usually present at birth and grow proportionally with the 

child; sudden enlargement later may be due to hemorrhage 

or infection.

• Diagnosis is made by ultrasound, chest radiograph, or CT 

scan. 

• Complications include:

° airway compromise; 

° disfigurement; 

° purplish discoloration (resulting from hemorrhage into the 

cyst); 

° infection (Staphylococcus or Streptococcus), which may cause 

rapid enlargement and airway compression; and 

° post-operative recurrence.

• Treatment includes conservative surgical resection. 

° Complete surgical resection is rare because the lesion is 

usually multilocular (especially lesions above the hyoid) 

and there is no well-defined cleavage plane between the 

lesion and normal tissue.

° Repeated partial excisions with preservation of all adjacent 

critical structures may be required. 

° Drain wound postoperatively by closed suction. 

° Needle aspiration of accumulated fluid may be required 

postoperatively. 

° Avoid injury to the facial nerve (cranial nerve VII).

° Injection of sclerosing agents (eg, OK-432, which is derived 

from group A Streptococcus pyogenes) may yield good results 

in cases with primarily macrocystic disease; sclerotherapy 

may also be used in conjunction with operative excision 

before and after the operation.
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Miscellaneous Conditions

Otorrhea

• Drainage of purulent fluid from the ear may represent acute 

or chronic otitis media with a tympanic membrane perforation 

or otitis externa (swimmer’s ear); cholesteatoma and temporal 

bone tumors may also present with chronic otorrhea.

• Treat by gently cleaning the ear canal with suction or 

cotton swabs, then apply antibiotic eardrops. Consider oral 

antibiotics for patients with systemic symptoms and signs.

Acute Otitis Externa 

• Diagnosis: severe pain with manipulation of the auricle, foulsmelling discharge, and ear canal edema.

• Treat by gently cleaning the ear canal, then administer 

antibiotic eardrops or 2% acetic acid drops for 10 days. 

Prescribe oral analgesics.

• A cotton or cellulose ear wick may be placed in an edematous 

ear canal to ensure the otic drops are properly delivered.

• Refer the patient to a specialist if the status of the tympanic 

membrane is unknown, if symptoms persist despite 

appropriate treatment, or for hearing loss or vertigo 

accompanying otorrhea.

Hearing Evaluation

• Hearing status may be tested using a 512-Hz tuning fork. Use 

one or more of the following:

° Weber test: Place the shaft of a vibrating tuning fork on 

the midline of the head (forehead, bridge of nose, upper 

central incisors) and ask the patient to point to the ear 

where the sound is loudest. In a normal hearing individual, 

the sound is midline. The sound is heard louder in an ear 

with conductive hearing loss; it may be heard in the betterhearing ear in patients with severe sensorineural hearing 

loss.

° Rinne test: Place the vibrating tuning fork shaft on the 

mastoid bone behind the auricle, then direct the tines 

toward the external auditory canal in the air. Ask the patient 
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Face and Neck

which sounds louder. Air conduction is normally better 

than bone conduction. If bone conduction is better (ie, the 

patient hears better with the tuning fork to the mastoid), 

then a conductive hearing loss is likely in the affected ear.

Hearing Loss in Children

• The most common cause of hearing loss in young children 

is chronic otitis media (fluid in the middle ear space). Other 

causes include congenital and acquired sensorineural hearing 

loss.

• Trauma is an uncommon cause of hearing loss but may impact 

hearing through a tympanic membrane perforation, ossicular 

chain disruption, or acoustic barotrauma that damages the 

inner ear.

• Foreign bodies.

Congenital Wryneck (Torticollis) 

• Congenital wryneck is evident in the early months of life due 

to fibrosis of the sternocleidomastoid muscle. 

• Physical examination reveals tender, palpable swelling in 

the lower part of the sternocleidomastoid muscle, with the 

patient’s head extended, and rotated toward the opposite side 

as the mass.

• Treatment includes:

° neck radiograph to exclude vertebral anomalies (KlippelFeil syndrome), 

° active and passive stretching exercises, or 

° surgical transection of the belly of the sternocleidomastoid 

muscle if the above is unsuccessful (rarely necessary). 

• 20% of those with congenital wryneck will have associated 

hip dysplasia. 

Epistaxis

• Anterior septal vessels are the most common source of 

epistaxis in children. 

• Treat by firmly pinching the nasal ala for 10 minutes (by the 

clock!); ice may be applied to the bridge of the nose during 

this time.
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Pediatric Surgery and Medicine for Hostile Environments

• Oxymetazoline may be sprayed into the nostrils or applied to 

cotton packing or strips and inserted into the nose to control 

epistaxis that is refractory to pressure.

• Apply hemostatic packing (Gelfoam [Pharmacia and Upjohn 

Co; Kalamazoo, Michigan] wrapped in Surgicel [Ethicon US, 

LLC; Somerville, New Jersey] or tamponade using a balloon 

device if bleeding persists despite several minutes of direct 

pressure).

• Consider a posterior source of epistaxis for persistent bleeding; 

secure the airway first and then pack the nasopharynx via the 

mouth until definitive care becomes available.

• Prevention: instruct the patient to avoid nose picking, use 

humidification, and apply petroleum jelly or other ointment 

(eg, mupirocin). NOTE: The patient will frequently vomit 

bright red blood swallowed from the nasal source.

Acute Bacterial Sinusitis 

• Acute bacterial sinusitis is a complication of an acute upper 

respiratory infection in 5% to 7% of children. 

• Symptoms include one of the following: 

° upper respiratory infection symptoms (nasal discharge 

and/or daytime cough) for more than 10 days without 

improvement,

° worsening symptoms after initial improvement, or 

° sudden onset of purulent nasal discharge and fever (≥ 39°C) 

for at least 3 days.

• Diagnosis is based on clinical evaluation; imaging is 

not necessary. Reserve sinus CT for suspected orbital or 

intracranial complications.

• Etiology: the typical infectious etiologies of acute bacterial 

sinusitis in children are Streptococcus pneumoniae, Haemophilus 

influenzae, and Moraxella catarrhalis.

• Treatment: amoxicillin with or without clavulanate is the firstline treatment for acute bacterial sinusitis. Ceftriaxone or other 

second- or third-generation cephalosporins are alternatives. 

Saline nasal irrigations and oral or topical decongestants may 

also be helpful. Antihistamines are not useful for treating acute 

sinusitis.
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Orthopedics

Chapter 17

Orthopedics

Orthopedic trauma, although rarely life-threatening, is often 

accompanied by injury to neurovascular structures as well 

as to other organ systems. Assessing and treating airway, 

breathing, and circulatory impairment takes priority in all cases. 

Immobilizing injured extremities will decrease pain, bleeding, 

and the risk of injury to adjacent structures.

Resources in Roles 1 to 3 military medical treatment facilities 

are focused on adult orthopedics; equipment tailored to 

pediatric sizes and specific problems may not be available. 

Weather, sanitation, and ease of transport may also alter 

treatment; for instance, external fixation of closed long-bone 

fractures may be elected over open fixation to obviate infection, 

or external fixation may be more practical than closed treatment 

in a heavy cast.

Medical providers should familiarize themselves with local 

medical care resources for follow-on treatment. Subsequent care 

must be compatible with available local civilian resources as 

well as with culturally acceptable norms. A general knowledge 

of the indigenous cultural views on health, gender, and specific 

conditions (eg, amputations and congenital deformities) is 

helpful in directing care for pediatric civilian casualties. 

Short-term intervention may have limited impact and cultural 

norms may affect efforts to improve outcome. Interventions and 

their complications may leave patients in worse condition after 

treatment than if they had not received treatment at all.

Epidemiology

Types of Orthopedic Care

• Trauma
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Pediatric Surgery and Medicine for Hostile Environments 

° Children are subjected to the same mechanisms of injury as 

war fighters. In the past two decades, the leading etiologies 

of pediatric orthopedic trauma seen in deployed military 

facilities are

▶ blast injury (ie, direct contact with an explosive device),

▶ penetrating injury,

▶ thermal injury,

▶ blunt force injury, and

▶ congenital malformations/reconstruction. 

° Deployed orthopedic surgeons may be asked to evaluate 

and treat mild to severe congenital anomalies. Healthcare 

providers must use good judgment when initiating 

reconstructive treatment because there may be limited 

means for follow-up or follow-on treatment.

• Infection

° Pediatric musculoskeletal infections may be caused by 

pathogens endemic to the geographic area of operations.

° Wound infections may be caused by common environmental 

microorganisms.

▶ Staphylococcus aureus remains the most common cause 

of musculoskeletal infection throughout the world.

▶ Salmonella typhi has been reported to be the most 

common infecting organism in Africa.

▶ Acinetobacter baumannii is common in southwest Asia. 

It is found in soil and can live on open surfaces for a 

number of days, enabling it to spread. Patients with open 

wounds and those on ventilators are susceptible to this 

multiple drug-resistant organism.

▶ Klebsiella pneumoniae, an organism that lives in water, 

is typically acquired in a hospital setting and is often 

associated with people with poor nutrition and those 

with slightly depressed immune systems.

▶ Pseudomonas aeruginosa thrives in moist environments 

and is a threat to patients with several kinds of injuries, 

including burns. Pseudomonas and Staphylococcus 

epidermidis are the most common causative agents of 

infection in extramedullary implants in local hospitals 

in Iraq.
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Orthopedics

▶ Clostridia are gram-positive, anaerobic, spore-forming 

bacilli found in high density in cultivated, rich soil. 

Clostridium perfringens is the most common cause of 

gas gangrene and food poisoning. Clostridium difficile is 

responsible for pseudomembranous colitis after longterm antibiotic use.

° Osteomyelitis and septic joints can be hematogenous or 

result from direct inoculation. The causative organisms are 

those found in the particular environment. 

▶ The first principle of treatment is to evacuate and drain 

purulent material when it is entrapped. 

▶ Eradicating osteomyelitis or a septic joint will require 

long-term antibiotic therapy. Remote facilities or 

indigenous hospitals may not have the requisite 

laboratory support to follow laboratory values. Surgeons 

may be required to evaluate a patient’s response to 

treatment and determine treatment duration. Whenever 

possible, treatment initiated in the military setting should 

be coordinated with local, indigenous medical support. 

Be mindful that the microbial profile and antibiotic 

availability in deployed areas may differ substantially 

from that in the continental United States.

Difference in Levels of Trauma

Although common pediatric orthopedic traumas may present to 

a military medical facility, most cases will be more complex. In 

civilian and military settings in the continental United States, the 

receiving facility often provides emergency care and transports 

the patient to a higher-level facility for definitive care. In theater, 

the major orthopedic care for local civilians will occur at the 

military facility, followed by transportation to a lower-level 

facility.

Amputations

• Children sustain amputations from the same mechanisms of 

injury as war fighters.

° Exsanguination is the immediate concern.
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Pediatric Surgery and Medicine for Hostile Environments 

° Explosive munitions with penetration and concussive 

blast effects create a large zone of injury with extensive 

contamination and the potential for associated neurovascular 

injury that may affect the level of final amputation.

• Indications for partial or complete traumatic amputation 

include

° irreparable vascular injury or failed vascular repair with 

an ischemic limb;

° life-threatening sepsis due to local infection, including 

clostridial myonecrosis; and

° severe soft tissue or bone injury beyond functional recovery.

• Amputations should be done at the most distal level of viable 

tissue (in contrast with traditional amputation levels; eg, below 

the knee, above the knee, etc) to preserve as much limb as 

possible.

° A longer residual limb is most desirable for prosthetic fitting 

and will serve the amputee best if prosthetic fitting is not 

possible. 

° The ability to return to the operating room for further 

treatment should influence the level of amputation and 

extent of debridement. 

° Children have a remarkable ability to heal wounds that 

initially appear nonviable. 

° Second-look surgery may preserve limb length and the 

ability to provide soft tissue coverage. 

° Open length-preserving amputation has two stages.

▶ Initial: At this stage, bone resection is completed at the 

lowest level possible.

▷ The residual limb is left open with large soft-tissue 

flaps, perhaps of questionable viability. 

▷ Negative-pressure dressings, if available, are one 

means of decreasing soft tissue and skin retraction and 

of stabilizing the residual limb pending a second-look 

surgery and are preferred to skin traction. Negativepressure dressings allow abundant formation of 

granulation tissue and reduce the need to transfer 

soft tissue to treat defects. 

▶ Reconstruction: The goal at this stage is to achieve 

sufficient healing for optimum function and prosthetic 

fitting. 
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Orthopedics

▷ Civilian pediatric amputees will undergo this phase 

in country, unlike military patients who will be 

evacuated out of the combat zone for reconstruction 

in a stable environment.

▷ All viable skin and soft tissue distal to the amputated 

bone should be preserved for future wound closure. 

These “flaps of opportunity” can be used to add 

length to the residual limb, regardless of irregularity. 

▷ Because viable soft-tissue coverage determines 

residual limb length, guillotine-type amputations are 

not advised and require revision to a more proximal 

level.

Technique

• A tourniquet is used to limit blood loss and preserve 

intravascular volume in trauma patients. There is very little 

literature on the use of tourniquets in the pediatric population 

(see Further Reading at the end of this chapter). General 

guidelines are as follows.

° Place the tourniquet on the most proximal portion of the 

limb.

° Use the widest cuff possible suitable for the limb, location, 

and procedure.

° Use a specifically designed limb protection sleeve for the 

cuff, if available. If not, use two layers of tubular stockinette, 

slightly stretched but not tight.

° Apply the tourniquet snugly over the sleeve.

° Determine the occlusion/systolic blood pressure and set 

the tourniquet pressure to 50 mmHg above that (average 

is 175 mmHg).

° Exsanguinate the extremity by elastic bandage or gravity, 

as appropriate for the case.

° If bleeding persists after cuff inflation, increase the cuff 

pressure in increments of 25 mmHg until the bleeding stops.

° Minimize tourniquet time (no more than 2 h without 

intervals of 15-min deflation time).

° Remove the cuff and sleeve as soon as possible after the 

tourniquet is deflated. Alternatively, an Esmarch bandage 

may be used to exsanguinate and control limb hemostasis. 
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Pediatric Surgery and Medicine for Hostile Environments 

Three wraps of 3- or 4-inch Esmarch bandage provide 

hemostasis for surgery in a safe pressure range (around 

230 mmHg) at the desired tourniquet location.

° Sterilize the entire extremity.

• Debride nonviable bone and devascularized soft tissue.

• Suture ligate major arteries and veins.

• Locate major nerves, provide gentle traction, and transect 

proximal to the level of amputated bone; ligate major nerves.

• Preserve muscle flaps, but do not suture.

• Full debridement of a blast injury may require extending 

incisions longitudinally to remove contamination along fascial 

planes.

Managing Local Amputees

• Definitive care will be provided in theater. 

• Following the principles of the Red Cross surgeons working in

relatively stable environments, local civilian pediatric patients 

will undergo delayed primary closure once their wounds are 

clean. 

• Prevent skin retraction of open residual limbs using skin 

traction or—preferably—a negative-pressure dressing (eg, 

VAC, Kinetic Concepts, Inc, San Antonio, Texas), until closure 

is possible. Skin traction may be accomplished through the 

classic technique of benzoin-secured stockinette and 1 to 2 lb 

of weight (Figure 17-1). In select situations, skin retraction 

can be prevented by placing large, loose trauma sutures with 

bolsters or vessel loops and skin staples at the wound margins. 

Preserving viable skin flaps, even if they are irregular, aids in 

closure and is preferable to skin grafting.

• Acceptance of an amputee patient and the type of prosthesis 

the patient receives vary depending on the local culture. 

Existing local resources for prosthetic fitting may be limited.

• When applicable, early prosthetic fitting, especially in upperextremity amputations, promotes best functional use of the 

prosthesis. Frequent prosthetic changes are expected.

• As a result of rapid growth rate and the quantity of young 

healing bone, various long-term problems may arise, 

especially in below-the-knee amputations, such as
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Orthopedics

Figure 17-1. Cut-away view of stockinette skin traction.

° anterior bowing associated with the distal element pointing 

medially; 

° varus bowing with the distal element pointing medially;

° heterotopic bone formation, requiring revision; and

° overgrowth phenomena in which the fibula may outgrow 

the tibia, causing bursa formation overlying the fibula and 

prominent bone spicules to project beneath or protrude out 

from the skin.

• These problems may be prevented or controlled by synostosis 

of the distal fibula and tibia, which results in an end-bearing 

residual limb (this procedure should not be performed until 

the soft tissues have fully healed). Additionally, transarticular 

(rather than metaphyseal) amputations in skeletally immature 

patients avoid this complication. 

Compartment Syndrome

Children with compartment syndrome do not exhibit the 

same symptoms as adults. The “six Ps” of acute compartment 

syndrome (pallor, pulselessness, paralysis, paresthesia, pain, 

poikilothermia) do not have the same diagnostic application 
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Pediatric Surgery and Medicine for Hostile Environments 

with children. The “three As” are more applicable to pediatric 

compartment syndrome (anxiety, agitation, and increased 

need for analgesia). Pediatric trauma patients should not 

have regional anesthesia, which may mask a developing 

compartment syndrome, and excessive narcotics should 

be avoided in patients at risk of developing compartment 

syndrome. Elevating fractured limbs above the level of the heart 

will minimize tissue edema and decrease the need for analgesics. 

When compartment syndrome is a concern, compartmental 

pressures should be measured immediately using a needle/

transducer instrument (eg, Intra-Compartmental Pressure 

Monitor, Stryker Corporation, Kalamazoo, Michigan). Pressures 

above 30 mm Hg are abnormal.

Compartment syndrome is a clinical diagnosis. If there is 

clinical evidence of compartment syndrome, the compartments 

should be released emergently. Caution: Obtunded patients 

and patients with nerve injuries or regional blocks who may 

not respond appropriately display atypical symptoms. These 

patients need thorough monitoring; the surgeon should have a 

low threshold for compartment release if compartment syndrome 

is suspected clinically.

• Two incisions are recommended for four-compartment 

fasciotomy of the leg—medial and lateral.

° The lateral incision will release the anterior and lateral 

compartment. 

▶ The incision should be long and centered over the 

anterolateral leg. 

▶ Incise down to fascia. 

▶ Identify the intermuscular septum. The septum is readily 

palpable by running a finger from medial to lateral and 

vice versa, feeling for the indentation. Make a transverse 

incision and use a freer instrument to confirm the 

presence of the intermuscular septum. 

▶ After the intermuscular septum has been identified, divide 

the fascia over the anterior and lateral compartments. 

▶ Identify and protect the superficial branch of the 

peroneal nerve, which may exit from the fascia of either 

compartment through a fascial defect. 
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Orthopedics

° The medial incision should be just posterior to the posterior 

border of the tibia. 

▶ Avoid injury to the saphenous nerve and vein. Enter 

the deep posterior compartment by releasing the 

fascia in this interval to expose the muscles of the deep 

compartment. 

▶ The superficial posterior compartment is easier to enter 

proximally on the leg. 

▶ After release, do not close the fascia wound. The skin 

may retract without tension and skin grafting may be 

required. 

▶ A “Jacob’s ladder,” using staples and vessel loops, may 

be constructed to provide skin tension.

▶ A sterile dressing or a wound vacuum may be applied.

• The two most common pitfalls in performing fasciotomy are 

failure to make a sufficiently long skin incision and failure to 

completely open all four compartments.

Fractures

Evaluating Fractures

• Obtain the patient’s history, perform a physical examination 

to fully assess injuries, and establish vascular and neurologic 

status of the patient’s extremities. 

• Fractures are separated into six classification categories (Figure

17-2). 

• Obtain radiographs of the adjacent joints (above and below 

the fracture in the case of a long-bone fracture), with images 

in two planes.

• Examine and cover open wounds, preferably with a sterile 

dressing soaked in povidone-iodine or other antiseptic.

• Early administration of antibiotics and delayed surgical 

management of open fractures do not increase the risk of 

subsequent infection. 

• Splint the involved extremity, including the joints above and 

below, for a long-bone fracture.

• Fracture reduction should be done with adequate anesthesia 

or analgesia.
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Pediatric Surgery and Medicine for Hostile Environments 

• After reduction and application of a cast or external fixator, 

reevaluate the limb’s vascular status and sensory and motor 

nerve function.

• Children’s fractures remodel 1 degree per month for the first 

24 months.

• Children have an incredible capacity to remodel malunited 

fractures. The degree of remodeling potential corresponds to 

the child’s remaining growth and the location of the fracture. 

In infants and children, the remodeling potential is typically 

large. In adolescents, growth may be estimated by comparing 

the patient’s size with his/her parent’s.

Figure 17-2. Salter-Harris classification of fractures involving the growth

plate. Type I: transverse fracture through the physis. Type II: fracture through

the physis and metaphysis. Type III: fracture through the physis and epiphysis. Type IV: fracture through all three (physis, metaphysis, and epiphysis).

Type V: physeal compression fracture.Type VI: peripheral physeal injury.

Type V Type VI

Type III Type IV

Type I Type II
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Orthopedics

• Fractures around the wrist, shoulder, and knee have a 

remarkable ability to remodel. Fracture remodeling near the 

elbow and hip after age 4 years is poor. 

Open Fractures

• Open fractures sustained in a combat area are produced by 

small arms (bullets) and explosive munitions (improvised 

explosive devices, mortars, artillery, land mines, grenades, 

or bombs).

• The most common battlefield injury is multiple fragment 

wounds that involve only the soft tissue.

• Open fractures caused by weapons of war are more severe 

than those seen in a noncombat setting.

• Initial treatment for open fractures

° Evaluate the wound while the patient is under anesthesia.

° Surgically incise the skin and fascia to inspect the soft tissue 

and fracture site.

° Excise devitalized tissue or debris.

° Copiously lavage with a physiological solution to 

decontaminate and remove debris, dead tissue, or 

hematoma.

° All wounds should initially be left open and closed at a 

later date.

° Negative-pressure wound therapy may be a useful adjunct, 

especially for more extensive wounds.

° Administer systemic antibiotics and tetanus prophylaxis 

appropriate for the wound.

° If there is a skin defect, perform coverage as a second, 

staged, operative procedure only after the wound is clean 

and free of necrotic tissue.

° Soft-tissue coverage procedures should be planned and 

performed in a stable environment.

Long-Bone Fractures

• General

° Internal fixation of pediatric fractures in theater is rarely, 

if ever, indicated due to operative conditions and an 

enhanced potential for infection.
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Pediatric Surgery and Medicine for Hostile Environments 

° Based on the patient’s size and available equipment, 

external fixation may be desirable for stabilizing long-bone 

fractures in theater. Appropriately sized fixators may not 

be available; the “pins in plaster” technique may be used 

to maintain length.

° Casting remains an acceptable treatment option, provided 

alignment can be maintained. Cast wedging is particularly 

helpful to control pediatric fractures that angulate in a cast. 

▶ Opening wedges are preferred because they increase 

the space available for swelling and can substantially 

reduce fracture angulation. 

▶ Using fluoroscopy, mark the point of angulation of 

the fracture. For a single-plane correction, the wedge 

should be done in the concavity of the deformity. The 

circumference of the cast is split greater than 50% at 

the distal end of the proximal fragment. The cast is 

spread and wedges placed in the gap to maintain 

the cast in the new position. Neurovascular status 

is monitored distal to the wedge. The wedge is 

assessed radiographically and is overwrapped, when 

acceptable.

▶ Skeletal traction is also useful for some fractures.

Upper Extremity Fractures

• Proximal humerus fractures

° The majority of proximal humerus fractures in the pediatric 

age group are treated conservatively with a sling and 

swathe for roughly 2 weeks. 

° The proximal humerus has a considerable ability to 

remodel. Reduce fractures with greater than 25 degrees of 

angulation in patients within 2 years of skeletal maturity. 

° Gradual return to normal function is allowed once pain 

subsides.

• Midshaft humerus fractures 

° Use a coaptation splint with a sling and swathe for comfort.

° This may be changed to a Sarmiento-type brace at 2 weeks 

(if available) instead of definitive treatment in long arm 

cast.

• Supracondylar humerus fractures
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Orthopedics

° Significantly displaced fractures (Gartland types 2 and 3) 

require closed reduction and percutaneous pinning; crossed 

medial and lateral pins (rather than two or more divergent 

or two to three divergent lateral pins) are adequate. Varus 

or valgus deformity of less than 10 degrees and extension 

deformity of less than 15 degrees is acceptable.

° Place the extremity in a long arm cast for 3 weeks and 

consider bivalving the cast if the extremity swells.

° Remove pins after 3 weeks and allow the patient to begin 

activities as tolerated.

° Avoid immobilization in more than 90 degrees of elbow 

flexion; this may lead to ischemic contracture.

° Type 2 fractures can sometimes be reduced and held 

without pinning with a long arm cast (see precautions 

above).

• Lateral condyle fractures

° Lateral condyle fractures are often difficult to diagnose in 

younger populations; when in doubt, diagnose with an 

arthrogram. The preferred location is posterior, into the 

olecranon fossa. 

° Perform the arthrogram.

▶ Palpate the olecranon, being mindful of the location of 

the ulnar nerve.

▶ Using sterile technique, insert the needle proximal to the 

tip of the olecranon until you hit bone, then withdraw the 

needle by a millimeter and inject the contrast material, 

ideally under fluoroscopy with a lateral view of the 

elbow. Avoid using excessive contrast material.

▶ If the fracture is not displaced or does not enter the joint, 

percutaneous fixation may be used. This will facilitate 

patient transport and will decrease the risk of fracture 

displacement. Two or three laterally-based divergent 

pins may be used to percutaneously fix a lateral condyle 

fracture. 

° Open reduction is indicated if the fracture enters the joint 

and there are more than 2 or 3 mm of displacement.

° Use a lateral approach; avoid stripping the posterior soft 

tissue attachments off the fragment because blood supply 

enters posteriorly.
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Pediatric Surgery and Medicine for Hostile Environments 

° Reduce the fragment and pin with two or more Kirschner 

wires.

° Immobilize in a long arm cast for 4 to 6 weeks, then remove 

pins after healing is noted. 

° Lateral condyle fractures are notorious for nonunion. 

• Elbow dislocation

° Reduce an elbow dislocation as soon as feasible, as 

dislocations become more difficult to reduce with time. 

There is a 10% neurologic injury rate, usually involving 

the ulnar nerve. 

° Evaluate the elbow’s range of motion under fluoroscopy, 

if possible, after reduction. 

° Immobilize the elbow in a posterior splint for 2 weeks, then 

the patient may begin motion. If the elbow is unstable with 

extension, immobilize it in appropriate degrees of flexion 

to maintain reduction. 

° Beware of medial epicondyle fractures, especially the 

entrapped medial epicondylar fragment. Suspect an 

epicondyle fracture when there is continued instability, joint 

subluxation, severe pain, and lack of medial epicondyle on 

anteroposterior radiographs of the elbow. Half of elbow 

dislocations cause a medial epicondyle fracture.

° Medial epicondyle fractures rarely require treatment, 

regardless of displacement, unless they are entrapped in the 

joint or the patient has significant ulnar nerve dysfunction 

(in which case, open reduction and pin—as opposed to 

screw—fixation is indicated).

° Use a 0.062-inch Kirschner wire instead of a 4.0 cannulated 

screw, with or without a washer. If the epicondylar piece 

fragments, it may be stabilized with suture. 

° Closed reduction of a trapped medial epicondyle fragment 

can be accomplished using the Roberts method.

▶ Attach the epicondylar piece to the flexor pronator mass. 

▶ Extend the wrist and supinate.

▶ Give valgus stress to elbow; the fracture may reduce if 

done acutely. 

° Most medial epicondyle fractures heal without operative 

treatment. A substantial portion that are treated without 

surgery heal with a fibrous union that is satisfactory.
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Orthopedics

° Radial neck fractures are common. Closed—as opposed to 

percutaneous or open—reduction may be indicated. 

▶ Acceptable reduction is less than 30 degrees of 

angulation. 

▶ The risk of avascular necrosis is significant for fractures 

that must be treated in open fashion due to the blood 

supply to the radial head. 

▶ Monteggia fractures: Beware of isolated ulnar fractures 

in children or ulna bowing without fracture. The radial 

neck should point toward the capitellum on any view 

of the elbow. 

▶ Radiographs may show an obvious olecranon fracture 

or an apophyseal sleeve avulsion injury. Treatment for 

children without forearm extension or displacement 

should be operative, with open reduction and internal 

fixation using a tension band with stainless steel or 

suture. 

• Forearm and wrist fractures

° Forearm and wrist fractures may involve the radius, ulna, 

or both, and may occur at the distal, middle, or proximal 

forearm.

° Remodeling potential is greatest in younger patients and 

in distal areas near the physis.

▶ Expect an angular correction of approximately 1 degree 

per month or 10 degrees a year for 2 years.

▶ Rotational deformities do not correct with growth; 

bayonet apposition of up to 1 cm is acceptable if 

the patient is less than 8 to 10 years old. If the initial 

displacement is outside this range, fracture reduction 

and casting are recommended.

▶ In general, immobilization consists of 4 weeks in a 

long arm cast, followed by 2 weeks in a short arm cast. 

Immobilization duration varies depending on fracture 

healing and age.

° Angulation greater than 20 degrees decreases the range of 

pronation and supination.

° Torus and buckle fractures are stable. 

° Consider intramedullary nailing for proximal 1/3 radial shaft 

fractures. Intramedullary nails should be 30% of the bone’s 

diameter.
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Pediatric Surgery and Medicine for Hostile Environments 

° Wrist fractures (at the distal third of the forearm) can be 

treated with 3 to 6 weeks of short arm casting, depending 

on the age of the child and the fracture type. 

▶ Carpal fractures are rare in children. If the patient has 

negative radiographs but tenderness over the snuff box, 

treat as a scaphoid fracture with a thumb spica case and 

repeat radiograph in 10 to 14 days. 

▶ For metacarpal injuries, avoid rotational deformity by 

buddy taping the fingers and flexing the metacarpal 

phalangeal joint to 90 degrees. 

▶ Angulation is better tolerated in the ulnar hand (10 

degrees in the index and middle finger, 40 to 50 degrees 

in the ring finger and small finger). 

° Fingertip amputations in children have a remarkable ability 

to heal. Err on the side of less aggressive treatment. For 

children less than 4 years old, a composite graft consisting 

of the defatted fingertip may be cleaned and sutured to 

cover the defect. The fingertip typically turns black but 

heals underneath. 

Lower Extremity Fractures

• Pelvic fractures (see Further Reading for additional guidance)

° Overall, pelvic fractures in pediatric patients are rare.

° Pelvic fractures are usually caused by a high-energy 

mechanism that results in other life-threatening injuries. 

Comprehensive workup using advanced life support 

principles is indicated.

° Children have greater plasticity, thicker cartilage, and more 

mobile joints than adults, and their vessels tend to spasm 

and not bleed (life-threatening hemorrhage is rare).

° Children have a lower mortality rate (10%–15%) from pelvic 

fracture than adults. Blood transfusions are required in 10% 

to 15% of children with pelvic fractures.

° The majority of children with pelvic fractures can be treated 

nonoperatively with a pelvic compression wrap or external 

fixator and have a much better prognosis than adults with 

pelvic fracture.

° Imaging
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▶ Take radiographs of the anteroposterior pelvis (inlet, 

outlet, and Judet views).

▶ Computed tomography (CT) scan is preferred, especially 

with image reconstructions.

▶ If an associated urethral or bladder injury is suspected, 

obtain a cystourethrogram.

° Treatment is based on age; fracture location, type, and 

stability; and concomitant injuries.

▶ Most pelvic injuries in children are treated nonsurgically 

and heal uneventfully. 

▶ Surgical indications include intraarticular acetabular or 

triradiate cartilage displacement of more than 2 mm, and 

pelvic ring displacement with more than 2 cm of limb 

length discrepancy.

▶ External fixation may be used for unstable fractures.

° Complications 

▶ Acetabular fracture or triradiate injury may lead to a 

dysplastic acetabulum and early degenerative changes.

▶ Sacroiliac joint pain.

• Femur fractures

° Certain current acceptable and standard treatments, such 

as internal fixation with plates, may not be reasonable in an 

austere environment because of infection risk and limited 

equipment availability.

° Treatment is typically based on the age and size of the

patient and the availability of equipment (Table 17-1).

Table 17-1. Guidelines for Acceptable Reduction in Femur 

Fractures

Procurvatum/

Age (y) Varus/Valgus Recurvatum Shortening

0–2 30° 30° 15 mm

2–5 15° 20° 20 mm

6–10 10° 15° 15 mm

11 and older 5° 10° 10 mm
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Pediatric Surgery and Medicine for Hostile Environments 

▶ Birth to 6 months old: Use a spica cast for diaphyseal 

fractures and a long leg cast for supracondylar fractures. 

The Pavlik harness that is recommended in the 

noncombat environment may not be available in theater.

▶ 6 months to 12 years old: Use an external fixator or 

pins in plaster. Submuscular bridge plating is a good 

option in a developed healthcare system, but may not 

be appropriate in theater. Skeletal traction may be used 

where external fixation is not available or not advised 

(eg, while a child is confined to bed); it requires limited 

operating room technology.

▶ 12 years and older: Use an external fixator. Intramedullary 

nailing or bridge plating are good options in a developed 

healthcare system, but may not be appropriate in theater. 

Kirschner wires may be used to stabilize transverse 

fractures. Smooth or treaded Kirschner wires may be 

used to transfix fractures after open reduction. After 

fixation with the Kirschner wire, cut flush with cortex. 

Plan to immobilize the joint above and below the fracture 

treated in this fashion.

° Proximal tibial metaphyseal Cozen fractures may develop 

a valgus deformity at 12 to 24 months after injury. Decrease 

this risk by providing a slight varus mold to the cast. Reduce 

the fracture and place the limb in a long leg cast with 20 to 

30 degrees of knee flexion for 6 weeks. More knee flexion 

makes it difficult to provide a varus stress. Most valgus 

deformities will remodel on their own and not require 

surgery. Discuss the growth deformity with the patient’s 

parents as soon as possible.

• Tibial shaft fractures

° The majority of tibia fractures are treated with closed 

reduction and long leg casting.

° Acceptable alignment: 50% apposition, less than 1 cm 

shortening, and 5 to 10 degrees of angulation in the sagittal 

and coronal planes.

° A long leg cast is applied with slight (10–20 degree) ankleplantar flexion and 45 degrees of knee flexion.

° Look for an increasing varus deformity in the tibia fracture 

with an intact fibula.
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Orthopedics

° Time to healing is based on age. Neonates heal in 2 to 3 

weeks, children in 4 to 6 weeks, and adolescents in 8 to 12 

weeks.

° External fixation and open reduction with internal fixation 

may be used if clinically indicated (eg, in the case of severe 

comminution, open fractures, etc). 

• Ankle fractures

° The majority of ankle fractures are Salter-Harris-type 

injuries and can be treated with closed reduction and a 

short leg cast.

° Displaced fractures (greater than 2 mm) that traverse the 

physis and involve the joint may require reduction and 

internal fixation.

° Physis may be crossed if the patient is near skeletal 

maturity.

° Tillaux fractures and triplane fractures are more complex 

ankle fractures and may need to be evaluated by CT scan 

to discern fracture pattern and displacement. Displaced 

Tillaux or triplane fractures are treated with open reduction 

and internal fixation. In an austere setting, open reduction 

with Kirschner wires and casting is an option. For children 

who are near skeletal maturity, crossing the physis is not 

concerning. 

° Growth arrest

▶ Physeal bar formation can cause angular and limb-length 

discrepancy. 

▶ Growth arrest is more closely linked to initial 

displacement than Salter-Harris classification. 

▶ Harris-Park growth arrest lines should be visible 6 

months after injury and indicate growth resumption. 

The growth arrest lines should be parallel to the physis; 

growth arrest lines that angulate toward the physis may 

indicate a physeal bar or partial growth arrest. 

▶ Consider CT to evaluate the presence and extent of 

physeal bar.

▶ Consider excising the bar based on its size, deformity/

discrepancy, and growth remaining.
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Pediatric Surgery and Medicine for Hostile Environments 

Further Reading

1. Lieberman JR, Staheli LT, Dales MC. Tourniquet pressures on 

pediatric patients: a clinical study. Orthopedics. 1997;20:1143–1147.

2. Tredwell SJ, Wilmink M, Inkpen K, McEwen JA. Pediatric 

tourniquets: analysis of cuff and limb interface, current practice, 

and guidelines for use. J Pediatr Orthop. 2001;21(5):671–676.

3. Holden CP, Holman J, Herman MJ. Pediatric pelvic fractures. J Am 

Acad Orthop Surg. 2007;15:172–177.
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Thoracic Cavity

Chapter 18

Thoracic Cavity 

General Approach to Thoracic Injuries

Incidence

Of pediatric trauma and combat injuries, 8% to 25% involve 

the lung, mediastinal structures (heart, aorta, esophagus, and 

bronchus), diaphragm, or chest wall. Blunt injuries are the most 

common, usually due to motor vehicle accidents or pedestrianversus-motor vehicle collisions, falls, or abuse. Penetrating 

injuries are rare but are more common depending on the 

amount of violence or combat within a region. Blast injuries 

are potentially due to a combination of blast wave, blunt, and 

penetrating mechanisms and may be caused by ignition of 

flammable liquids or explosion of an improvised explosive 

device.

Clinical Presentation

• Up to two-thirds of pediatric trauma patients with thoracic 

injuries will have stable vital signs upon presentation.

• Ribs in pediatric patients are incompletely mineralized, 

making them more pliable than those of an adult. Therefore, 

rib fractures signify a large amount of kinetic force to the chest 

and underlying structures. 

• Symptoms will vary depending on mechanism, anatomic 

location of injury, and concomitant injuries to other systems, 

such as the head, neck, or abdomen.

Evaluation

• The physical examination for pediatric thoracic injury follows 

the guidelines of advanced trauma life support and proceeds 

as follows:
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Pediatric Surgery and Medicine for Hostile Environments 

° perform primary survey and resuscitation, followed by

° secondary survey, then

° transfer to appropriate echelon of care.

• Clinical predictors of thoracic injuries with blunt trauma 

are hypotension, tachypnea, external chest wall signs of 

contusions or lacerations, decreased breath sounds, and 

decreased Glasgow Coma Scale score.

• Unlike in adults, severe thoracic injuries can be present in 

children without rib fractures.

• To diagnose, use ultrasound, plain chest radiographs, 

computed tomography (CT) scans (these are more sensitive 

than plain radiographs but are rarely available in developing 

countries or at forward-deployed stations), or other adjuncts, 

if available (eg, magnetic resonance imaging, bronchoscopy, 

echocardiogram).

Treatment

• Initial treatment for most thoracic injuries can generally be 

addressed as follows.

° Establish patent airway and oxygenation.

° Provide assisted ventilation, if required.

° Resuscitate for active bleeding, but use fluids judiciously 

for pulmonary contusions or lacerations.

° Provide adequate analgesics, especially with multiple rib 

fractures.

° Give antibiotics for suspected infection or injury to the 

tracheobronchial tree or esophagus.

Thoracic Injuries Based on Anatomic Site

Lung

• Pneumothorax 

° Types

▶ Simple: collapse of lung without open wound or 

mediastinal shift.

▶ Open: rare case of a collapsed lung due to open wound 

to pleural space.

▶ Tension: surgical emergency where the presence of a oneway valve between the lung and pleural space results in 
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a mediastinal shift, tracheal deviation, and flattening of 

the diaphragm and subsequent hypotension as a result 

of decreased cardiac filling. Not well tolerated due to the 

mobility of mediastinal structures in pediatric patients. 

° Clinical presentation

▶ Any open or penetrating wound on the chest wall should 

be a concern for a pneumothorax.

▶ Other signs include absent or decreased breath sounds, 

tachypnea, respiratory distress, and hypoxia.

▶ Tracheal deviation, engorged neck veins, or unilateral 

absence of breath sounds with hypotension suggest a 

tension pneumothorax.

° Diagnosis

▶ Clinical diagnosis can be made when there is absence 

of breath sounds, respiratory distress, hyperresonance, 

decreased oxygen saturations, pallor, or cyanosis.

▶ Ultrasound and plain chest radiograph may also be used 

for diagnosis; however, tension pneumothorax requires 

emergent treatment first, before a chest radiograph.

° Treatment

▶ For tension pneumothorax, treat emergently with needle 

decompression at the second intercostal space in the 

midclavicular line. Insert a large-bore needle or an 

angiocatheter over the rib to decompress. For adolescent 

patients, adequate needle length (1.5–2 inches) is 

required.

▶ Perform a chest tube thoracostomy into the fourth 

intercostal space at the midaxillary line by incising the 

skin over the fifth rib and tunneling subcutaneously to 

the fourth intercostal space. 

▷ Refer to the table in the front of this book for ageappropriate thoracostomy tube sizes. Consider 

inserting a pigtail catheter in lieu of a thoracostomy 

tube, if available (not recommended for evacuation 

of a hemothorax).

• Hemothorax

° Hemothorax is most often due to laceration and hemorrhage 

resulting from injury to the lung, intercostal artery, internal 

mammary artery, or a mediastinal blood vessel.
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Pediatric Surgery and Medicine for Hostile Environments 

° Symptoms

▶ decreased breath sounds, dullness to percussion;

▶ hypotension and tachycardia; and

▶ respiratory distress.

° Diagnosis: chest radiograph, showing opacification of the 

affected side, blunting of the costophrenic angle, or loss of 

the diaphragm border.

° Treatment

▶ A chest tube will treat most cases of hemothorax (see 

description for chest tubes in Pneumothorax section). 

Because of the small diameter of the drainage holes, 

pigtail catheters tend to clot frequently and are not 

recommended for treating hemothorax. They may be 

considered for evacuating air or some effusions. 

▶ Emergent thoracotomy is indicated for penetrating 

trauma if the following signs are present: 

▷ Rapid loss of 20 cc/kg or more than 20% to 25% of 

estimated blood volume from chest tube drainage.

▷ Continuous bleeding that is greater than 2 to 4 mL/

kg/h over 2 to 4 hours.

• Pulmonary contusion 

° Pulmonary contusion is the most common type of blunt 

injury in children, occurring in two-thirds of patients.

° Children’s compliant chest wall transmits impact forces to 

the intrathoracic structures, often without external evidence 

of injury to the chest wall (ie, absence of rib fractures). 

° Parenchymal hemorrhage and edema produce 

intrapulmonary shunting (alveolar ventilation and 

pulmonary perfusion [V/Q] mismatch) that results in 

hypoxia, atelectasis, and pneumonia.

° Symptoms

▶ Rib fractures indicate a significant impact force to the 

chest and probable underlying pulmonary contusion.

▶ Pulmonary contusion may initially present with minimal 

symptoms, but may progress with manifestations of 

respiratory distress.

° Diagnosis

▶ Plain radiographs will demonstrate opacification in the 

area of direct trauma. Blast injuries may show diffuse 
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Thoracic Cavity

opacification due to blast wave injury.

▶ CT scan is rarely indicated initially.

° Treatment consists of:

▶ observation and supportive care (oxygen),

▶ analgesics (consider intercostal nerve blocks) if ribs are 

fractured,

▶ judicious use of intravenous fluids, 

▶ effusion or hemothorax drainage, and 

▶ careful observation for infection or pneumonia, which 

increase complication rates. Intubation and ventilator 

assistance may be indicated based on injury severity 

and initial treatment response.

° Most pulmonary contusions resolve within 10 days. 

° Pneumatocele (air-filled area of pulmonary parenchyma) 

is a possible long-term complication that usually resolves 

in 4 to 6 months without surgical intervention. 

• Lung laceration

° Lung laceration is most common after penetrating trauma 

or rib fractures.

° Clinical presentation

▶ Lung laceration can present with signs and symptoms 

associated with hemothorax and pneumothorax.

▶ The most serious complication of lung laceration is an 

air embolus.

° Suspect lung laceration in any penetrating trauma to the 

thorax.

° Treatment

▶ Place a chest tube for associated hemothorax or 

pneumothorax.

▶ Thoracotomy may be required for massive hemorrhage, 

large pneumothorax not responsive to chest tube 

thoracostomy, or air embolus.

• Rib fractures and flail chest

° Rib fractures signify significant trauma to the chest wall 

and underlying structures.

° Flail chest refers to the paradoxical motion of the 

chest wall due to multiple fractures of adjacent ribs, 

resulting in inadequate ventilation of the underlying lung
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Pediatric Surgery and Medicine for Hostile Environments 

(“pendelluft”). 

° Clinical presentation includes

▶ localized pain, tenderness, and crepitus at fracture sites;

▶ respiratory distress and hypoxia; and

▶ paradoxical motion of the chest wall. 

° Rib fractures and flail chest are commonly associated with 

underlying lung contusion.

° Diagnosis

▶ Plain radiographs are used to evaluate for fractures 

and possible associated contusion, hemothorax, and 

pneumothorax.

▶ Fractures or contusions may not be visualized initially; 

it may be necessary to obtain repeat imaging studies at 

48 hours.

° Treatment consists of supportive care with analgesics (narcotics, nonsteroidal antiinflammatories, intercostal blocks, 

epidural), supplemental oxygen, and chest physiotherapy.

Ventilator support with continuous positive airway pressure or positive end-expiratory pressure on assisted ventilation may be required.

Heart and Pericardium

• Pericardial tamponade

° Pericardial tamponade is the result of fluid accumulation 

within the pericardial space that prevents adequate preload 

filling of the right atrium.

° Pericardial tamponade is a rare occurrence. Clinical 

presentation includes:

▶ Beck’s triad (hypotension, muffled heart sounds, and 

distended neck veins),

▶ pulsus paradoxus, and

▶ tachycardia. 

° Diagnose with ultrasound. A focused assessment with 

sonography for trauma (FAST) scan will demonstrate 

lucency (fluid) within the pericardial sac.

° Treatment 

▶ Needle pericardiocentesis is a temporizing measure only. 

Insert a long needle via the subxiphoid approach, angled 

at 45 degrees toward the patient’s left shoulder or tip of 
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Thoracic Cavity

the left scapula. Aspiration of even a small volume of 

blood will result in improved hemodynamics. In most 

instances, this blood will be defibrinated and will not clot.

▶ Perform a “subxiphoid window” incision, grasp and 

incise the pericardial sac, and place a pericardial tube 

to relieve or prevent a tamponade.

▶ Perform an emergent left posterolateral thoracotomy if 

the patient does not respond to pericardiocentesis.

• Myocardial contusion

° Myocardial contusion is the most common type of blunt 

cardiac injury that can cause arrhythmias and death. The 

right ventricle is most commonly affected.

° Myocardial contusion may be asymptomatic. 

° Myocardial contusion is usually associated with blunt 

trauma to the anterior chest. Unexplained tachyarrhythmia 

is the most common symptom (supraventricular tachycardia 

and ventricular fibrillation are common).

° Diagnosis

▶ Electrocardiogram will show nonspecific ST-T wave 

changes.

▶ Creatinine phosphokinase (muscle band fraction) will be 

elevated, as will troponin I and T levels (most accurate).

▶ Echocardiogram will show decreased ejection fraction 

and septal wall motion abnormality.

° Treatment 

▶ Observe patient for 24 hours on a cardiac monitor, or 

transfer patient to higher echelon of care.

▶ Administer vasopressors if hypotension ensues.

Ruptured Diaphragmatic Hernia

• Blunt or penetrating trauma to the diaphragm may result in 

herniation of the bowel contents into the chest. 

• Clinical presentation

° Occurs on the left side in more than 80% of cases. The liver 

serves to buttress the right hemidiaphragm.

° There are no specific clinical signs, but ruptured 

diaphragmatic hernia can present with respiratory distress.

° Traumatic diaphragmatic hernias may be associated with 

injury to the spleen, liver, kidney, gastrointestinal tract, 
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Pediatric Surgery and Medicine for Hostile Environments 

and chest wall.

° Delayed diagnosis is common. 

▶ Plain radiographs may show an elevated or ill-defined 

hemidiaphragm, an abnormal gas pattern, bowel 

within the left chest above the diaphragm, or the course 

of a nasogastric tube passing above the level of the 

diaphragm. Initial films should include lateral views and 

can be normal in 30% to 50% of cases, thus repeat films 

should be obtained if a ruptured diaphragmatic hernia 

is clinically suspected. 

▶ A CT scan of the chest and abdomen can confirm diagnosis.

° Treatment

▶ In the case of acute trauma, perform emergent laparotomy 

and repair the diaphragm using nonabsorbable suture 

material.

▶ In the case of a delayed repair, a transthoracic approach 

to repair the diaphragm may be preferred because of 

intraabdominal adhesions.

Aortic Injury

• Aortic injury rarely occurs in children and is usually due 

to rapid deceleration that causes a tear at the level of the 

ligamentum arteriosum (obliterated ductus arteriosus), or the 

takeoff of the left subclavian artery. 

• Patients often present with a history of rapid deceleration with 

fractures to the first, second, or third ribs or the scapula.

• Diagnose using chest radiograph, which will show 

abnormalities that may include

° mediastinum widening,

° pleural or apical cap,

° deviation of the trachea to the right, 

° deviation of the esophagus (or nasogastric tube) to the right, 

° obliteration of the aortopulmonary window,

° obliteration of the aortic knob,

° widened paratracheal stripe,

° elevation of the right mainstem bronchus,

° depression of the left mainstem bronchus, and

° left hemothorax.

• CT scan and transesophageal echocardiography can provide 
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Thoracic Cavity

further detail.

• Treatment

° Stabilize and transfer the patient to a facility with a vascular 

or cardiothoracic surgeon. 

° Repair can be delayed until after severe injuries to the 

central nervous system and solid organs are addressed.

° Careful control of blood pressure by beta blockade may be 

required. Esmolol, administered as a continuous infusion 

and titrated based on frequent or continuous blood pressure 

determinations, is the preferred drug in this instance.

Trachea and Bronchus Injury

• Tracheal and bronchial injuries are more common than injuries 

to the great vessels and are usually due to blunt trauma.

• Symptoms include respiratory distress, hypoxia or cyanosis, 

hemoptysis, and massive air leakage from the chest tube. 

• Diagnosis 

° Chest radiograph will show massive subcutaneous and 

mediastinal emphysema and failure of the lung to reexpand after chest tube placement, especially if the lung 

falls to the lower half of the pleural cavity.

° Flexible bronchoscopy may be used to diagnose injury and 

facilitate selective intubation over the injury site.

• Treatment 

° Establish an airway using endotracheal intubation with or 

without flexible bronchoscopy.

° Drain via a thoracostomy tube if a significant pneumothorax 

is present.

° Transfer the patient to a medical facility with highfrequency ventilation capabilities if the patient cannot be 

oxygenated.

° If the injury covers more than a third of the circumference 

of the trachea, perform an emergent posterolateral 

thoracotomy and repair operatively using interrupted, 

nonabsorbable sutures, if possible. Lung resection may be 

necessary.

° Most small lacerations or injuries will spontaneously heal 

without surgery.
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Pediatric Surgery and Medicine for Hostile Environments 

Penetrating Esophageal Injuries

• Penetrating injury is rare. Clinical presentation includes fever, 

chest pain, tachycardia, hematemesis, and subcutaneous 

emphysema along the neck.

• Diagnosis

° Plain chest radiographs may show mediastinal air, 

pneumothorax, or pleural effusion.

° Upper gastrointestinal study with water-soluble contrast 

material is usually definitive.

° CT scan of the neck, chest, and abdomen with contrast may 

be helpful.

• Treatment 

° Stabilize the airway.

° Transfer the patient to a medical treatment facility with the 

appropriate surgical capabilities.

° Administer antibiotics.

° Penetrating injury is best treated within 12 hours by 

thoracotomy, surgical repair, and drainage. 

° Delayed diagnoses may require cervical diversion, 

gastrostomy tube placement, and chest tube drainage.

Infections of the Lung and Pleura

Complications of Bacterial Pneumonias (see Chapter 29, 

Infectious Diseases)

Pneumatocele

• A pneumatocele is a small, thin-walled cyst resulting from 

necrosis and liquefaction of lung parenchyma.

• It is usually seen in young children with Staphylococcus aureus

pneumonia but can also occur with group B Streptococcus and 

Haemophilus influenzae pneumonia.

• Most pneumatoceles are asymptomatic and incidental

findings. Pneumothorax or pyopneumothorax can be 

complications after rupture.

° Diagnosis is made by chest radiograph or CT scan, which 

will show intrapulmonary air pockets without air-fluid 

levels. 

° Differential diagnosis includes congenital lung cysts.
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Thoracic Cavity

• Pneumatoceles usually resolve spontaneously (whereas 

congenital cystic lesions do not).

Lung Abscess

• The most common cause of lung abscess is pulmonary 

aspiration. It may also result from operations on the upper 

respiratory tract (eg, tonsillectomy, tooth extractions). 

• The most common sites are the superior segment of the right 

lower lobe (supine position), posterior segment of the right 

upper lobe (lying on right side), and basilar segments of lower 

lobes (upright position).

• Typical organisms that cause lung abscess are anaerobes (most 

common), Staphylococcus aureus, Streptococcus viridans, and 

group A hemolytic Streptococcus and Pseudomonas.

• Lung abscess can occur due to congenital pulmonary 

adenomatoid malformation, bronchogenic cysts, or intralobar 

sequestration.

• Clinical presentation includes fever, chills, malaise, and 

productive cough; chest pain; hemoptysis; and weight loss 

and anorexia.

• Diagnosis can be made by chest radiograph and CT scan, 

which show an intrapulmonary cavity with an air–fluid 

level. White blood cell count or C-reactive protein will also 

be elevated. 

• Treatment

° Administer antibiotics for 6 to 8 weeks. 

° Perform bronchoscopy with direct aspiration of fluid. 

° Provide chest physiotherapy.

° Acutely ill infants may require percutaneous pigtail catheter 

drainage if they are unresponsive to antibiotic therapy.

° Indications for surgical resection (usually a segmental 

resection) are as follows:

▶ Chronic abscess lasting longer than 3 months or thickwalled (greater than 4–6 cm) abscesses. 

▶ Bronchial stenosis.

▶ Progression to empyema.

▶ Massive hemoptysis.
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Pediatric Surgery and Medicine for Hostile Environments 

Empyema

• Empyema is the accumulation of purulent fluid in the pleural 

space.

• Stages

° Exudative or acute: thin pleural fluid, pH less than 7.2, low 

cell count. 

° Fibropurulent: many polymorphonuclear leukocytes, pH 

less than 7.2, decreased glucose, deposition of fibrin, fluid 

loculations.

° Organizing: thick exudates, constricting fibrous peel 

encapsulates the lung.

• Organisms that commonly cause empyema include 

Streptococcus pneumoniae, S aureus, and H influenza, but the 

organism can vary depending on the region.

• Early treatment with intravenous antibiotics may prevent the 

effusion from becoming infected and forming an empyema.

• Anaerobic empyemas are associated with the highest mortality 

rate.

• Symptoms include tachypnea, fever, and persistent cough. 

• Diagnosis is made by physical examination, chest radiograph, 

CT scan, ultrasound, and thoracentesis (differential diagnosis 

of transudate), which will reveal the following:

° pH less than 7;

° turbid or purulent appearance;

° protein greater than 3 g, or pleural fluid protein to serum 

protein ratio greater than 0.5;

° glucose less than 40 mg/dL;

° lactate dehydrogenase (LDH) greater than 200 units/L, or 

pleural fluid LDH to serum LDH ratio greater than 0.6;

° cell count with large numbers of polymorphonuclear 

leukocytes; and 

° Gram stain showing organisms.

• Treatment consists of intravenous antibiotics and either of the 

following:

° Nonloculated fluid: thoracostomy tube drainage.

° Loculated fluid: video-assisted thoracoscopic surgery or 

possibly thoracotomy with pleural decortication.
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Thoracic Cavity

Mediastinal Masses

• Common causes of masses of the anterior mediastinum 

include ectopic thyroid, lymphoma, teratomas, and masses 

involving the thymus.

• Common causes of masses of the middle mediastinum include 

bronchogenic cysts, cardiac tumors, lymphadenopathy, 

lymphoma, pericardial cysts, and vascular abnormalities.

• Common causes of masses of the posterior mediastinum 

include esophageal duplication, meningomyelocele, 

neurogenic tumors (eg, neuroblastoma), and sarcomas.

Miscellaneous Conditions

• Spontaneous pneumothorax 

° Spontaneous pneumothorax results from a ruptured 

subpleural apical bleb.

° Clinical presentation

▶ The typical patient is a thin, lean, adolescent male, often 

a smoker.

▶ Diminished breath sounds are present on the ipsilateral 

chest.

▶ Tympany to percussion may be heard on auscultation.

▶ There may be a mediastinal shift to the contralateral 

side (if under tension), which may decrease the venous 

return, resulting in hypotension and tachycardia. 

° Diagnosis is made by posteroanterior and lateral chest 

radiographs. Use chest CT scan to assess for the presence 

of apical blebs. 

° Treatment

▶ If the patient exhibits symptoms of a tension 

pneumothorax: perform emergent needle decompression 

through the second intercostal space at the midclavicular 

line.

▶ If the size of the pneumothorax is estimated to be less 

than 15%: observe and give oxygen by mask.

▶ If the size of the pneumothorax is estimated to be greater 

than 15%: insert a small intrathoracic (pigtail) catheter 

and attach to a suction drainage device or Heimlich 

valve.
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Pediatric Surgery and Medicine for Hostile Environments 

▶ Treatment for recurrence or persistent air leak: use videoassisted thoracoscopic surgery for apical pleurectomy 

(endostapler) and pleurodesis (mechanical or chemical).

• Hemoptysis

° Hemoptysis may be caused by pulmonary hypertension, 

bronchiectasis, a foreign body, congenital pulmonary 

malformations, or infections. 

° Hemoptysis usually stops spontaneously; however, 

treatment may include bronchoscopic localization and 

selective bronchial artery embolization. If those are 

unsuccessful, perform lobectomy.
279

Vascular Surgery

Chapter 19

Vascular Surgery

Introduction

The majority of congenital vascular abnormalities are benign 

and require no treatment. Traumatic vascular injuries in children 

in Iraq and Afghanistan usually involve the extremities, with 

the brachial artery being the most commonly injured vessel. It 

is important to recognize that the energy generated by highvelocity, fragmented projectiles produces large soft-tissue 

cavitation with the potential for direct or indirect vascular injury, 

with concurrent injuries to adjacent soft tissue, nerves, and bony 

structures.

Hemangiomas

• Benign tumors of vascular tissue, vascular birthmarks, 

and vascular malformations are the most common tumors 

of infancy. They are considered a type of hamartoma and 

develop from abnormal angiogenesis.

• Hemangiomas are usually solitary, located on the head or 

neck, and occur most often in females. They

° typically appear within a week after birth;

° may be superficial lesions that are raised, bright red, and 

bosselated; and

° may be deep lesions that are raised and appear blue-purple.

• The natural history of a hemangioma is characterized by 8 to 

12 months of rapid growth followed by involution occurring 

over 1 to 5 years.

• Complete resolution is usually achieved by age 5 to 7 years.

• Classification

° Neonatal staining (“stork’s bite”): light pink lesion on the 

back of the neck in the midline; usually fades spontaneously.
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° Salmon patch: a light pink variety of intradermal 

hemangioma that sits level with the skin surface, blanches 

with pressure, and does not change over years. Can be 

treated with cover-up creams or laser treatment.

° Capillary hemangioma (port-wine stain, nevus flammeus): 

hyperkeratotic patches (abnormal nerve endings) on the 

facial skin (deep in the dermis) that are supplied by cranial 

nerve V (trigeminal). These lesions are permanent (they

do not enlarge or regress) and may be associated with 

Sturge-Weber syndrome (indicating central nervous system 

involvement). They can be treated with laser ablation.

° Spider angioma: small, central arteriole with a network of 

radiating intradermal capillaries; these usually appear at 

age 3 to 4 years and regress spontaneously.

° Juvenile hemangioma: congenital vascular malformations 

that usually regress spontaneously after a period of rapid 

growth. This is a soft, spongy, nontender, reticular pattern 

of blood vessels in skin over a mass. Treatment consists of 

observation.

° Strawberry (capillary) hemangioma: these intensely 

red lesions undergo a period of very rapid growth; 

complications may develop before regression.

° Congenital arteriovenous (AV) fistulas: multiple and 

diffuse lesions, 50% of which occur in the head and neck. 

Treatment consists of intermittent pneumatic compression 

and complete surgical resection.

° Arterial hemangioma: pulsatile masses that exhibit bruits or 

thrills and may be associated with sign bleeding or marked 

regional gigantism. Treatment consists of surgical resection 

of all AV shunts.

° Venous malformations (cavernous hemangioma): spongy, 

subcutaneous swellings with a bluish discoloration; these 

do not regress and may grow to gigantic size, causing 

disfigurement. Treat with injections of sclerosing agents 

(eg, tetradecyl sulfate).

° Kasabach-Merritt syndrome: rapidly enlarging, 

solitary lesion that presents with hemolytic anemia, 

thrombocytopenia, and coagulopathy. Treat with interferon.
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° Visceral hemangioma: most commonly occurs in the liver 

and manifests with hepatomegaly, anemia, coagulopathy, 

and high-output heart failure. Treatment is indicated for 

large and symptomatic lesions; use steroids, interferon, or 

embolization.

• Diagnose with complete blood count, platelet count (red 

blood cells and platelets can be trapped/sequestered, resulting 

in lower peripheral white blood cell and platelet counts), 

computed tomography scan with intravenous contrast, 

magnetic resonance imaging, or angiogram (rarely indicated).

• Complications

° Ulceration (most common complication).

° Bleeding from ulceration.

° Cosmetic concerns.

° Infection.

° Kasabach-Merritt syndrome: rapidly enlarging, 

solitary lesion that presents with hemolytic anemia, 

thrombocytopenia, and results in coagulopathy.

° Compromise of vital structures (eg, airway, eye).

° Disseminated intravascular coagulation after surgical 

resection.

° Internal organ involvement.

▶ Liver: hepatomegaly, congestive heart failure.

▶ Lung: hemoptysis, recurrent pneumonia.

▶ Treatment for internal organ involvement includes 

administering prednisone or cyclophosphamide and 

performing hepatic artery embolization or ligation.

• General treatment principles

° Observation only unless complications arise.

° First-line treatment is propranolol or steroids.

° Embolization can be useful for treating liver lesions and as 

a preoperative adjunct to surgical resection.

° Kasabach-Merritt syndrome is often treated with vincristine.

° Surgical treatment is only indicated in very rare cases that 

fail to respond to less invasive treatments.

° Laser (argon) treatment is especially useful for port-wine 

stains and head and airway lesions, but is not indicated for 

strawberry capillary or cavernous hemangiomas.
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Lymphangioma

The lymphatic vessels drain protein-rich fluid leaked from 

capillaries and return it to the blood. Lymph travels through 

the cisterna chyli, to the thoracic duct, and on to the left 

internal jugular vein at its junction with the subclavian vein. 

Lymphangiomas develop as a result of abnormal embryologic 

development of the lymphatic system. The neck and axilla are 

common sites. Unlike hemangiomas, lymphangiomas do not 

regress spontaneously. 

• Types include cystic hygroma and lymphedema.

• They are soft, nontender, and grow with the child.

• Diagnosis is made by ultrasound.

• Types of benign lymphatic tumors

° Cystic hygroma (see Chapter 16, Face and Neck): although 

these are benign, cystic hygromas can be very difficult 

to resect because of their close approximation to critical 

structures (ie, nerves and vasculature).

° Lymphedema: an abnormal accumulation of lymphatic fluid 

in interstitial fluid due to abnormal development (aplasia 

or hypoplasia of lymphatic channels) or obstruction. There 

are three types: 

▶ congenital (Milroy’s disease; present at birth), 

▶ praecox (appears in adolescence), and 

▶ tarda (occurs in middle age).

• Treatment

° Excision is only indicated for cosmesis, compression of 

vital structures (eg, airway), and to avoid the remote risk 

of infection.

° In the remote setting, observation alone is appropriate for 

small to moderate asymptomatic lesions.

° Large lesions often require a combination of staged excision 

and sclerotherapy. Recurrence is common.

° Complications include infection (eg, lymphangitis, 

cellulitis) and lymphangiosarcoma.
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Venous Disorders

• Embryology: right umbilical vein regresses before birth (this 

may account for a gastroschisis defect occurring to the right 

of the umbilicus).

• AV malformations

° Truncal malformations arise from major arterial 

branches. They are hemodynamically active with large 

communications and often form on the upper extremities, 

head, or neck.

° Diffuse malformations have multiple small communications, 

are seldom hemodynamically active, and commonly exhibit 

a bruit.

° Malformations are bright red, exhibit increased skin 

temperature, and manifest an audible bruit.

° Complications include bleeding, distal ischemia, and 

congestive heart failure.

° Diagnose by arteriography.

• Treatment can include surgical excision (high recurrence 

rate), use of compression garments, selective embolization, 

and proximal ligation (contraindicated, but ligating multiple 

small feeding vessels may help).

• Congenital anomalies of central veins

° Duplication of superior vena cava.

° Anomalous pulmonary venous return (total or partial).

▶ Infant is cyanotic at birth and has a right-to-left shunt.

▶ Associated with atrioseptal defect.

° Absence of inferior vena cava, resulting in venous drainage 

through the azygos system; associated with situs inversus.

° Preduodenal portal vein: often associated with duodenal 

anomalies and malrotation, but also associated with situs 

inversus.

• Diagnose the above disorders with Doppler ultrasound.

• Treat thrombotic complications of congenital anomalies of 

central veins with heparin anticoagulation or, in the case 

of acute thrombosis of major veins that is life- or organthreatening, use thromboplastin.
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Arterial Disorders

Arteriovenous Malformations

• Usually occur in lower limbs and are associated with unilateral 

limb hypertrophy (hemihypertrophy).

• A hepatic arteriovenous malformation (AVM) in a newborn 

may produce congestive heart failure.

• Intestinal AVM may produce bleeding.

• Physical findings include increased warmth, swelling, and 

pulsating varicosities.

• Diagnose by Doppler ultrasound, angiography, or magnetic 

resonance imaging.

• Treat for complications, such as bony erosion, pain, and 

functional disability.

• Treatment may include surgical excision and angiographic 

embolization.

Visceral Aneurysms 

• Visceral aneurysms, though rare, occur most commonly in 

the renal and splenic arteries.

• Treat by resection and reanastamosis if the aneurysm is larger 

than 2 cm.

Connective Tissue Disorders

Marfan Syndrome

• Physical findings include tall, thin body habitus, 

arachnodactyly, and lens dislocation.

• Symptoms include inguinal hernias, spontaneous 

pneumothorax, pectus carinatum, and aneurysms of the 

ascending aorta, which results from cystic medial necrosis that 

ruptures the intima and initiates aortic dissection (sudden aortic 

insufficiency is a common early manifestation of aneurysm).

Acquired Disorders

• Kawasaki disease: manifested by skin rash, erythema, edema 

of the hands and feet, arthritis, cervical adenopathy, and 

conjunctivitis and aneurysms of the coronary and peripheral 

arteries.
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• Thrombi and emboli: occur in infants of diabetic mothers and 

manifest with dehydration and polycythemia, which may 

produce a state of hyperviscosity and result in thrombosis.

° Umbilical artery catheters may be associated with aortic 

and renal artery thrombosis that leads to hypertension and 

heart failure.

° Treat with heparin, hydration, and, in some cases, total 

parenteral nutrition.

• Occlusive syndromes

° Intracranial and extracranial arteries (eg, sickle-cell disease, 

which is the most common cause of stroke in children).

° Renal artery stenosis (resulting from fibromuscular 

dysplasia).

▶ Symptoms include hypertension, producing headache, 

visual disturbance, and congestive heart failure.

▶ This is the second most common cause of surgically 

correctable hypertension (coarctation is first).

▶ Usually bilateral.

▶ Diagnose using aortogram with renal angiography.

▶ Treat with reconstruction using a hypogastric artery 

graft from the aorta to the distal renal artery.

▷ Saphenous vein grafts are contraindicated because of 

the potential for aneurysmal dilatation when used in 

children.

▷ Transaortic balloon dilatation may be effective if 

stenosis is in branches, but not if stenosis is at a renal 

orifice (eg, ostium).

Traumatic Vascular Injury

Due to the laxity of soft tissue, vascular injuries in children may be 

associated with greater blood loss from third spacing compared 

to adults; collateral blood flow is also more extensive in children 

because of the lack of atherosclerotic narrowing in their vessel 

lumens. The most commonly injured vessels are the brachial, 

superficial femoral, and popliteal arteries (Tables 19-1 and 19-2).

• General principles

° Apply direct pressure to control bleeding.
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Table 19-1. Arteries to Ligate Versus Arteries to Reconstruct

Arteries Arteries That

That May Routinely Be Ligated Should Be Reconstructed

Digital, radial, or ulnar (not both, Common/internal carotid

preserve ulnar when possible) Subclavian

External carotid Axillary

Brachial (if distal to profunda and Brachial (if there is no Doppler

adequate signal is present at wrist) signal at the wrist)

Subclavian branches Common iliac

Internal iliac and profunda External iliac

femoral arteries* Superficial femoral

Popliteal

Tibioperoneal trunk

Celiac

Aorta

*Preserve at least one tibial vessel. The posterior tibial artery is the most 

critical to repair, followed by the dorsalis pedis and the peroneal arteries, 

respectively.

° Indications for mandatory surgical exploration include 

pulsatile bleeding, expanding hematoma, absence of distal 

pulses (cold or pale limbs), thrill, and bruit.

° Findings that may permit close observation with serial 

Doppler ultrasound for 24 hours include history of 

hemorrhage at the scene, nonexpanding hematoma, 

diminished (but present) pulse, proximity injury, and nerve 

deficit.

• Equipment needed

° Stethoscope.

° Doppler ultrasound.

° Argyle vascular shunts (Medtronic, Minneapolis, Minn; Fr 

sizes 8, 10, 12, 14).

° Fogarty embolectomy balloon-tipped catheters (Edwards 

Lifesciences Corporation, Irvine, Calif; Fr sizes 2, 3, 4, 5).

° Heparin (100 units/mL saline flush).

° Heparin, unfractionated (for intravenous administration 

when there are no associated injuries to the head, chest, or 

abdomen).
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° Prolene (Ethicon Inc, Somerville, NJ) suture material on 

vascular needles (3-0, 4-0, 6-0, 7-0). 

° Loupes.

° Fine vascular instruments (bulldog clamps, Castroviejo 

scissors, DeBakey clamps, etc).

• Vascular examination

° Vasospasm is common in children under 10 years of age. 

Warm the extremity and wait 30 to 45 minutes. If vasospasm 

does not improve, consider papaverine injection.

° Check pulse.

° Assess ankle brachial index (ABI); less than 0.9 or a 

difference between the lower extremities greater than 0.1 

is abnormal.

° Use Duplex ultrasound.

° Perform on-table angiography.

▶ Computed tomography angiography with 3-dimensional 

reconstruction may be useful to detect occult vascular 

injury and avoid conventional angiography.

▶ Catheter-directed angiography is useful for localizing 

injuries with abnormal physical examinations (ABI 

< 0.9) or soft signs of injury; hard signs of injury (eg, 

expanding hematoma, pulselessness, bruit, or thrill) 

should be explored. 

Table 19-2. Veins to Ligate Versus Veins to Reconstruct

Veins That Veins That Should Be Reconstructed

May Routinely Be Ligated

Internal and external jugular Popliteal for prevention of extremity 

Brachiocephalic venous hypertension and potential 

Left renal for compartment syndrome

Infrarenal inferior vena cava Common and external iliac, if time and 

(to control damage) patient condition permit

Internal iliac Portal vein

Tibialis Right renal vein

Carotid

Mesenteric

Subclavian
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• To treat diminished inflow or outflow secondary to an embolic 

occlusion of vessel lumen, carefully perform an embolectomy 

with a small Fogarty catheter and continuously flush with 

heparinized (1 unit/mL) saline and papaverine (30–60 mg in 

100 cc).

• Principles of performing a vascular anastomosis

° It is essential to magnify the operative field by properly 

adjusted loupes or microscope.

° A reversed segment of greater saphenous vein from an 

uninjured limb makes an ideal conduit, although small 

vessel size may contribute to technical challenges or 

necessitate a panel or spiral graft. 

° Alternate veins for interposition grafts are basilic, internal 

jugular, and internal iliac.

° Avoid using prosthetic vascular material due to the 

associated risk of infection.

° Blood vessels will grow with the patient, so an autogenous 

graft with an interrupted suture line is favored over 

prosthetic conduits of fixed diameter.

• A spatulated, primary end-to-end anastomosis has the best 

patency rate and can be performed when segmental loss is 

limited to less than 0.5 cm; a patch repair is an option when 

greater than 50% of the native wall is preserved to avoid a 

residual stenosis.

• Any anastamosis must be tension-free, have sufficient inflow 

and outflow, not leak, and provide adequate soft tissue 

coverage if it is to remain patent.

• Classic extremity fractures that contribute to vascular injury 

are those in the humerus (brachial artery), tibial plateau, and 

proximal tibia (tibioperoneal trunk). Bony fixation should 

precede vascular repair.

• A continuous Doppler assessment should always confirm 

the pulse examination; an ABI less than 0.9 is abnormal and 

should be investigated. C-arm and fluoroscopy units should 

be available for focal vascular visualization, but complete 

angiography is rarely necessary.

• Micropuncture needles with intrinsic guide wires are helpful 

for emergent arterial and venous access.
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• Assess grafts for flow every 3 months for 2 years, then 

biannually for 3 years, and then annually for life.

• Intraluminal shunts (eg, Argyle) may be used as a temporizing 

measure to prevent tissue ischemia, with revision if the patient 

demonstrates symptoms of ischemia. 

° This maneuver may be limb-saving when a patient must 

be transferred to a higher echelon of care for definitive 

vascular repair. 

° It is imperative that the dressing clearly state in writing 

that a vascular shunt is in place and identify the vessel that 

is shunted, the size of the shunt, and the date and time it 

was placed and the name and contact information for the 

surgeon who performed the procedure. This information 

must be verbally communicated to the medical officer 

responsible for the patient during transport as well as 

to the receiving physician. This point cannot be overemphasized.

• Findings on a chest radiograph suspicious for associated injury 

to the thoracic aorta include

° widened mediastinum,

° apical “cap,”

° fractures of the first or second ribs,

° fracture of the scapula, and

° rightward deviation of the trachea/endotracheal tube.

• Surgical artery exposure

° Ascending aorta/arch: median sternotomy with or without 

cervical extension.

° Descending aorta: left posterolateral thoracotomy at fourth 

intercostal space.

° Subclavian artery

▶ Left: left posterolateral thoracotomy at fourth intercostal 

space with “trap door” median sternotomy.

▶ Right: median sternotomy with right cervical extension.

° Common femoral: vertical groin incision, with extension 

cephalad into abdomen for proximal control if necessary.

° Superficial femoral/popliteal: medial incision of leg posterior 

to sartorius, with extension through semitendinosus and 

semimembranosus into lower leg.

° Tibial vessels: medial incision.
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• Common technical pitfalls

° Revascularization of an extremity after more than 4 to 6 

hours of ischemia necessitates a fasciotomy. A two-incision 

fasciotomy of the leg must release all four compartments.

° Inadvertent failure to reverse the interposed segment of 

peripheral vein.

° Excessive graft length, resulting in kinking and graft 

thrombosis.

° Inadequate graft length, resulting in anastomosis disruption

due to excessive tension.

° Failure to adequately cover the graft with viable soft tissue,

leading to desiccation and disruption.

° A break in sterile technique, resulting in graft infection.

° Inadequate debridement may create an intimal flap, leading 

to occlusion.

° Poor distal runoff, resulting in occlusion or vasospasm.

° Inadequate immobilization of the associated bony injury, 

resulting in graft disruption.

° Failure to prevent, recognize, or treat a compartment 

syndrome after revascularization, resulting in graft 

occlusion and tissue loss from ischemia.

• Postoperative management (all records should include time 

of observation and name of observer)

° Frequently monitor distal pulses by palpitation and 

Doppler ultrasound.

° Assess capillary filling, warmth, and sensation.

° Monitor for hematoma formation.

° Observe for compartment syndrome.
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Chapter 20

Abdominal Wall, Peritoneum, and 

Diaphragm 

Abnormalities of the abdominal wall, peritoneum, and 

diaphragm usually present in infancy.

Disorders of the Umbilicus

Umbilical Drainage

• Omphalitis is a life-threatening infection of the newborn 

abdominal wall around the umbilical stalk.

° Etiology 

▶ Omphalitis may be caused by poor hygiene and care of 

the umbilical stalk after birth.

▶ It is most commonly caused by Staphylococcus aureus.

▶ Clostridium perfringens (purple wound) is rare, but is 

associated with high mortality.

° Omphalitis may result in portal vein thrombosis, 

leading to portal hypertension and, eventually, to upper 

gastrointestinal bleeding (treated nonoperatively).

° Treatment

▶ Give broad-spectrum antibiotics to cover Staphylococcus 

aureus. 

▶ Surgically debride and excise umbilical vessels and 

necrotic soft tissue, if needed.

• Granulomas are collections of inflamed tissue.

° Treat small granulomas with silver nitrate. Repeated 

applications over several weeks may be required.

° Treat large granulomas by surgical excision (electrocautery).

• Polyps are vitelline duct remnants consisting of a small piece 

of intestinal mucosa.

° They appear as glistening, cherry-red nodules in the base 

of the umbilicus. They are often mistaken for granulomas.
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° Polyps are usually asymptomatic, but may cause local 

irritation because of persistent moisture.

° Treatment 

▶ Initially, try silver nitrate cauterization (rarely effective).

▶ Surgically excise with the central core of the umbilicus 

for polyps that persist beyond 6 to 12 months.

° Persistence of vitelline duct structures include 

omphalomesenteric sinus, fistula, Meckel’s diverticulum, 

cysts, and bands.

Urachal Sinus

• Urachal sinus is a cord-like, mucosal-lined structure extending 

from the dome of the bladder to the lower border of the 

umbilical ring.

• Symptoms include urinary fistula with urine drainage from 

the umbilicus.

• Urachal sinus is often associated with urinary tract anomalies, 

such as bladder outlet obstruction (eg, posterior urethral 

valves) and recurrent cystitis.

• Diagnose with ultrasound and voiding cystourethrogram.

• Treatment

° A small fistula may close after 1 to 2 weeks of bladder 

decompression with a Foley catheter.

° Excise the entire tract down to the bladder via an 

infraumbilical incision. Leave Foley catheter for 3 to 5 days 

following operation.

Urachal Cyst

• A urachal cyst may occur anywhere along the urachal tract, 

from the umbilicus to the bladder.

• Symptoms include enlarging suprapubic or infraumbilical 

mass, which may become infected, resulting in a urachal 

abscess (which may appear as an infection of the abdominal 

wall).

• Diagnose with ultrasound. 

• Treat an infected cyst with antibiotics and abscess drainage, 

then excise the cyst via an infraumbilical incision after 

the acute inflammation has resolved. A cyst may resolve 
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Abdominal Wall, Peritoneum, and Diaphragm

spontaneously by 12 months of age if it is not infected. If 

it persists beyond that period, the cyst should be resected 

because of the potential for malignant degeneration.

Patent Omphalomesenteric Sinus

• Patent omphalomesenteric sinus may be caused by a persistent 

vitelline duct, usually at the site of a Meckel’s diverticulum 

(located in the terminal ileum).

• Symptoms

° Contents of the small bowel may drain through the 

umbilicus. 

° Obliterated cord may become fixed to the umbilicus and 

may be associated with a closed-loop intestinal obstruction.

• Diagnose with ultrasound or sinogram.

• Surgically excise via an infraumbilical excision, with closure 

of the ileal defect or segmental small bowel resection.

Umbilical Hernia

• Umbilical hernias are very common in infants and children 

before 5 years of age and often resolve when the rectus muscles 

develop. Unlike in adults, incarceration is rare in children.

• Surgical repair is needed for cases of incarceration, 

strangulation, or evisceration; for a herniation that is 

proboscis-like (repair at 2 years of age); and a fascial defect 

that persists beyond 3 to 4 years of age. Pain may indicate 

impending incarceration and should prompt repair regardless 

of age.

• Repair technique

° Meticulously cleanse the periumbilical skin.

° Give one dose of intravenous (IV) antibiotics to cover 

Staphylococcus within 1 hour of the surgical start time.

° Perform infraumbilical incision and excise the sac, if 

possible.

° Complete a transverse fascial closure using an interrupted, 

long-term absorbable suture (Vicryl, [Ethicon US, LLC, 

Somerville, New Jersey] or polydioxanone [PDS; Ethicon 

US, LLC, Somerville, New Jersey]). Never use mesh!

° Attach dermal umbilical skin to the underlying fascia.
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Pediatric Surgery and Medicine for Hostile Environments 

° Use a pressure dressing for 72 hours to prevent a 

hematoma.

° Nonsteroidal antiinflammatory drugs are usually sufficient 

for postoperative analgesia, especially if the wound was 

infiltrated with a local anesthetic. 

Epigastric Hernia

• Epigastric hernias occur at the linea alba above the umbilicus.

• They usually result from a congenital fascial defect.

• An epigastric hernia manifests as a protrusion of preperitoneal 

fat that appears as a small, palpable, irreducible mass in the 

midline (usually supraumbilical, often multiple).

• Symptoms include pain and tenderness.

• Treat by operatively repairing via a transverse incision.

Spigelian Hernia

• A Spigelian hernia is located between the semilunar line and 

lateral border of the rectus sheath.

• It is prominent when the patient is crying and straining.

• The sac may contain omentum or bowel.

• Diagnosis is made by computed tomography scan or 

ultrasound.

• Treat with surgical repair.

Inguinal Disorders

Anatomy

• Processus vaginalis is a peritoneal diverticulum that extends 

through the internal inguinal ring. Failure to close may result 

in an indirect inguinal hernia. In an indirect hernia, a hernia 

sac is anterior and medial to the cord structures, lateral to the 

epigastric vessels.

• A communicating hydrocele occurs when intraperitoneal 

fluid has tracked down the patent processus vaginalis into 

the tunica vaginalis. In females, a hydrocele may occur along 

the round ligament (canal of Nuck), presenting as a bulge or 

mass in the labia majora.
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Abdominal Wall, Peritoneum, and Diaphragm

Incidence of Inguinal Hernias

• Incidence is approximately 3% overall.

• Male-to-female ratio is about 10 to 1.

• Incidence on the right is approximately 50%, left approximately 

25%, and bilateral approximately 15% because of the later 

descent of the right testis and delayed obliteration of the 

processus vaginalis.

• Incidence is increased in premature infants (approximately 

20% incidence).

• Increased-risk patients include those with cystic fibrosis, 

chronic lung disease, connective tissue disease, and those on 

peritoneal dialysis or with a ventriculoperitoneal shunt.

• Treat with routine bilateral explorations.

• Direct and femoral hernias are rare in children.

Hydrocele

• Noncommunicating hydroceles usually resolve by 12 months 

of age; if not, they should be considered hernias and repaired.

• Diagnosis is made by transillumination or ultrasound. 

The hydrocele is usually absent upon waking, and most 

prominent once the child is ambulatory because gravity moves 

intraperitoneal fluid through the processus.

• If the hydrocele is present after 12 months of age, treat by 

ligating the patent processus vaginalis and excising the 

hydrocele. Aspiration is not recommended. If the processus is 

patent, the hydrocele will recur; if the hydrocele is encysted, 

it will resolve spontaneously.

Symptoms of Inguinal Disorders

• Indirect hernia is the most common sign of an inguinal 

disorder. 

° An indirect hernia manifests as a groin bulge that extends 

toward the top of the scrotum.

° A palpable mass in a female in the labia majora usually 

represents an ovary (if the mass is bilateral, suspect 

testicular feminization syndrome; strangulation is rare).

° Visibility is better during periods of increased intraabdominal 

pressure (eg, crying, stooling).
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Pediatric Surgery and Medicine for Hostile Environments 

° The spermatic cord thickens as it crosses pubic tubercle 

(“silk glove” sign).

° Hernia sac is anteromedial to cord structures and lateral to 

the epigastric artery and vein.

• Direct hernia is rare in children. It may result from an injury 

to the floor of the inguinal canal during a previous hernia 

operation. It occurs medial to epigastric vessels.

• Hydrocele

° Communicating: intermittent scrotal swelling.

° Noncommunicating: remains the same size.

° Ultrasound may be valuable in distinguishing a hydrocele 

from an inguinal hernia; transillumination is less specific.

° Hydroceles usually resolve spontaneously by 2 years of 

age. If not, resection should be performed.

General Principles of Treatment

• Treatment for inguinal disorders is required in certain patients, 

including

° Those with a hernia on physical examination or with a 

convincing history consistent with a hernia.

° Patients who present with incarcerated hernias that can 

be reduced. These patients should be admitted and have 

semielective repair before discharge (waiting 24 hours 

from the time of reduction to operation permits edema to 

subside).

° Premature infants with (usually indirect) hernias. These 

should be repaired prior to the child’s discharge.

° Patients with an undescended testicle at the time of hernia 

repair. Perform an orchiopexy at the same time.

• Infants less than 50 weeks old (corrected gestational age) who 

were premature should be admitted for overnight observation 

postoperatively to monitor for residual effects of anesthesia 

(apnea and bradycardia).

• Excise an appendix testis to prevent torsion.

Complications

• Incarceration occurs when sac contents (usually bowel) cannot 

be reduced nonoperatively. This is much more common with 

indirect hernias (Figure 20-1).
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Abdominal Wall, Peritoneum, and Diaphragm

° Incarceration is most common in infants less than 1 year 

old.

° Symptoms include severe irritability, cramping abdominal 

pain, and vomiting.

° Physically, incarceration manifests as a firm, nontender 

mass in the groin.

° Pathology: decreased venous and lymph drainage 

increases edema and pressure. This leads to decreased 

arterial perfusion and eventual gangrene and necrosis, 

which presents as scrotal redness, edema, or a mass 

(strangulation).

° Treatment

▶ Attempt reduction.

▷ Sedate (using midazolam 0.05–0.1 mg/kg, or chloral 

hydrate).

▷ Elevate the lower body.

▷ Apply ice to the hernia sac.

Figure 20-1. Inguinal hernia containing incarcerated intestine. 
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Pediatric Surgery and Medicine for Hostile Environments 

▶ If nonoperative reduction is successful, admit the patient 

for repair in 24 hours.

▶ If nonoperative reduction is unsuccessful, perform 

immediate operative reduction via an inguinal incision.

▶ If the patient’s bowel is infarcted, perform a resection 

through the groin incision if possible; if not, perform a 

laparotomy.

▶ Surgical exploration of the contralateral groin is

controversial. The decision to proceed with surgery 

should be based on the patient’s ability to obtain surgical 

care should a hernia occur, and the risk of testicular or 

vas deferens injury. 

° Complications of incarceration include

▶ gonadal infarction,

▶ intestinal obstruction, and

▶ gangrenous bowel.

▷ Physical appearance: erythematous scrotum.

▷ Attempts at reduction are usually unsuccessful.

° Recurrence

▶ A direct hernia may occur at the repair site of a previous

indirect hernia if there has been an intraoperative injury 

to the floor of the inguinal canal.

▶ Excessively tight closure of the internal inguinal ring can 

result in recurrence.

▷ Symptoms include tender, swollen testis.

▷ Treatment consists of reexploration and inspection of 

the testis.

Abdominal Wall Defects

Gastroschisis

• “Gastroschisis” is Greek for belly cleft (Figure 20-2).

• Bowel is histologically normal, but thickened and shortened 

due to prolonged contact with amniotic fluid. These changes 

are reversible with time and after reduction into the abdominal 

cavity.

• The defect is almost always to the right of the umbilical cord 

(which is normally positioned) and separated from it by a skin 

bridge.
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• Midgut, stomach, and gonads are the most commonly 

herniated organs (liver rarely herniates in gastroschisis).

• There is no sac covering the herniated viscera.

• Malrotation is always present (in both gastroschisis and 

omphalocele).

• Associated anomalies are rare (except intestinal atresia).

Omphalocele

• In most cases, the bowel is covered by an intact membrane, 

from which the umbilical cord arises (ie, herniation into the 

base of the umbilical cord) so gastrointestinal tract function is 

usually normal; in a “ruptured” omphalocele, the membrane 

is not intact.

• Malrotation is present.

• The omphalocele often contains liver.

Incidence

• Gastroschisis-to-omphalocele ratio is 2–3:1.

• Both are associated with prematurity.

Figure 20-2. Gastroschisis. 
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Anomalies

• Gastroschisis

° Associated conditions include

▶ undescended testicles (common),

▶ atresias due to vascular compression in utero,

▶ hypoperistalsis, and

▶ necrotizing enterocolitis.

• Omphalocele

° Sixty percent of patients with omphalocele have associated 

abnormalities (cardiac, vertebral, limb, and chromosomal 

[eg, trisomy 13, 18, or 21]).

° Associated with Beckwith-Wiedemann syndrome, which 

can result in or be associated with

▶ macroglossia, which may cause airway problems;

▶ visceral hypertrophy (cardiomegaly, pancreatic β-cell 

hyperplasia that results in hypoglycemia);

▶ Meckel’s diverticulum, gastrointestinal tract duplications, 

and ambiguous genitalia; and

▶ increased association of malignant tumors (Wilms’, 

neuroblastoma, adrenal).

° Prenatal ultrasound (greater than 13 weeks gestation) is 

usually accurate.

° Vaginal delivery is not associated with more complications 

than cesarean delivery, with the exception of large 

omphaloceles.

° Treatment

▶ Insert an orogastric tube and place to low suction.

▶ Use a “bowel bag” or plastic cling film to conserve 

body heat, minimize evaporative heat loss, and prevent 

traction or twisting of the mesenteric blood supply; 

this is the most important aspect of pretransport and 

preoperative preparation.

▶ Antibiotics

▷ Ampicillin (100 mg/kg/day)

▷ Gentamicin (5–7 mg/kg/day)

▶ IV fluids

▷ 20 cc/kg Ringer’s lactate or 5% albumin.

▷ 150 to 175 cc/kg Ringer’s lactate during the first 24 

hours.
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▷ If not adequately hydrated, the child may become 

hypotensive on induction of anesthesia due to 

hypovolemia.

▶ Vitamin K

▷ Premature infant: 0.5 mg intramuscular.

▷ Full-term infant: 1 mg intramuscular.

• Omphalocele and gastroschisis

° Steps for primary closure

▶ Excise the omphalocele sac (except if it is attached to the 

liver).

▶ Inspect the umbilical cord and number of umbilical 

arteries (the presence of a single artery may be associated 

with an absent kidney).

▶ Inspect the bowel for atresias or perforations 

(omphalocele), do not attempt to undo matted loops of 

bowel.

▶ Manually stretch the abdominal wall.

▶ In gastroschisis, if a larger opening is required to reduce 

the herniated viscera, open the fascia cephalad in the 

midline.

▶ Manually extrude meconium from the colon after anal 

dilatation and saline irrigations (do not perform an 

enterotomy to evacuate meconium).

▶ Do not excise a Meckel’s diverticulum.

▶ The liver must be reduced carefully to avoid torsion of 

the hepatic veins or occlusion of portal vein inflow that 

results in hemodynamic instability and injury to the 

capsule (omphalocele).

▶ Close the fascial defect and skin.

° Complications of an excessively tight closure include

▶ Respiratory insufficiency secondary to excessive 

pressure on the diaphragm. Peak inspiratory pressure 

should be less than 35 cm H2O after fascial closure; 

abdominal compartment pressure should be less than 

15 cm.

▶ Vena cava compression, resulting in decreased venous 

return.

▶ Decreased renal vein flow, resulting in decreased 

glomerular filtration rate.
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▶ Decreased mesenteric artery flow, resulting in bowel 

ischemia (an immediate primary repair in an infant with 

respiratory distress syndrome is contraindicated due to 

resultant high mortality).

▶ If there is any question about bowel viability, place a silo 

and perform a second look in 12 to 24 hours.

° Do not attempt definitive repair until chromosomal 

abnormalities and possible cardiac defects have been 

evaluated.

° Delayed primary closure

▶ Sew silicon-plastic or Gore-Tex (WL Gore & Associates, 

Inc, Newark, Del) sheets to the edges of the fascia; a 

silicon-plastic bag (with an integrated spring to hold 

the base open) can also be used and does not require 

suturing.

▶ Gradually reduce the silo over several days.

▶ Remove the silo and perform primary fascial closure 

after about 7 days, or, in the case of a large omphalocele: 

▷ Allow the sac (which must be intact) to thicken and 

epithelialization to occur before applying escharotic 

or desiccating agents.

▷ Use Acticoat (Smith & Nephew, London, England) 

dressing and change every 4 to 5 days.

▷ Povidone-iodine may be associated with iodine 

absorption and suppression of thyroid-stimulating 

hormone.

▷ 0.5% silver nitrate may be associated with 

hyponatremia.

▷ Apply silver sulfadiazine twice a day for 2 weeks and 

perform primary skin closure in about 2 months.

▷ Indications for applying escharotic agents include 

suspected chromosomal syndromes (eg, trisomy 

13 or 18); severe, unstable cardiac defects (eg, 

hypoplastic left heart, hypoplastic aortic arch); and, 

in premature infants, hyaline membrane disease, 

primary pulmonary hypertension, and sepsis.
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Abdominal Wall, Peritoneum, and Diaphragm

• Intestinal atresia

° Conserve bowel when feasible.

° Perform ileostomy.

° Both gastroschisis and omphalocele are always associated 

with intestinal nonrotation (malrotation), which is typically 

benign and does not require treatment due to the low risk 

for volvulus.

° Postoperative considerations

▶ Provide ventilator support for 48 to 72 hours, 

pharmacological paralysis (using pancuronium 

bromide).

▶ Provide total parenteral nutrition until full enteral feeds 

can be resumed, which may require weeks to months.

▷ Normal intestinal absorption may be delayed for 

weeks.

▷ Dysmotility problems may persist for weeks to 

months.

▶ If gastrointestinal contrast studies show no evidence of 

obstruction, do not operate; operating will only create 

new adhesions.

▶ Place a gastrostomy tube, continue total parenteral 

nutrition, administer physical therapy for sucking, give 

erythromycin to increase motility, and be patient.

▶ Administer 5% albumin infusions, as needed.

▶ Continue antibiotics until the silicon-plastic silo has been 

removed.

▶ The patient may experience increased gastroesophageal 

reflux due to increased intraabdominal pressure; this 

rarely requires fundoplication.

° After successful skin closure of a giant omphalocele, a 

ventral hernia repair may be associated with hemodynamic 

instability due to hepatic venous anatomy.

° Long-term complications

▶ Stricture may result in a small-bowel obstruction.

▶ Ventral hernia.

▶ Undescended testicles.

° Survival depends on prematurity, size of the defect, and 

severity of associated anomalies.
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Pediatric Surgery and Medicine for Hostile Environments 

Disorders of the Peritoneum and Peritoneal Cavity

Abdominal Compartment Syndrome

• Etiology: increased intraabdominal pressure due to an 

inflammatory process (eg, perforated appendix) or any spaceoccupying condition (eg, bleeding, edema) that increases the 

volume of the abdomen.

• Symptoms include

° sepsis,

° respiratory distress due to pressure on the diaphragm,

° oliguria due to renal vein compression,

° hypotension due to vena cava compression and decreased 

venous return,

° vasomotor changes, and 

° acidosis due to hypoperfusion.

• Abdominal distension is an obvious physical manifestation.

• Diagnosis is made when intraabdominal pressure is greater 

than 20 cm H2O, as determined by measuring bladder 

pressures.

• Treatment consists of assisted ventilation, IV fluid 

administration, addressing the underlying cause, and 

abdominal decompression using a silo or wound vacuum 

device.

Meconium Peritonitis

• Meconium peritonitis is frequently associated with cystic 

fibrosis as the etiology of obstruction.

• Types

° Pseudocyst: meconium is contained by necrotic bowel and 

omentum; the cyst wall is lined with calcium.

° Plastic: free perforation causes marked generalized 

inflammatory reaction and adhesions.

° Generalized: prenatal perforation with continuing leak 

produces meconium ascites.

• Etiology

° Intrauterine volvulus of meconium-filled loop of bowel 

leads to intestinal vascular compromise.

° This results in bowel ischemia then atresia, which leads to 

obstruction and, finally, perforation.
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Abdominal Wall, Peritoneum, and Diaphragm

° Symptoms include polyhydramnios, abdominal distension, 

and bilious vomiting.

• Diagnosis

° Prenatal ultrasound will show polyhydramnios, dilated 

bowel loops, or calcifications.

° Abdominal radiograph shows dilated loops of intestine and 

intraabdominal calcifications (linear calcifications may line 

the processus vaginalis and scrotum).

• Treatment

° For obstruction or pneumoperitoneum, perform laparotomy 

with conservative resection.

° In asymptomatic cases, observe the patient closely.

Omental and Mesenteric Cysts

• Omental and mesenteric cysts usually result from 

lymphangiomas.

• Symptoms include pain, vomiting, and abdominal mass.

• Diagnose with computed tomography scan or ultrasound.

• Treat with excision.

Ascites

• Etiology

° Urinary tract malformation (eg, ureteropelvic junction 

obstruction, posterior urethral valves) resulting in 

obstruction (most common etiology in the neonate).

° Immune hydrops (Rh incompatibility, cardiac anomalies).

° Pancreatitis.

° Ovarian cyst or tumor.

° Chyle due to lymphatic abnormality.

• Treat the underlying abnormality.

Peritoneal Adhesions

• Immediate postoperative bowel obstruction is usually due to 

small bowel intussusception.

• Diagnose via an upper gastrointestinal study with small-bowel 

follow through.

• Treat initially by placing a nasogastric tube, administering 

IV fluids and antibiotics, and performing a laparotomy with 

adhesion lysis for a complete obstruction.
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Congenital Diaphragmatic Hernia

• Normal openings in the diaphragm occur at the aorta, vena 

cava, and esophagus.

• Late-onset diaphragmatic hernias are diagnosed with a chest 

radiograph in an asymptomatic patient.

• Symptoms include gastrointestinal obstruction and respiratory

distress (eg, severe hypercarbia, hypoxia).

• Treat by repairing hernia.

• Differential diagnosis may be congenital cystic adenomatoid 

malformation or sequestration.

• Defects

° Esophageal hiatus (Morgagni’s hernia; stomach prolapses 

into the mediastinum).

° Congenital posterolateral defect (Bochdalek hernia).

° Anomalous attachment of diaphragm to sternum and ribs.

° Epigastric omphalocele and retrosternal defect in the

diaphragm and pericardium (Pentalogy of Cantrell), 

producing herniation within the pericardium.

° Attenuation of the tendinous or muscular portion of the 

diaphragm produces eventration (usually secondary to 

phrenic nerve injury).

• Incidence

° Associated with malrotation.

° Occurs more frequently in females than males.

° Occurs most often on the left (90%).

• Diagnosis

° Prenatal diagnosis

▶ Polyhydramnios (75% incidence).

▶ Associated with major central nervous system, cardiac, 

and chromosomal abnormalities (eg, trisomy 13 and 18). 

Many of these cases end in stillbirth.

° Postnatal diagnosis

▶ View prenatal ultrasound.

▶ A chest radiograph will show the tip of the nasogastric 

tube to be above the diaphragm, indicating herniation 

of the viscera into the chest and a mediastinum shift.

▶ Babygram will show intestinal loops herniated into the 

chest (Figure 20-3).
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Abdominal Wall, Peritoneum, and Diaphragm

Figure 20-3. Defect in the posterolateral aspect of the left hemidiaphragm 

with intestinal loops herniated into the left chest.
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Pediatric Surgery and Medicine for Hostile Environments 

▶ Rule out associated abnormalities (which occur in 

15%–25% of cases) in the following.

▷ C e n t r a l n e r v o u s s y s t e m : h e a d , s p i n e 

(meningomyelocele).

▷ Heart (most common): patent ductus arteriosus, 

ventricular septal defect.

▷ Kidneys.

▷ Lung: sequestration (occurring most commonly in left 

lower lobe).

▶ Rule out chromosomal (trisomy 13) and metabolic 

abnormalities.

• Pathophysiology

° A herniated viscus becomes distended with air, displacing 

the mediastinum.

° Increased pulmonary artery pressure and pulmonary 

vascular resistance result from decreased pulmonary 

artery branches and thickened muscularis of 

bronchioles.

° A right-to-left shunt through a patent ductus 

arteriosus and the foramen ovale results in hypoxia, 

hypercarbia, and acidosis; these lead to increased 

pulmonary vasoconstriction.

° Acidosis and hypercarbia lead to pulmonary vasodilation.

° Alkalosis and hypocarbia lead to pulmonary 

vasoconstriction.

• Physical symptoms and appearance include respiratory 

distress (evident by grunting, flaring, retracting, and 

cyanosis), scaphoid abdomen, shifted heart sounds, decreased 

bowel sounds, tracheal deviation, and bilateral pulmonary 

hypoplasia (more severe on the side of herniation).

• Treatment

° Support spontaneous respiration; provide sedation 

with paralysis only if necessary.

° Perform endotracheal intubation (avoid bag-mask 

ventilation to prevent insufflation of air into the stomach 

and small bowel).

° Insert Replogle nasogastric tube.

° Ventilator settings

▶ Peak inspiratory pressure less than 25 cm H2O.
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Abdominal Wall, Peritoneum, and Diaphragm

▶ Positive end expiratory pressure less than 6 cm H2O (to 

minimize barotrauma).

▶ 100% oxygen.

▶ Adjust rate and inspiratory-expiratory ratio to maximize 

partial pressure of oxygen (PaO2), decrease partial 

pressure of carbon dioxide (PaCO2).

▶ Maintain pH greater than 7.20 (permissive hypercapnia).

° Place an umbilical venous catheter, umbilical arterial 

catheter (postductal), or right radial arterial line (preductal). 

When placing an umbilical arterial catheter, ideal arterial 

blood gas levels should be as follows. 

▶ PaO2 greater than 40 mmHg. 

▶ PaCO2 less than 30.

▶ pH greater than 7.5.

° Administer sodium bicarbonate or trimethylamine drip.

° Provide volume replacement (Ringer’s lactate or 5% 

albumin).

° Maintain mixed venous saturation (from right atrium) 

greater than 65%.

° Administer dopamine or dobutamine, as needed.

° Tolazoline enhances histamine release, but can result in 

hypotension and peptic ulcers.

° Nitric oxide (an endothelium-derived relaxing factor), 

which decreases pulmonary vasoconstriction, may be 

helpful.

° Perform surgical repair after pulmonary hypertension has 

resolved.

° Appropriate pulmonary vasodilators to administer 

include prostaglandin E1 and E2; appropriate 

pulmonary vasoconstrictors include prostaglandin 

F, thromboxane A1 and B2, and leukotrienes.

• Surgical repair

° Perform surgical repair when the patient is physiologically 

stable, not as an emergency measure.

° A diaphragmatic hernia is not an indication for fetal 

surgery.

° Administer general anesthesia (eg, pancuronium).

° Make a subcostal abdominal incision for right-sided or leftsided defects or thoracoscopy. In patients with a delayed 
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Pediatric Surgery and Medicine for Hostile Environments 

presentation, there are often dense adhesions between the 

incarcerated abdominal viscera and the lung, and repair is 

best approached via a transthoracic incision (posterolateral 

incision through the seventh intercostal space).

° Reduce herniated viscera by excising the hernia sac, which 

is present in 10% to 20% of patients and may be easily 

missed.

° Primary repair

▶ For a small defect, use nonabsorbable suture material 

and pledgets.

▶ For large defects, use bioprosthetic or synthetic 

prosthesis.

° Place a thoracostomy tube to underwater seal.

° A purple-brown mass near or in the left lower lobe may 

represent a sequestration.

▶ Blood is usually supplied from a branch of the abdominal 

aorta below the diaphragm.

▶ Treatment consists of excision with repair of the 

diaphragm.

• Postoperative care

° Administer IV fluids (dopamine or dobutamine may be 

added).

° Anticipate pneumothorax.

• Results

° Overall mortality is approximately 50% (unchanged for 

the past 20 years).

° Prognosis is determined by the degree of hypoplasia.

° Lung volumes approach equality on a ventilation/perfusion 

scan.

° Residual volume and functional residual capacity are 

increased.

° Vital capacity, forced expiratory volume, and minute 

ventilation volume are normal or slightly decreased.

Eventration of the Diaphragm

• The most common cause of diaphragm eventration is injury 

to the phrenic nerve from the neck stretching during birth or 

from iatrogenic operative trauma.

• Symptoms
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Abdominal Wall, Peritoneum, and Diaphragm

° Inspiration leads to negative intrathoracic pressure, 

which causes herniation of the viscera into the ipsilateral 

chest.

° This leads to mediastinum shift to the contralateral side, 

which results in respiratory distress or pneumonia.

° Diaphragm eventration occurs more frequently in the left 

diaphragm than the right.

• Diagnosis

° Chest radiograph will show diffuse elevation of the 

hemidiaphragm (eventration).

° Fluoroscopy or ultrasound of the diaphragm shows an 

elevated diaphragm with paradoxical motion.

° Differential diagnosis is a congenital diaphragmatic hernia 

with hernia sac.

• Treatment

° Initially intubate with assisted ventilation.

° Perform posterolateral, transthoracic (seventh 

intercostal space) plication using multiple rows 

of nonabsorbable suture, only if the patient is 

symptomatic (ie, ventilator support is required for 

longer than 2 weeks, the patient is in respiratory distress, 

and the patient cannot tolerate exercise).

° Complications

▶ Recurrence (10%–15% of cases).

▶ Chest wall deformity if plication is excessively taut.
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313

Gastrointestinal Tract

Chapter 21

Gastrointestinal Tract

Surgical conditions involving the pediatric gastrointestinal (GI) 

tract are common and may encompass an almost endless array of 

anatomic malformations and pathophysiology. Surgeons should 

always keep in mind that their ability to accurately diagnose and 

treat many of these conditions will depend greatly on available 

resources and equipment, as well as on their personal level of 

expertise and that of other critical members of the operative 

and postoperative care team (ie, anesthesiologists, nurses, and 

respiratory therapists). Surgeons practicing in an environment 

with limited resources should accept the fact that good intentions 

do not always guarantee patient benefit.

Esophageal Conditions

Tracheoesophageal Fistula and Esophageal Atresia

• Epidemiology and risk factors

° Tracheoesophageal fistula (TEF) and esophageal atresia 

(EA) occur in 2.4 per 10,000 live births.

° Associated risk factors include prematurity (52%), Down 

syndrome (10%–20%), duodenal atresia (10%), maternal 

diabetes, and prolonged exposure to oral contraceptives 

or thalidomide.

° There is a higher incidence of TEF and EA in Caucasians, 

males, mother’s first progeny, children of older mothers, 

and in those with a family history of EA.

• Prenatal findings

° Typical findings are polyhydramnios and a lack of a 

stomach bubble on radiograph (pure atresia).

° Sometimes these findings are absent and the diagnosis is 

made after birth.

• Symptoms include
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° Copious salivation (drooling) and aspiration at the time of 

first feeding, which is usually glucose water.

° Choking, coughing, respiratory distress, and cyanosis.

° Aspiration of acidic gastric secretions, resulting in chemical 

pneumonia (the most common cause of death).

° Abdominal distention as the stomach fills with air passing 

through the TEF (if present).

• Diagnosis

° In a newborn, a nasogastric (NG) tube cannot be passed into 

the stomach and curls in the blind upper esophageal pouch 

(if proximal and distal—“pure” EA). The most common 

form of TEF or EA is a proximal EA with a distal TEF (85% 

of cases).

° The bowel gas pattern seen on a radiograph of the chest 

and abdomen will aid in diagnosis.

▶ Patients with pure atresia or distal EA with proximal 

TEF will manifest a gasless abdomen.

▶ A fistula between the trachea and esophagus appears as 

a gas-filled stomach and bowel.

° A contrast swallow should be avoided unless the diagnosis 

cannot be established by other means.

• Initial treatment

° Give nothing by mouth.

° Pass an NG tube (Replogle or sump-type tube) and place 

to low continuous suction. The tube should be irrigated 

periodically, as it tends to become occluded with secretions.

° Initially provide maintenance intravenous (IV) fluids and 

consider starting total parenteral nutrition (TPN). 

° Elevate the patient’s head to minimize aspiration.

° Administer antibiotics (ampicillin and gentamicin).

° Evaluate for associated VACTERL (vertebral, anorectal, 

cardiac, TEF, renal, and radial limb) abnormalities.

▶ Take plain radiographs to rule out vertebral and limb 

anomalies.

▶ Perform an echocardiogram to define cardiac anatomy 

and physiology.

▶ Perform a renal ultrasound to detect anomalies.

° Operative repair is best performed at a tertiary medical 

facility with neonatal intensive care unit capabilities and a 

pediatric surgeon.
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Gastrointestinal Tract

° Pure atresias without a fistula are considered to be “longgap” and are treated initially with a gastrostomy tube and 

enteral support until growth is sufficient to approximate 

the ends of the esophagus (3–4 months). Certain long-gap 

atresias may require esophageal replacement if primary 

anastomosis is not feasible. Options for esophageal 

replacement include

▶ gastric transposition,

▶ gastric tube,

▶ colonic interposition, and 

▶ jejunal interposition. 

Corrosive Injury of the Esophagus

• Incidence and demographics

° The leading cause of corrosive injury of the esophagus 

is accidental ingestion in children. It is more common in 

developing countries where warning labels are not widely 

used.

° Accidental caustic ingestions in children less than 5 years 

old and suicide attempts in young adults over the age of 

20 result in a bimodal distribution.

• Common injury-causing agents

° Alkali agents

▶ Strong liquid alkalis (hydroscopic) are the most common 

cause of corrosive injury to the esophagus due to 

liquefaction necrosis (solids are more difficult to swallow 

and are usually expectorated).

▶ Potassium hydroxide and sodium hydroxide (eg, 

detergents, laundry powders, button batteries, drain 

cleaners) are associated with severe injury.

▶ Sodium hypochlorite (bleach) and detergents seldom 

cause clinically significant injuries.

▶ Ammonia (eg, glass cleaners, toilet bowl cleaners) may 

also cause injury.

▶ Injury to the esophagus is much more common than 

injury to the stomach in alkali burns. 

° Acidic agents

▶ Strong acids have an odor and bitter taste that can induce 

emesis and thus can be protective.
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Pediatric Surgery and Medicine for Hostile Environments 

▶ Rapid acid transit causes sparing of the esophagus, but 

injures the stomach by coagulation necrosis.

▶ Hydrochloric acid (eg, pool cleaners, metal and bowl 

cleaners) and sulfuric acid (eg, drain cleaners, car 

batteries) also commonly cause injury.

▶ Hydrofluoric acid (eg, antirust products) can cause 

calcium abnormalities.

• Symptoms of corrosive injury of the esophagus include

° vomiting;

° dysphagia;

° drooling, inability to swallow saliva;

° abdominal or upper abdominal pain; and

° burns of the mouth or pharynx.

• Diagnosis and management

° The first priority is to assess the airway with direct 

visualization of the oropharynx and fluid resuscitation. 

Significant edema may require intubation.

° Attempt to identify the agent and degree of exposure.

° Perform esophagogastroduodenoscopy using a flexible 

endoscope, with the patient under general anesthesia, 

within 12 to 24 hours of injury.

▶ This is the most accurate means of identifying the extent 

and severity of the esophageal and gastric injury.

▶ Injured areas appear as a whitish coagulum surrounded 

by an area of hyperemia.

▶ The endoscope should be passed only up to (but not 

through) the level of injury.

▶ Avoid instrumentation after 24 to 36 hours after injury.

▶ Deep, circumferential burns have a high incidence of 

stricture.

° Cine esophagram is an accurate means of assessing the 

extent of esophageal injury including motility, and may 

help predict later stricture formation.

° Chest and abdominal radiographs may identify 

pneumoperitoneum, pneumomediastinum, or pleural 

effusions, which are findings of full-thickness injury to the 

stomach or esophagus.

• Treatment
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Gastrointestinal Tract

° If the patient does not have mucosal injury, discharge and 

follow up in 3 to 4 weeks.

° If the patient has a minimum to moderate burn, administer 

antibiotics (ampicillin and gentamicin) and perform an 

esophagram within 48 hours.

° If motility is undisturbed:

▶ Give clear liquids for 72 hours.

▶ After 72 hours, advance to a regular diet.

▶ Discontinue antibiotics on the 14th day.

▶ Discharge the patient and follow up regularly over the 

next 3 to 4 weeks.

° In severe cases:

▶ Advance a string at the time of esophagogastroduodenoscopy.

▶ Place a gastrostomy tube.

▶ Give antibiotics; steroids have no therapeutic value and 

should not be administered.

▶ If the cine esophagram is normal, give nothing by mouth 

until the patient can swallow saliva, then give only 

clear liquids. Advance the patient to a regular diet. Stop 

antibiotics and repeat the contrast swallow. Discharge 

the patient if the swallow is normal on the 21st day.

▶ If the cine esophagram is abnormal, give nothing by 

mouth until a gastrostomy tube can be used. On the 21st 

day, stop antibiotics and repeat a contrast swallow. If the 

swallow is normal, discharge the patient with monthly 

follow-up for 1 year. If a stricture is present, initiate 

esophageal dilatations.

• Long-term complications include stricture (treat with monthly 

dilatations for 1 y), achalasia, and squamous cell carcinoma 

(latency may be longer than 20 years).

• Severe cases may require esophageal replacement (see section 

under Esophageal Atresia).

Esophageal Perforation

• Esophageal perforation is usually iatrogenic (nasogatric tube, 

endoscope).

• Symptoms

° Drooling, bloody mucus with oral suctioning. 

° Respiratory distress (in newborns and infants).
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Pediatric Surgery and Medicine for Hostile Environments 

° Subcutaneous emphysema.

° Substernal chest pain.

° Septic shock.

° Pleural effusion.

• Diagnosis

° Chest radiograph will show pneumothorax, pneumoperitoneum, pneumomediastinum, and pleural effusion.

° Perform esophagram using water-soluble contrast.

• Treatment

° For traumatic perforation of the cervical esophagus in 

a newborn, insert an NG tube and administer broadspectrum antibiotics.

° For perforation of the intrathoracic esophagus with 

symptoms of mediastinitis (fever, manifestations of sepsis, 

leukocytosis):

▶ Perform a posterolateral thoracotomy at the sixth 

intercostal space (left side for low esophageal 

perforations, right side for midesophageal perforations).

▶ Administer broad-spectrum antibiotics.

▶ Perform primary repair of the esophagus if the 

perforation is more than 24 hours old (interpose 

pericardial, pleural, or strap muscle patch) and consider 

placing a gastrostomy tube.

▶ Place a chest tube for mediastinal drainage.

° For contained perforations of the intrathoracic esophagus 

without symptoms of mediastinitis, observation, TPN, and 

antibiotics alone are often sufficient. 

° For cervical perforations, drainage, antibiotics, and followup studies are required. 

° If the perforation is more than 24 hours old with marked 

contamination, treat as above and consider performing a 

cervical esophagostomy, gastrostomy, and mediastinal/

pleural drainage.

Gastroesophageal Reflux

• Reflux is normal in infants until 10 to 15 months of age when 

children assume a more upright posture, ingest a more solid 

diet, and develop increased lower esophageal sphincter tone.

• Symptoms include
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Gastrointestinal Tract

° Recurrent vomiting, failure to thrive, and dysphagia. 

° Recurrent aspiration pneumonia, coughing, stridor, and 

laryngospasm.

° Asthma-like symptoms.

° Esophagitis (occult blood loss causing iron-deficient 

anemia; may result in eventual stricture).

° Apnea, sudden infant death syndrome, and retrosternal 

burning (older children).

° Sandifer syndrome (voluntary contortions of the head, neck, 

and trunk associated with reflux esophagitis, producing 

iron-deficiency anemia).

• Diagnosis

° Obtain a cine esophagram, contrast swallow, and upper 

gastrointestinal (UGI) series.

° Perform esophagoscopy with biopsies (to diagnose 

esophagitis and Barrett’s esophagus).

• Nonsurgical treatment (80% success rate)

° Thicken feedings.

° Position patient upright during and after feeds.

° Administer oral erythromycin, a prokinetic (2–3 mg/kg/

dose before meals), to assist with gastric emptying.

° Give an antacid or H2-blockers (eg, ranitidine) to decrease 

acidity, or proton pump inhibitors (eg, omeprazole).

° Give frequent, small-volume feeds or continuous tube 

feedings.

• Surgical treatment

° Nissen fundoplication (360-degree wrap).

▶ Indicated for

▷ Esophageal stricture (especially if it occurs following 

a TEF repair with gastroesophageal reflux disease, 

and does not respond to serial dilatations).

▷ Severe esophagitis (especially with secondary 

anemia).

▷ Barrett’s metaplasia (replacement of the normal 

stratified squamous epithelium lining of the esophagus 

by simple columnar epithelium resulting from chronic 

irritation secondary to gastroesophageal reflux).

▷ Recurrent aspiration pneumonia.

▷ Medical management failure.
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▷ Repeated vomiting with failure to thrive.

▷ Severe apneic spells.

° Postoperative complications include

▶ wrap disruption resulting in recurrent symptoms,

▶ excessively tight wrap resulting in dysphagia (this 

usually responds to dilation),

▶ slippage of the wrap onto the stomach, and

▶ hiatal hernia with displacement of the wrap into the 

mediastinum.

Esophageal Strictures

• Etiology includes reflux esophagitis, corrosive ingestion, and 

anastomotic scarring (may be aggravated by gastroesophageal 

reflux).

• Treatment consists of

° serial dilatations,

° antireflux procedure (if strictures are due to reflux 

esophagitis),

° local resection (if stricture is short and circular), and

° esophageal replacement (not a procedure performed in a 

resource-limited environment).

• Types of dilators include

° Tucker (passed over a string);

° Hurst, Maloney (mercury-weighted);

° Jackson; and

° pneumatic balloon.

Stomach and Duodenum

Infantile Hypertrophic Pyloric Stenosis

• Infantile hypertrophic pyloric stenosis (HPS) occurs in 2 to 4 

per 1,000 births.

• Etiology is multifactorial with proven X-linked factor.

• Male-to-female ratio is 4 to 1 (most common in firstborn 

males). HPS occurs much more frequently in Caucasians than 

African Americans.

• HPS usually occurs at 2 to 6 weeks of age.

• Symptoms include

° nonbilious projectile vomiting,
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° ravenous appetite shortly after an episode of emesis, and

° blood-tinged emesis (which may be due to gastric or 

esophageal irritation).

• Physical examination

° Visible peristaltic waves (left to right) are apparent during 

a test feed of glucose water.

° A palpable olive (hypertrophied pyloric musculature) 

above and to the right of the umbilicus is palpable in 80% 

of cases if the child is not crying.

° Signs of dehydration (sunken fontanelle, dry mucous 

membranes and lack of tears during crying, lack of 

wet diapers) are apparent if there is significant loss of 

intravascular volume due to prolonged episodes of emesis.

• Diagnosis

° Diagnosis can be made by physical examination findings, 

as described above. If physical examination is doubtful, 

ultrasound is diagnostic in almost all cases.

° HPS ultrasound criteria for pyloric stenosis 

▶ Diameter of pylorus greater than 14 mm.

▶ Pyloric muscular thickness greater than 3 mm.

▶ Thickened pyloric length greater than 16 mm.

° A contrast UGI series should be performed only if the 

physical examination and ultrasound are not diagnostic. 

A “string sign” shows a thickened, narrow pyloric canal.

• Laboratory tests

° Typically, the patient’s electrolytes demonstrate a 

hypochloremic, hypokalemic metabolic alkalosis.

° Hypokalemia enhances the secretion of hydrogen in urine, 

resulting in a paradoxical aciduria.

° Increased bilirubin (indirect) is due to decreased glucuronyl 

transferase activity and may result in jaundice.

• Treatment

° Correct fluid, electrolyte, and acid-base abnormalities using 

crystalloid boluses of 20 cc/kg of normal saline, then D5 1/2 

normal saline plus potassium chloride (2–4 mEq/kg after 

patient urinates) at 1.5 times the maintenance volumes.

° Resuscitation is adequate when the patient achieves a 

urine output of about 2 cc/kg/h, electrolytes are normal, 

and serum bicarbonate is less than 28 mEq/L (patients with 
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Pediatric Surgery and Medicine for Hostile Environments 

uncorrected metabolic alkalosis are at risk for dysrhythmias 

and apnea from general anesthesia) and chloride greater 

than 95 mEq/L.

° An anesthesiologist should aspirate the patient’s stomach 

before inducing anesthesia to decrease the risk of aspiration 

on intubation.

° Ramstedt pyloromyotomy

▶ Surgical approaches include transverse right upper 

quadrant incision, periumbilical incision, and 

laparoscopic pyloromyotomy. 

▶ A longitudinal incision is then made through the 

hypertrophied muscle to relieve the constriction while 

avoiding mucosal perforation.

• Postoperative feeding can be as needed after 4 hours 

postoperatively, or feedings may be gradually increased.

° Initiate small-volume oral feedings of glucose and water 

at 4 to 6 hours following operation. For example, give

▶ 15 cc oral electrolyte solution every 2 hours × 3, then

▶ 30 cc oral electrolyte solution every 2 hours × 3, then

▶ 30 cc full-strength formula or breast milk every 2 hours 

× 3, then

▶ 60 cc full-strength formula or breast milk every 3 hours 

× 3, then

▶ 90 cc full-strength formula or breast milk every 4 hours.

° If vomiting occurs, wait 2 hours and retry the last volume 

tolerated.

• Treating complications

° Mucosal perforation

▶ Close the perforation in two layers using a polyglactin 

(absorbable, synthetic, braided) suture over an omental 

patch.

▶ Perform a second myotomy at a site 180 degrees from 

the first site.

▶ Give nothing by mouth and maintain an NG tube on 

suction for 24 hours before starting feeds. Consider 

obtaining a UGI study prior to reinitiating feedings.

° Vomiting is usually secondary to gastritis or reflux and 

resolves in 1 to 2 days in almost all cases.

° In the case of wound infection, prescribe antibiotics. Open 

the wound if an abscess is present.
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° Bleeding may indicate the need for reexploration.

° Consider the presence of an incomplete myotomy 

only if vomiting continues for more than 5 to 10 days 

postoperatively, is forceful, or follows every feeding. Upon 

reexploration, redo the myotomy at a site 180 degrees from 

the original site.

° Arrhythmias and apnea are associated with general 

anesthesia in patients with uncorrected metabolic alkalosis 

(ie, serum bicarbonate less than 28 mEq/L); monitor pulse 

oximetry and apnea postoperatively.

Gastric Antral Web

• Pathology: submucosal web in the distal antrum is covered 

by gastric mucosa (no muscular layer present).

• Produces incomplete obstruction with an insidious delay in 

symptoms.

• Symptoms include postprandial, nonbilious vomiting, failure 

to thrive, and epigastric pain.

• Diagnosis (similar to duodenal atresia with a web) 

° A UGI contrast study will demonstrate a small amount 

of contrast passing through a ring of tissue in the distal 

stomach.

° Upper endoscopy may be required if UGI is equivocal.

• Treatment consists of dilatation or endoscopic incision. 

• Surgical correction

° Perform a longitudinal gastrotomy incision over the site.

° Excise a portion of the web.

° Close the gastrotomy transversely.

Gastric Perforation

• Neonatal

° Gastric perforation is more common in males, with 

incidence of 1 in 3,000 live births. Causes include ischemic 

insult from perinatal stress, gastric overinflation, and 

damage by an NG tube.

° Symptoms include poor feeding, abdominal distention, and 

lethargy. 

° Other signs include tachycardia, lethargy, poor perfusion, 

tachypnea, hypotension, and peritonitis.
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Pediatric Surgery and Medicine for Hostile Environments 

° Abdominal radiograph will show massive pneumoperitoneum and elevated diaphragms.

° Gastric perforation usually occurs on the greater curvature.

° Treatment

▶ Give nothing by mouth.

▶ Carefully place an orogastric tube. 

▶ Provide fluid resuscitation.

▶ Administer broad-spectrum antibiotics.

▶ Surgical treatment consists of transverse abdominal 

incision to identify the perforation, two-layer closure, 

and gastrostomy.

• Posttraumatic (eg, secondary to an NG tube or postoperative 

endoscopy)

° Diagnose using UGI study with water-soluble contrast.

° Treatment

▶ Provide IV fluid resuscitation (20 cc/kg bolus Ringer’s 

lactate).

▶ Place an NG tube under fluoroscopic guidance.

▶ Administer antibiotics (ampicillin plus gentamicin).

▶ Perform a two-layer operative closure. 

▶ Perform a gastroduodenostomy (Billroth I operation) if 

the distal stomach is necrotic.

Bezoars

• Types

° Trichobezoar (hair; usually seen in those with behavior 

disorders or in intellectually disabled children).

° Phytobezoar (undigested vegetable fibers).

° Lactobezoar (milk; caused by improper milk preparation, 

as with powdered formulas or concentrated milk requiring 

reconstitution or dilution).

• Symptoms include nonbilious vomiting, dehydration, and 

failure to thrive.

• A palpable epigastric mass may be evident on physical 

examination.

• Diagnosis is made by UGI series or endoscopy.

• Treatment consists of gastrotomy and surgical removal 

if the patient is symptomatic (symptoms of gastric outlet 

obstruction) and endoscopic removal is not possible.
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Duodenal Obstruction

• Etiology

° Duodenal atresia or web.

° Annular pancreas.

° Preduodenal portal vein.

• Anomalies associated with duodenal atresia include 

° Down syndrome (30%);

° GI abnormalities, including annular pancreas, malrotation, 

biliary anomalies, and anterior portal vein; and 

° anomalies involving the cardiac, renal, and central nervous 

systems.

• Symptoms

° Prenatal ultrasound may demonstrate polyhydramnios 

with dilated, fluid-filled stomach.

° Bilious vomiting occurs after starting feeds, although 15% 

of cases have the obstruction proximal to the ampulla of 

Vater and vomiting may be nonbilious.

° Infants have usually passed meconium by 24 hours of age.

• Diagnose using plain abdominal radiographs, which 

characteristically show a “double bubble” sign (representing 

air in the stomach and duodenum), with the absence of gas 

distally in the GI tract.

• Treatment

° Preoperative preparation

▶ Place an NG tube to suction to decompress the stomach 

and duodenum.

▶ Provide IV fluid resuscitation (10–20 mL/kg of crystalloid 

or 5% albumin as a bolus, then maintenance). Urine 

output should be about 2 mL/kg/h.

▶ Administer antibiotics (eg, ampicillin and gentamicin).

▶ Perform echocardiogram to rule out congenital cardiac 

anomalies.

° Operation

▶ Emergency operative correction should be performed 

after fluid resuscitation and evaluation for possible 

cardiac abnormalities.

▶ Malrotation discovered at the time of abdominal 

exploration for an intestinal atresia must be corrected.
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▶ Perform a transverse, right supraumbilical incision, 

extending to the midline.

▶ If a “windsock web” is present,

▷ Pass a Foley catheter (about size 8 Fr) through the 

length of the duodenum into the proximal jejunum 

and slowly withdraw.

▷ Perform duodenotomy along the lateral aspect to 

avoid injury to the ampulla of Vater, which is located 

medially. 

▷ Excise the web. The medial portion may be left in 

place. 

° In the case of duodenal atresia and annular pancreas,

▶ “Kocherize” the duodenum.

▶ Perform a duodenoduodenostomy (one layer, diamondtype anastomosis) if possible, or duodenojejunostomy 

(often required for annular pancreas). Never perform a 

duodenogastrostomy, which carries a risk of marginal 

ulceration.

▶ If the proximal duodenum is significantly dilated, 

consider suture plication (interrupted Lembert sutures) 

or stapled tapering duodenoplasty (using an endostapler) 

on the antimesenteric side.

▷ Place a transanastomatic nasojejunal tube to initiate 

early feedings.

▷ Place an orogastric tube for gastric decompression 

until bowel function returns.

▶ Return to normal bowel function is frequently delayed; 

consider using a central venous catheter for TPN.

Small Intestine

Malrotation With or Without Volvulus

• The ligament of Treitz extends from the left side near the 

second lumbar vertebrae to the sacroiliac joint in the right 

lower quadrant.

• Failure of mesenteric fixation during fetal development permits 

the midgut to rotate the last 90 degrees counterclockwise 

around the narrow mesenteric pedicle, containing its entire 

blood supply (superior mesenteric artery and superior 

mesenteric vein).
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Gastrointestinal Tract

• The risk of volvulus in patients with malrotation does not 

decrease with age and should probably be surgically corrected, 

even in asymptomatic patients.

• Symptoms of midgut volvulus include

° bilious vomiting (always rule out malrotation with volvulus 

and duodenal atresia in a newborn with bilious vomiting);

° possible abdominal distention;

° painful, tender abdomen;

° hematemesis, hematochezia;

° acutely ill appearance;

° sepsis; and

° shock (hypoperfusion state).

• Diagnosing midgut volvulus

° Plain abdominal radiographs will show dilated stomach 

(double bubble) and gasless abdomen, but a normal film 

does not rule out malrotation.

° Ultrasound may be used to determine the relative positions 

of the superior mesenteric artery and superior mesenteric 

vein.

° UGI series shows the lack of a normal C loop of the 

duodenum and the ligament of Treitz lying to the right of 

the spine, entire opacified small bowel on the right side, 

and duodenal obstruction with the proximal duodenum 

appearing as a corkscrew at the obstruction point (if 

volvulus is present).

• Treating midgut volvulus

° Midgut volvulus is a surgical emergency.

° Perform a right transverse upper-abdominal incision.

° Eviscerate and inspect the entire small bowel for areas of 

atresia or perforation.

° Reduce a volvulus by counterclockwise rotation of the 

midgut.

° Divide duodenal-colonic (Ladd’s) bands, which extend 

from the cecum across the first and second portions of the 

duodenum to the retroperitoneum at the right gutter.

° Widen the mesentery (this is the most important step to 

prevent recurrence).

° Separate the duodenum from the cecum and place the 

cecum in the left lower quadrant; position the duodenum 
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Pediatric Surgery and Medicine for Hostile Environments 

and the proximal jejunum in the right lower quadrant and 

the ascending colon in the left upper quadrant.

° Perform an appendectomy (the new, nonanatomical 

location of the cecum and appendix may delay a diagnosis 

of acute appendicitis later in life).

• Treating ischemic or necrotic small bowel

° If a short segment is necrotic but the remainder is normal, 

perform a conservative resection and primary anastomosis.

° If a short segment is necrotic but the remainder is of 

questionable viability, perform conservative resection with 

stoma formation. If the entire bowel from the proximal 

jejunum to the mid-transverse colon is necrotic, close the 

abdomen without resection and initiate palliative care. 

° Consider reexploration of the abdomen in 12 to 24 hours if 

large portions of the intestine or stomas appear ischemic.

Intestinal Atresias

• Intestinal atresias are the most common cause of congenital 

intestinal obstruction in newborns.

• They are caused by lack of recanalization of the bowel (for 

duodenal atresia) or by fetal intestinal infarction secondary 

to prenatal mesenteric infarction (jejunal or ileal atresias).

• Small-intestinal atresia most commonly occurs at the distal 

ileum. Diagnose by obtaining a UGI series with small-bowel 

follow-through.

• Colonic atresia represents only 5% of intestinal atresias, most 

commonly occurring at the level of the transverse colon. 

• Diagnose by contrast enema. May be associated with 

Hirschsprung’s disease.

• Prenatal ultrasound usually reveals polyhydramnios (more 

than 2,000 mL total amniotic fluid volume).

• Postnatal diagnosis 

° Early, bilious vomiting is associated with duodenal and 

proximal jejunal obstruction. Delayed (hours to days) 

vomiting is associated with distal intestinal obstruction.

° Failure to pass meconium in the first 24 to 48 hours of life 

may indicate an atresia, but passage of meconium does 

not exclude atresia.
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° Presence or absence of abdominal distention depends on 

the level of the obstruction.

° Jaundice (increased indirect bilirubin) may be associated 

with an atresia. β-glucuronidase in the intestinal mucosa 

deconjugates direct bilirubin and enhances enterohepatic 

recirculation of bilirubin in the presence of a bowel 

obstruction.

• Radiographs

° Obtain plain films.

° Double-bubble sign is associated with duodenal obstruction 

(atresia, annular pancreas).

° Triple-bubble sign shows air in the stomach, duodenum, 

and bowel proximal to the area of small intestinal atresia.

° Use limited UGI series to rule out malrotation or volvulus.

° Paucity of gas may be present in the postatretic bowel.

° Contrast enema may show the presence of a microcolon 

and dilated, air-filled proximal bowel, and may assist in 

the diagnosis of other causes of intestinal obstruction (eg, 

Hirschsprung’s disease, meconium ileus).

• Treatment

° Preoperative

▶ Place an NG tube for decompression of the UGI tract.

▶ Administer IV fluids.

▶ Administer broad-spectrum antibiotics.

▶ Rule out associated anomalies and cystic fibrosis.

° Perform operative treatment for duodenal atresia (see 

Duodenal Obstruction), small bowel atresia, or colonic 

atresia.

° Operative treatment of small bowel atresia 

▶ Inspect the entire small bowel for areas of atresia or 

stenosis.

▶ Flush saline into the distal bowel to rule out additional 

areas of atresia or stenosis proximally and distally.

▶ Resect the dilated proximal bulbous tip to avoid 

postoperative functional obstruction.

▶ Perform primary end-to-end oblique anastomosis 

(a stapled, antimesenteric tapering duodenoplasty 

[duodenal atresia] or enteroplasty [small bowel] of the 

dilated proximal bowel is recommended to minimize 

the length of bowel resected).
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Pediatric Surgery and Medicine for Hostile Environments 

▶ Preserve the distal ileum and ileocecal valve, if possible, 

to prevent vitamin B12 and fat malabsorption. If primary 

anastomosis is not possible (eg, in premature infants or 

in the case of peritonitis), perform an ileostomy with 

exteriorization of one or both limbs.

° In the case of colonic atresia, perform a primary anastomosis 

if possible, but consider Hirschsprung’s disease (which may 

require temporary diversion).

° Postoperative

▶ Place an NG tube to low continuous suction.

▶ Parenteral nutrition may be required due of the high 

incidence of prolonged postoperative ileus (sometimes 

persisting for several weeks).

▶ Use elemental formulas (Nutramigen or Pregestimil 

[Mead Johnson Nutrition, Glenview, Ill]) and iron 

supplementation.

• Immediate and long-term complications include the following.

° Sepsis resulting from an anastomotic leak.

° Functional obstruction from megaduodenum (may be 

treated with reoperation with resection, plication, or 

tapering enteroplasty).

° Duodenogastric reflux and esophagitis (treated medically).

° Mechanical obstruction resulting from stenosis, adhesions, 

or internal hernia.

° Short gut syndrome due to extensive intestinal resection. 

• Mortality is usually associated with the presence of complex 

congenital heart disease (especially Down syndrome with 

endocardial cushion defect).

Meckel’s Diverticulum

• Meckel’s diverticulum occurs on the antimesenteric border of 

the distal ileum. It is often referred to as a “disease of twos,” 

because it 

° is 2 inches long,

° occurs 2 feet from the ileocecal valve,

° is usually symptomatic by 2 years of age,

° affects 2% of the population,

° involves two potential types of heterotopic mucosa (gastric 

is more common than pancreatic),
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Gastrointestinal Tract

° occurs as a 2-to-1 ratio in males to females, and

° involves two blood supplies (mesenteric and vitelline 

arteries).

• Symptoms

° The most common presentation (40%–50%) in pediatric 

patients (< 5 years old) is sudden, painless, lower GI 

bleeding, which may be life threatening.

° Symptoms are secondary to peptic ulceration in the adjacent 

ileal mucosa.

° Occult bleeding (black, tarry stools resulting in anemia).

° Meckel’s diverticulum is the most common cause of massive 

rectal bleeding in pediatric patients (esophageal varices 

secondary to a history of omphalitis is the most common 

cause of massive hematemesis in this age group, and can 

be managed conservatively in almost all cases).

° Meckel’s diverticulitis pain is indistinguishable from that 

caused by acute appendicitis. It may cause an intestinal 

obstruction by acting as a lead point for intussusception 

or ileal volvulus around a fixation point to the umbilicus.

• Littré hernia is a Meckel’s diverticulum trapped in an 

incarcerated umbilical or inguinal hernia.

• In a resource-limited environment, diagnose using ultrasound, 

especially if the presentation is intussusception (“donut or 

target sign”), or use computed tomography (CT) scan with 

oral contrast. Meckel’s scan (technectium-99m pertechnetate 

isotope scan) will not be available in a deployed setting.

• Complications 

° Hemorrhage is the most common complication in children.

° Obstruction is the most common complication in adults. 

Fibrous bands forming an attachment from the diverticulum 

to the abdominal wall may act as a lead point for ileocolic 

intussusception. 

° Perforation.

° Localized ileal volvulus.

• Treat symptomatic cases by surgical excision (treatment 

of asymptomatic cases is controversial, but most pediatric 

surgeons feel that incidental diverticulectomy is not indicated).

° If a narrow base is present, perform a wedge resection with 

transverse closure or stapled closure at the base.
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Pediatric Surgery and Medicine for Hostile Environments 

° If a wide base is present or there is significant inflammation 

in the adjacent intestine, perform a segmental resection with 

end-to-end ileoileostomy.

° If manual intussusception reduction is not possible, 

perform a segmental resection.

Necrotizing Enterocolitis

• Necrotizing enterocolitis is the most common surgical 

emergency in neonates (infants less than 30 days old). 

Premature infants account for 90% of cases, but 10% occur in 

full-term newborns.

• Necrotizing enterocolitis usually occurs after the tenth day 

of life when coliform bacteria colonize the GI tract, but may 

occur at any time during the neonatal period.

• The most commonly affected sites are the terminal ileum and 

right colon (a “watershed” area).

• The most common pathology is ischemic necrosis of the 

superficial mucosa.

• Microthrombi occur secondary to platelet aggregation 

throughout the mesentery.

• Necrotizing enterocolitis is characterized by “skip areas” of 

involvement.

• Pneumatosis intestinalis is a pathognomic finding on 

abdominal imaging and is a manifestation of gas produced 

by bacteria within the intestinal wall.

• Radiographic findings

° Plain abdominal films demonstrate intramural bowel gas.

° Hydrogen gas (from Escherichia coli) will be evident by the 

presence of pneumatosis intestinalis.

° Air in the portal venous system (associated with septic 

pylephlebitis) is a poor prognostic sign (however, these 

findings alone are not indications for operative intervention 

and are reversible with medical management).

° Pneumoperitoneum may be present (secondary to GI 

perforation).

° Static intestinal loops (persistent loops of adynamic or 

edematous bowel) are often seen on serial abdominal 

radiographs.

° The earliest, most common radiographic finding is 

distention of multiple bowel loops.
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Gastrointestinal Tract

° Bowel gas is diminished.

° Ascites is a grave sign.

° Abdominal wall ecchymosis is frequently indicative of 

underlying necrotic bowel and peritonitis.

• Physical examination

° The patient’s initial symptom will often be feeding 

intolerance (high feeding residuals), but some infants may 

have never been fed.

° Abdominal distention is the most common sign.

° Lethargy, bilious vomiting, rectal bleeding (usually 

as guaiac-positive stools), coagulopathy (especially 

thrombocytopenia), tachycardia or bradycardia, apnea, 

edema and erythema of the abdominal wall, and thermal 

lability are also common signs and symptoms.

• Laboratory studies

° Thrombocytopenia (secondary to microvascular plugging 

and binding to gram-negative endotoxin) is the most 

relevant laboratory finding and may indicate disease 

progression with serial labs. It also may suggest fungal 

infection.

° Leukopenia may be evident.

° Laboratory studies may also show metabolic or lactic 

acidosis (pH less than 7.2, with an anion gap), especially 

with decreased serum sodium.

• Medical treatment

° Give nothing by mouth. 

° Provide NG or orogastric tube decompression of the UGI 

tract.

° Give IV (not enteral) antibiotics (ampicillin, gentamicin, 

and vancomycin or cefotaxime) for at least 10 days to cover 

E coli, Klebsiella, Enterobacter, Pseudomonas, and Clostridium 

difficile. 

° Maintain long-term central venous access and parenteral 

nutrition.

° Take serial abdominal radiographs every 6 to 8 hours to 

screen for pneumoperitoneum.

• Surgical treatment

° Pneumoperitoneum is an absolute indication for surgical 

intervention.
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Pediatric Surgery and Medicine for Hostile Environments 

° Relative indications for peritoneal drainage or laparotomy 

include

▶ deterioration on aggressive medical management 

(increasing acidosis, decreasing platelets);

▶ positive peritoneal aspirate (brown color, positive Gram 

stain), which suggests the presence of gangrenous or 

perforated bowel;

▶ palpable abdominal mass;

▶ progressive peritonitis (edema or erythema of the 

abdominal wall);

▶ intestinal obstruction;

▶ fixed, dilated loops of intestine (unchanged after 24 h) 

on serial abdominal radiographs; and

▶ portal vein gas (pylephlebitis).

° Operative technique

▶ Make a right, transverse, supraumbilical incision.

▶ Perform conservative resection of only frankly 

gangrenous bowel to prevent short-bowel syndrome.

▶ Preserve the ileocecal valve, if possible.

▶ Perform a second-look laparotomy at 24 to 48 hours to 

assess marginally viable bowel. 

▶ Administer broad-spectrum antibiotics and TPN 

postoperatively.

▶ In very small, ill, premature infants, consider a peritoneal 

drainage procedure using a 1/4-inch Penrose drain placed 

percutaneously under local anesthesia. This may be 

an effective temporizing (or definitive) therapeutic 

measure in an unstable, high-risk, premature infant with 

peritonitis, respiratory failure, or shock. 

▶ If resection of multiple necrotic segments is necessary, 

perform a proximal stoma and multiple primary 

anastomoses of the distal, defunctionalized bowel.

• Postoperative complications

° The most common complication after surgery is stricture 

due to cicatricial healing of the injured mucosa, which may 

also be seen several weeks following successful medical 

management.

▶ Stricture often presents weeks to months later as a bowel 

obstruction.
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Gastrointestinal Tract

▶ Diagnose by contrast enema.

▶ Treat by performing a segmental resection and primary 

anastomosis.

° Short-bowel syndrome, resulting from extensive bowel 

resection, is another potential complication.

▶ Prevent short-bowel syndrome by performing 

conservative resection and second-look operations 

when the viability of the bowel at the initial operation 

is in question.

▶ Treatment consists of TPN, elemental enteral formulas 

as tolerated, and prevention of central venous line 

infections.

° Malabsorption (usually reversible) may result from 

extensive mucosal injury.

° Survivors of severe necrotizing enterocolitis remain at high 

risk for growth and developmental delay. 

Intussusception

• Intussusception occurs in 2 to 4 per 1,000 live births, 

predominantly in males.

• Idiopathic intussusception, seen in otherwise healthy children 

6 to 24 months old, is usually due to hypertrophy of Peyer’s 

patches in the terminal ileum from an antecedent viral 

infection (eg, rotavirus, reovirus, or echovirus); seasonal 

incidence (midwinter and early summer) corresponds with 

upper respiratory infections and GI viral disease.

• Pathological lead points are present in only 5% of children 

with intussusception, but with increased frequency in children 

older than 4 years of age. They may be caused by

° Meckel’s diverticulum (most common),

° polyps (juvenile, hamartoma),

° malignant tumors (eg, lymphoma, lymphosarcoma),

° Peutz-Jeghers syndrome,

° intestinal duplications,

° hemangioma,

° appendix,

° cystic fibrosis (due to inspissated feces in the terminal 

ileum), or 
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Pediatric Surgery and Medicine for Hostile Environments 

° Henoch-Schönlein purpura (hamartomas in the intestinal 

wall act as lead points for ileal-ileal intussusception).

• The most common site for intussusception in the pediatric 

age group is ileocolic; however, when associated with 

postoperative abdominal and thoracic operations, the most 

common site is ileal-ileal. 

• Pathophysiology

° Proximal portion of bowel (intussusceptum) is drawn into 

the distal loop (intussuscipiens) by peristaltic activity.

° Mesentery of the proximal bowel is compressed and 

strangulated, leading to venous obstruction resulting 

in edema of the bowel wall. This leads to obstruction of 

arterial inflow, gangrene, and, potentially, to perforation 

and peritonitis.

• Symptoms

° Intussusception is characteristically seen in an otherwise 

healthy child.

° Patient will have paroxysms of abdominal cramping 

(usually lasting 10–15 minutes) and intermittent vomiting 

(70% of cases), screaming, and drawing of legs up to the 

abdomen.

° Patient will have dark red (bloody) mucoid (“red currant 

jelly”) stools.

° An elongated (sausage-shaped) mass in the right upper 

quadrant may be present. 

° Symptoms include tachycardia, fever, and hypotension (if 

perforated), as well as absence of bowel in the right lower 

quadrant (Dance sign).

• Radiographic tests

° Take flat and upright abdominal films. A cecal gas shadow 

may be absent in the right iliac fossa, and small bowel 

obstruction may be evident (air–fluid levels may be present 

on upright abdominal radiograph).

° Ultrasound may show a “target sign,” most often in the 

right lower abdomen.

° Air enema or contrast enema will demonstrate a coiledspring appearance of the lead point, which is diagnostic 

and may result in therapeutic reduction.

• Treatment
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Gastrointestinal Tract

° Initial stabilization

▶ Administer IV fluids to restore intravascular volume.

▶ Give nothing by mouth.

▶ Administer antibiotics if the patient will be going to the 

operating room.

▶ Place an NG tube to suction.

° Laboratory tests include complete blood count, electrolytes, 

blood urea nitrogen, glucose, and creatinine.

° Attempt hydrostatic reduction using water-soluble 

diatrizoate sodium or air enema (contraindicated in the 

presence of peritonitis or pneumoperitoneum).

° Suspend the enema bag no higher than 1 m above the anus. 

Hold for 3 minutes and limit to 3 attempts.

° Insufflation of air (maximum pressure of 80–120 mmHg) via 

a rectal tube is an alternate method to attempt reduction.

° To be considered a successful reduction, contrast must pass 

into the terminal ileum. 

° If reduction is unsuccessful, operative exploration and 

reduction are indicated.

° Nonoperative treatment is effective more than 80% of the 

time.

• Recurrence rate is 5% to 7%.

° Diagnose using air or contrast enema.

° After the second recurrence, operative intervention is 

indicated because of the high likelihood of a pathologic 

lead point.

° If contrast or air reduction is unsuccessful, or if physical 

examination reveals a tender or rigid abdomen:

▶ Perform laparotomy using a transverse, right lower 

incision.

▶ Attempt manual reduction by gently milking the 

intussusceptum out of the intussuscipiens (never pull 

it out).

▶ Perform an appendectomy and resection of frankly 

gangrenous bowel or lead point (eg, Meckel’s 

diverticulitis) if present, and an ileocecostomy with 

primary ileocolic anastomosis.

° Postoperative intussusception is evident by a small bowel 

obstruction in the early postoperative period (around 

postoperative day 5). It most commonly occurs as an 
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Pediatric Surgery and Medicine for Hostile Environments 

ileoileal intussusception and no attempt should be made 

at radiographic reduction. Treat with manual, operative 

reduction.

Meconium Disease

• Meconium ileus 

° Meconium ileus is a generalized mucoviscidosis of exocrine 

secretions, resulting in inspissated meconium causing 

intraluminal intestinal obstruction in a newborn.

° It affects all exocrine glands and is usually associated with 

cystic fibrosis.

° Bronchi and alveoli are obstructed by thick mucoid 

secretions.

° Pancreatic ducts are obstructed, leading to recurrent 

pancreatitis.

° Intestinal involvement is characterized by obstruction 

resulting from thick, viscous mucus as water migrates out 

of the intestinal lumen.

° Other organs affected include sweat and salivary glands, 

nasal mucus membranes, and reproductive organs (males 

are sterile).

° Differential diagnosis includes Hirschsprung’s disease 

(especially total aganglionosis), hypothyroidism, small left 

colon syndrome, colonic or ileal atresia, and meconium 

plug syndrome.

° Radiographic findings (on abdominal radiograph) include 

▶ Multiple distended loops of intestine mimicking small 

bowel obstruction, but air–fluid levels are rarely present 

because of the viscosity of the intraluminal meconium 

and because the bowel is completely filled with fluid or 

meconium.

▶ Course, granular, soap-bubble (“ground glass”) 

appearance due to the presence of air within thick 

meconium (Neuhauser sign). 

▶ Prenatal perforation with meconium peritonitis 

and complicated meconium ileus (due to liberated 

lipases and bile salts) resulting in calcium deposition 

(saponification). Uncomplicated meconium ileus will 

show no clinical or radiographic evidence of perforation 

or peritonitis.
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Gastrointestinal Tract

▶ Prominent air–fluid levels suggesting intestinal atresia 

or volvulus, which is usually associated with a gasless 

abdomen. 

▶ Ascites and pneumoperitoneum indicative of postnatal 

colonic perforation.

° Nonoperative treatment

▶ Ensure the patient is well hydrated.

▶ Insert an NG tube.

▶ Administer broad-spectrum antibiotics (ampicillin and 

gentamicin).

▶ Perform fluoroscopically visualized enema with 

a hyperosmolar agent (meglumine diatrizoate or 

N-acetylcysteine).

° Operative treatment

▶ Operative treatment is indicated for complicated 

patients (ie, those with perforation or peritoneal signs, 

volvulus, gangrene, or atresia) or after a failed attempt 

at nonoperative treatment.

▶ Technique

▷ Perform enterotomy at ileum or appendectomy (with 

irrigation and drainage) through the appendiceal 

stump (to avoid an anastomosis or ileostomy). Send 

appendix to pathologist to check for presence of 

ganglion cells to rule out Hirschsprung’s disease.

▷ Run the entire length of the bowel to rule out areas of 

necrosis or atresia. If any are discovered, they should 

be resected.

▷ Pass a red rubber catheter proximally and distally 

▷ Irrigate with saline or N-acetylcysteine (mucolytic). 

▷ Perform a primary anastomosis, ileostomy and mucus 

fistula or Bishop-Koop end-to-side (proximal dilated 

bowel to side) anastomosis, Santulli anastomosis 

(proximal ileostomy with end-to-side anastomosis), 

or tube ileostomy.

▷ Administer antibiotics for 3 days. 

▷ Continue NG suction and later consider 10% 

N-acetylcysteine by gastric tube, if needed.

▷ Patient may require rectal irrigations.

▷ Initiate oral feedings and pancreatic enzymes 5 to 10 

days after operation.
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Pediatric Surgery and Medicine for Hostile Environments 

• Meconium plug syndrome

° Meconium plug syndrome develops when a newborn fails 

to excrete fetal meconium from the colon. 

° Symptoms include abdominal distention and colonic 

obstruction resulting from a plug of inspissated meconium, 

which is usually whitish gray distally, green proximally.

° Physical findings include obstructing meconium and 

colonic hypomotility.

° Differential diagnosis includes Hirschsprung’s disease, 

hypokalemia, hypocalcemia, and increased glycogen.

° Meconium plug syndrome is associated with hypoglycemia 

in infants of diabetic mothers. It is not usually associated 

with cystic fibrosis.

° Abdominal radiograph will reveal multiple loops of dilated 

bowel; however, it is difficult to distinguish between large 

and small bowel in a neonate.

° Treat with diatrizoate sodium enema. Operation is rarely 

necessary (rule out Hirschsprung’s disease by rectal 

biopsy).

Large Intestine

Acute Appendicitis

• Acute appendicitis is the most common acute surgical 

condition of the abdomen; it parallels the amount of lymphoid 

tissue in the appendix (peak incidence is during the midteenage years).

• Fecaliths, which obstruct the lumen, are the most common 

cause of luminal obstruction and the most common factor 

in the etiology of acute appendicitis. Other causes include 

lymphoid hyperplasia, seeds, and worms (eg, pinworms, 

Ascaris).

• Pathophysiology

° Acute appendicitis begins with an obstruction of the lumen. 

Normal mucosal secretion continues, followed by bacterial 

overgrowth, then appendiceal distention. 

° Nerve endings of visceral afferent sympathetic pain fibers 

are stimulated through the celiac ganglion to the tenth 

thoracic segment causing vague, dull, diffuse pain in the 
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Gastrointestinal Tract

midabdomen or lower epigastrium; this pain is referred to 

the umbilical area (tenth dermatome).

° Parietal peritoneum becomes irritated by the inflamed 

appendix, causing pain to be localized to the right lower 

quadrant.

° Stimulation of peristalsis leads to cramping pain.

° Appendiceal distention increases secondary to bacterial 

proliferation, which produces reflex nausea and vomiting.

° Venous pressure is exceeded while arterial inflow continues, 

resulting in engorgement and vascular congestion.

° Bacteria from the lumen translocate into the bloodstream.

° Reflex nausea and vomiting result, as does severe visceral 

pain, from the increased distention.

° The appendiceal wall becomes infarcted, resulting in 

gangrene, perforation, and peritonitis.

• Symptoms

° Localized pain in the right lower quadrant is the most 

important diagnostic finding on physical examination.

° Pain is initially centered in the lower epigastrium or 

periumbilical area (serosa of the appendix becomes 

inflamed and pain localizes to the right lower quadrant 

after 4–6 h as a result of parietal peritoneal inflammation).

• Anatomical locations

° A long or retrocecal appendix with an inflamed appendiceal 

tip results in pelvic pain.

° If the inflamed appendix lies near the ureter or bladder, 

appendicitis may occur at a retrocecal location (two-thirds 

of all cases of appendicitis occur here) and present as flank 

or back pain (most commonly), nausea, vomiting, and 

increased white blood cell count; microscopic hematuria 

or pyuria may occur.

° Appendicitis at a pelvic location presents as suprapubic 

pain from an inflamed tip lying against the bladder, which 

may cause urinary frequency and dysuria.

▶ If there is tenderness on a rectal examination, the 

inflamed tip is most likely lying adjacent to the rectum.

▶ An abscess may present with severe urinary symptoms 

and diarrhea.
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Pediatric Surgery and Medicine for Hostile Environments 

° Appendicitis at a retroileal location results in testicular pain 

from irritation of the spermatic artery and ureter; anorexia 

almost always accompanies appendicitis (if a child is truly 

hungry, appendicitis is unlikely).

° Vomiting is frequent.

° Symptoms usually progress from anorexia, to abdominal 

pain, to nausea with vomiting; if vomiting precedes 

the onset of abdominal pain, the diagnosis should be 

questioned (in favor of gastroenteritis).

° High-grade fever (greater than 100°F, 38°C) is rare except 

in cases of perforation with peritonitis.

° The most important physical finding is point tenderness 

over McBurney’s point (at the junction of the lateral onethird and medial two-thirds of a line from the anterior 

superior iliac spine to the umbilicus), usually accompanied 

by guarding and muscle spasm.

° Individual may also show

▶ Psoas sign (pain on extension of the right thigh, which, 

when the patient is in the lateral decubitus position, 

stretches the irritated iliopsoas muscle). 

▶ Obturator sign (passive internal and external rotation 

of the flexed right thigh stretches the obturator internus 

muscle, producing pain). 

▶ Rovsing’s sign (pain in the right lower quadrant upon 

palpation of the left lower quadrant). 

° Cutaneous hyperesthesia will be seen in segments T10, T11, 

and T12.

° Preoperative diagnosis based on medical history and 

physical examination should be correct in 85% to 90% of 

cases.

° Symptoms are secondary to bacterial toxins and absorption 

of dead tissue toxins and include fever, tachycardia, 

hypotension, and leukocytosis.

• Laboratory findings

° White blood cell count will be about 10,000 to 18,000, with 

left shift. Counts greater than 18,000 are indicative of a 

perforation. 

° Infants and young children may be unable to mount an 

increased white blood cell count, delaying diagnosis and 

leading to an increased incidence of rupture.
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Gastrointestinal Tract

° Obtain a urinalysis to rule out a urinary tract infection and 

pregnancy.

° Ultrasound will show the appendiceal diameter to be 

greater than 7 to 8 mm, edema, periappendiceal fluid, and 

fat stranding. Rule out gynecological problems such as 

ovarian cysts and tubal pregnancy. 

▶ A gas-filled appendix usually indicates appendicitis with 

proximal obstruction.

▶ A distended loop of small bowel may be present in the 

right lower quadrant (“sentinel loop”).

▶ Multiple loops of distended small intestine may 

significantly hamper visualization of the appendix on 

ultrasound.

° Take a chest radiograph to rule out right lower lobe 

pneumonia.

° A CT scan (with oral and IV contrast) will often reveal 

inflammation, fat stranding, and fluid; however, CT 

scan should be reserved for patients with a questionable 

diagnosis of appendicitis to minimize radiation exposure. 

Patients with a clear clinical history and examination for 

appendicitis do not require a CT scan.

• Complications of appendicitis occur in approximately 5% of 

cases but increase with perforated appendicitis. They include 

° Superficial wound or port-site infection. Treat by reopening 

the skin and subcutaneous tissue, and begin saline wetto-dry dressing. Administer broad-spectrum antibiotics 

and consider methicillin-resistant Staphylococcus aureus

coverage, if needed.

° Pelvic abscess, the most common complication of ruptured 

appendicitis. Treat with antibiotics and image-directed 

catheter drainage, depending on size and location.

° Ileus. Place an NG tube and administer IV fluids.

° Small bowel obstruction. Initially, place an NG tube. If the 

obstruction fails to resolve, operate again, lysing adhesions. 

° Appendiceal stump blowout. Drain or perform a tube 

cecostomy. 

• Prognosis

° The principal factor determining mortality is rupture.

▶ Unruptured: 0.1% mortality.
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Pediatric Surgery and Medicine for Hostile Environments 

▶ Ruptured: 3% mortality.

▶ Cause of death is usually uncontrolled gram-negative 

sepsis.

▶ Appendiceal rupture

▷ Deaths from appendicitis are almost always 

secondary to complications of perforation, resulting 

in gram-negative sepsis (E coli and Bacteroides are the 

most common organisms). Incidence of appendiceal 

rupture is significantly higher in pediatric and 

geriatric age groups due to delayed diagnosis.

▷ Young children may not be able to form a phlegmon to 

wall-off a perforation or abscess because of a paucity 

of omentum.

• Symptoms

° Temporary pain relief after perforation is rare; localized 

pain progresses to encompass the entire right lower 

quadrant.

° A tender, boggy mass in the peritoneal area indicates the 

presence of a phlegmon or abscess.

° Symptoms usually last greater than 36 hours and include 

temperature elevation between 102°F and 104°F (39°C to 

40°C), increased white blood cell count (20,000 to 35,000 

with extreme left shift), and hemoconcentration.

° Pylethrombophlebitis (septic thrombophlebitis of the portal 

vein) is a complication of gangrenous appendicitis heralded 

by chills, spiking fever, right lower quadrant pain, and 

jaundice. Septic clots may embolize to the liver, producing 

multiple pyogenic abscesses.

° The most common sites of seeding from an appendiceal 

perforation are the pouch of Douglas (pelvic cul-de-sac) 

and the right subhepatic space (via the right gutter).

• Preoperative diagnosis should be made correctly in 

approximately 85% to 90% of cases and depends on three 

major factors:

° anatomical location of the inflamed appendix,

° stage of the process (simple or ruptured), and

° age and sex of the patient (harder to diagnose in young 

females).

• Appendicitis during pregnancy
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Gastrointestinal Tract

° This is the most common extrauterine surgical emergency 

(though incidence of appendicitis is not increased by 

pregnancy).

° White blood cell count normally increases in pregnancy, 

but a left shift is abnormal.

° The appendix moves superiorly and laterally as pregnancy 

progresses.

° Laparoscopy may be helpful if diagnosis is uncertain.

° The fetal mortality rate from maternal appendicitis is 8.5%; 

the rate of fetal mortality from maternal perforation and 

peritonitis increases to 35%.

° Treat by NG tube decompression and providing IV fluids 

and preoperative antibiotics appropriate to cover Bacteroides 

fragilis (gram-negative rod; eg, cefotetan or clindamycin).

° Nonoperative management may be appropriate to treat a 

periappendiceal abscess.

° Drain the abscess percutaneously or operatively.

° If symptoms regress, manage conservatively.

° If needed, perform an interval appendectomy at 6 to 8 

weeks.

° If appendicitis is not found,

▶ rule out adnexal disease (if tuboovarian abscess is found, 

incise and drain only, do not resect tube or ovary),

▶ examine the mesentery for adenopathy (mesenteric

lymphadenitis), and

▶ examine the small bowel for a distance of about 3 ft 

to rule out Crohn’s disease, ulcerative colitis, terminal 

ileitis, and Meckel’s diverticulitis.

• Gynecological disorders are important in the differential 

diagnosis of appendicitis.

° Gynecological disorders compose the highest rate of missed

diagnoses in young adult females.

° Differential diagnosis includes pelvic inflammatory disease 

(the most common erroneous diagnosis), ruptured Graafian 

follicle (mittelschmerz), and ruptured ectopic pregnancy.

• Diseases in males that may cause lower abdominal pain 

include torsion of the testis and acute epididymitis (see 

Chapter 24, Genitourinary Tract).
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Pediatric Surgery and Medicine for Hostile Environments 

• Urinary tract infections may cause lower abdominal pain 

and are part of the differential diagnosis of appendicitis (see 

Chapter 24, Genitourinary Tract).

° Symptoms of urinary tract infection include urinary 

frequency and dysuria.

° Suprapubic or costovertebral angle tenderness is evident 

on physical examination.

° The patient’s temperature will be greater than 101°F (about 

38°C).

° Urinalysis shows pyuria, hematuria, elevated leukocyte 

esterase, and nitrites.

• Ureteral stones (urolithiasis) may also cause flank and lower 

abdominal pain (see Chapter 24, Genitourinary Tract).

° Ureteral stones manifest as severe colicky abdominal or 

flank pain that radiates to the pelvis.

° Laboratory findings show hematuria but neither fever nor 

increased white blood cell count.

° Renal ultrasound and complete urologic evaluation are 

required for pediatric patients.

° Treatment consists of pain control, IV hydration, metabolic 

studies, and stone analysis, where feasible.

Acute Gastroenteritis

• Etiologies

° The viral form of acute gastroenteritis is manifest by profuse 

watery diarrhea, nausea, and vomiting. Hyperperistaltic 

abdominal cramps precede watery stools, and vomiting 

precedes the onset of abdominal pain. Complete blood 

count is usually normal or may show a right shift (increased 

lymphocytes).

° Bacterial gastroenteritis caused by Salmonella and Shigella

often results from the ingestion of contaminated food. 

Symptoms include bloody diarrhea, skin rash, bradycardia, 

leukopenia, chills, and fever.

▶ Typhoid fever is usually due to Salmonella typhosa, which 

is cultured from stool or blood. Symptoms include 

maculopapular rash, bradycardia, leukopenia, and ileal 

perforation (in 1% of cases).
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Gastrointestinal Tract

▶ Treat with chloramphenicol.

° Bacterial caused by Yersinia enterocolitica or Campylobacter 

results from ingesting food contaminated by feces or urine.

▶ Symptoms include cervical and mesenteric lymphadenitis, 

ileus, and colitis.

▶ Treat with ampicillin or gentamicin.

Primary Peritonitis

• Primary peritonitis is rare in children. When it does occur, it 

usually affects children between the ages of 2 and 6 years old. 

It is more common in females than in males.

• Symptoms include abdominal pain and fever, with or without 

nausea or vomiting.

• Physical findings include fever, tachycardia, and diffuse 

peritonitis.

• Diagnose with peritoneal aspiration. If only a single species 

of streptococci is seen, the patient has primary peritonitis and 

needs medical treatment. If mixed flora is seen, the patient has 

secondary peritonitis and the etiology must be investigated.

• If operation is performed, thoroughly evaluate the patient 

for appendicitis or bowel perforation. Most operations are 

negative. Cultures of ascetic fluid should be performed with 

abdominal irrigation using normal saline.

Henoch-Schönlein Purpura

• Henoch-Schönlein purpura usually occurs 2 to 3 weeks 

following an upper respiratory infection.

• Most children with Henoch-Schönlein purpura are 2 to 6 years 

old. 

• Symptoms include crampy abdominal pain, palpable purpuric 

rash, rectal bleeding, and small bowel intussusception.

• Laboratory findings include thrombocytopenia, elevated 

blood urea nitrogen, and proteinuria.

• Treat with bed rest, fluids, and systemic corticosteroids. 

Surgery is only indicated for severe intussusception that 

cannot be reduced nonoperatively.
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Pediatric Surgery and Medicine for Hostile Environments 

Hemolytic Uremic Syndrome

• Hemolytic uremic syndrome is caused by a specific strain 

of E coli (O157/H7) found in contaminated meat or fecalcontaminated pools and lakes.

• Symptoms include bloody diarrhea, abdominal pain, 

vomiting, low-grade fever, hematuria, acute renal failure, and, 

rarely, seizures.

• Laboratory findings include anemia (secondary to hemolysis), 

leukocytosis, thrombocytopenia, hematuria, and uremia.

Constipation

• Symptoms of constipation include cramping abdominal pain 

with decreased bowel movements, excessive straining during 

defecation, nausea, vomiting, and incomplete evacuation of 

stools. 

• In young children, a hard, stool-filled colon is evident on 

palpation. 

• Laboratory tests usually show normal values.

• Abdominal radiographs typically show a large stool burden.

• Treat with hydration, dietary modifications, stool softeners, 

laxatives, or enemas.

Pneumonia

• Physical findings of pneumonia include rales in the right lower 

lobe and an absence of point abdominal tenderness. 

• Diagnosis is made by chest radiograph, which demonstrates 

focal infiltrates in the right lower lobe.

Typhlitis

• Typhlitis is a bacterial invasion of the intestinal wall (usually 

cecum).

• It is usually seen in immunocompromised patients (eg, 

those with cancer, HIV, on immunosuppressive therapy, or 

transplant patients).

• Patients at highest risk are those with absolute neutrophil 

counts less than 1,000 cells per microliter.

• Symptoms include right lower quadrant abdominal pain and 

neutropenia (mimics appendicitis).
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Gastrointestinal Tract

• CT scan reveals inflammation of the right colon and terminal 

ileum.

• Treatment is typically nonoperative because of high mortality. 

Broad-spectrum antibiotics and serial examinations are 

recommended and operative intervention is only indicated 

for perforation. 

Hirschsprung’s Disease (Congenital Megacolon)

• Normally, neural crest cells form neuroblasts, which migrate 

in a craniocaudal direction to the distal rectum in the twelfth 

week of gestation, becoming enteric ganglion cells (Auerbach 

[myenteric] plexus, and Meissner’s [submucosal] plexus). 

• Pathology

° Absence of submucosal ganglion cells (Meissner’s plexus) 

and intramuscular plexus (Auerbach plexus).

° Enlarged, hypertrophic, nonmyelinated nerve fibers result 

in enlarged nerve trunks in the submucosa, muscularis 

mucosa, and Auerbach intramuscular plexus.

° Increased acetylcholinesterase in postsynaptic muscularis.

° Calretinin staining for neural tissue can assist in the 

diagnosis, as well. 

° The most common site of aganglionosis is the rectosigmoid 

due to arrested migration of neuroblasts (80%).

• Symptoms include

° Failure to pass meconium within 48 hours after birth. 

Premature infants have a higher failure rate in passing 

meconium, but Hirschsprung’s disease is more common 

in term infants.

° GI tract obstruction (distention, bilious vomiting).

° Enterocolitis (the major cause of morbidity and mortality).

° Fecal soiling. Although this is rare, there is increased 

incidence in patients with trisomy 13.

• Differential diagnosis includes 

° (In neonates) sepsis, necrotizing enterocolitis-associated 

stricture, meconium plug or ileus, and intestinal atresias.

° Habit constipation associated with a full rectal ampulla and 

fecal soiling. In Hirschsprung’s disease, the rectal ampulla 

is usually empty.
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Pediatric Surgery and Medicine for Hostile Environments 

° Functional constipation (infrequent, large, firm stools 

accompanied by pain and bleeding from anal fissures). 

A history of normal stool frequency during infancy 

is associated with functional constipation, not with 

Hirschsprung’s disease. 

° Hypothyroidism.

• Diagnosis (NOTE: Due to the special stains and expertise 

needed to diagnose Hirschsprung’s disease, no attempt should 

be made to provide definitive treatment. End ileostomy is 

recommended if Hirschsprung’s is suspected and the patient 

cannot be transferred to a facility offering advanced pediatric 

surgical care.)

° Perform rectal biopsy (suction or full-thickness) to rule out 

retained Hirschsprung’s disease.

° Perform a contrast enema.

▶ A conical transition zone from the distal, nondilated, 

aganglionic colon or rectum to the proximal (ganglionic) 

dilated colon is seen on contrast enema.

▶ A transition zone may be absent in neonates.

▶ A contrast enema excludes other causes of colonic 

obstruction, including small left colon syndrome, 

meconium plug syndrome, and atresia.

° Nonsurgical treatment (recommend in limited-resource 

environment)

▶ NG tube decompression in the upper GI tract.

▶ Administer IV fluids and antibiotics (ampicillin, 

gentamicin, and metronidazole).

▶ Perform rectal irrigations with 20 cc/kg warm Ringer’s 

lactate three times daily using a soft, rubber catheter.

▶ If the above measures are unhelpful and the patient 

cannot be urgently transferred to the care of a pediatric 

surgeon, consider performing a colostomy.

° Surgical treatment

▶ Perform a leveling colostomy of normally innervated 

(biopsy-proven) bowel.

▶ If no clear-cut transition zone can be determined, the 

patient may have total colonic aganglionosis. If a biopsy 

diagnosis is unobtainable, perform an ileostomy.

▶ Refer the patient to a facility with pediatric surgery 

capability, if possible.
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Gastrointestinal Tract

• Hirschsprung’s-associated enterocolitis is a potentially lethal 

complication.

° Symptoms include abdominal distention, diarrhea, 

vomiting, fever, lethargy, and, if severe, sepsis and 

perforation.

° This complication usually occurs in children less than 3 

years old and is the most common cause of death in affected 

children.

° It may occur before or after colostomy or pull-through.

° Laboratory tests show high levels of C difficile toxin and 

elevated white blood cell count.

Rectum and Anus

Rectal Prolapse (Procidentia)

• True prolapse is present when there are circular folds of fullthickness bowel. Pseudo prolapse involves radial folds of 

mucosa only.

• Treatment

° Temporarily, tape buttocks together to achieve manual 

reduction. 

° Rule out cystic fibrosis and parasites.

° Discourage the patient from prolonged sitting or straining 

during a bowel movement.

° Prescribe stool softeners.

° Administer submucosal injection hypertonic glucose (50%) 

or hypertonic saline (20%).

° Administer 5 cc per treatment.

° Use a #18 spinal needle for four-quadrant sclerosis. Inject 2 

cc posteriorly and 1 cc in the other three quadrants (almost 

all cases will resolve spontaneously without an operative 

procedure).

Anal Fissure

• Anal fissures are the most common cause of rectal bleeding 

in newborns.

• Symptoms include blood streaks on the outside of stool and 

constipation.
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Pediatric Surgery and Medicine for Hostile Environments 

• Physical examination will show superficial tear of the anal 

mucosa, usually in the posterior midline. A sentinel skin tag 

indicates a chronic fissure. Fifty percent of anal fissures are 

associated with fistula-in-ano (see below).

• Anal fissures are caused by stretching and tearing during 

evacuation of large, hard stools.

• Nonoperative treatment consists of stool softeners, dilatation 

(may require manual stretch under sedation), and sitz baths.

• Operative treatment includes partial lateral internal 

sphincterotomy and botulinum toxin injection.

Perianal and Perirectal Abscess

• In infants, perianal and perirectal abscesses can develop from 

an infected diaper rash. In children, rule out Crohn’s disease, 

leukemia, and immunodeficiency syndromes.

• Symptoms include fever and pain.

• Treat with incision, drainage, and sitz baths.

• Abscesses may be associated with a fistula-in-ano (see below).

Fistula-in-Ano

• Fistula-in-ano results from a perianal abscess extending from 

a crypt to the perianal skin (suspect when an abscess recurs).

• Treat with fistulotomy (over a probe), tract curettage, or, if 

fistula is complex or high, place a seton tie.

• Older patients with multiple fistulas should be evaluated for 

Crohn’s disease. 

Imperforate Anus

• Imperforate anus is diagnosed clinically by an absence of 

an anal opening or abnormal location of the anal orifice 

(rectoperineal or rectovestibular fistula).

• Evaluate for associated VACTERL defects (especially cardiac 

defects).

• Treat initially with NG tube decompression and IV hydration, 

and transfer patient to a center with pediatric surgical 

capabilities.

• If the patient cannot be transferred, perform a descending 

colostomy and mucus fistula.
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Gastrointestinal Tract

Preoperative Mechanical Bowel Preparation

• Give polyethylene glycol electrolyte solution (25–35 cc/kg/h 

for 4–6 h via an NG tube; safe in infants and children). Recent 

literature shows an increase in infection in children treated in 

this manner; use selectively.

• Add an oral erythromycin base and neomycin.
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Pediatric Surgery and Medicine for Hostile Environments 
355

Hepatobiliary Tract

Chapter 22

Hepatobiliary Tract

Liver

Trauma

• Diagnosis

° Use computed tomography (CT) scan with intravenous 

(IV) and oral contrast to rule out associated injury to the 

upper gastrointestinal tract. It is imperative that the patient 

be hemodynamically stabilized prior to transport from the 

resuscitation area (eg, triage area, emergency department 

trauma bay, etc) to radiology.

° Focused assessment with sonography for trauma (FAST) 

examination may also aid diagnosis. In pediatric patients, 

this is not a proven, reliable test and should only be 

considered to have excluded injury in patients who have 

a very low likelihood of injury.

° Diagnostic peritoneal lavage. 

• Treatment

° Nonoperative management for hemodynamically stable 

patients consists of serial examinations, including serial 

hematocrits, to detect ongoing blood loss. Typed and crossmatched blood should be readily available if needed. The 

current American Pediatric Surgical Association guidelines 

are as follows. (Abbreviated protocols are being studied. 

Shorter hospitalization length and discharge activity 

restriction may be appropriate.)

▶ Put patient on bed rest in the hospital for injury grade 

+ 1 day.

▶ Intensive care unit observation is only required for grade 

IV injuries.

▶ Discharge activity restriction period = (injury grade + 2 

weeks).
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Pediatric Surgery and Medicine for Hostile Environments 

° Laparotomy may be indicated for persistent hemodynamic 

instability and ongoing blood loss (greater than 50% 

of blood volume or 40 cc/kg of packed red blood cells 

transfused).

▶ Consider activating massive transfusion protocol. 

▶ The primary goal is to stop the bleeding and “get out” 

before the lethal triad of coagulopathy, acidosis, and 

hypothermia develops. This is the basis for “damage 

control” surgery.

▶ Pack the abdomen with gauze sponges upon initial entry.

▶ In a patient with trauma involving multiple organ 

systems, give early consideration to damage control (it is 

essential to make this decision before irreversible shock 

develops).

▷ Leave the abdomen packed with gauze sponges.

▷ Apply a temporary abdominal closure (using a 

vacuum device).

▷ Resuscitate in the intensive care unit (correct 

hypothermia, acidosis, and hypotension).

▷ Re-explore the abdomen in 24 to 48 hours.

▶	 Debride devitalized tissue using the “finger fracture”

technique.

▶ Perform direct suture ligation of bleeding vessels.

▶ Control bleeding.

▷ Clamp the hepatoduodenal ligament, which contains 

the hepatic artery, portal vein, and common bile duct 

(Pringle maneuver). 

▷ Obtain proximal and distal control of the vena cava.

▶ Parenchymal bleeding may be controlled with chromic 

sutures swedged on blunt liver needles and placed over 

omental “pledgets.”

Hemobilia

• Hemobilia is a sequelae of hepatobiliary tract trauma.

• Symptoms include a triad of right upper quadrant pain, 

bleeding from the upper gastrointestinal tract (hematemesis 

or melena), and hyperbilirubinemia.

• Diagnose with angiography or CT scan.

• Treatment with selective embolization is preferred over 

surgical exploration.
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Hepatobiliary Tract

Infections

• Pyogenic abscesses

° Etiology

▶ intraabdominal source of bacteria (eg, from intestinal 

perforation);

▶ penetrating or blunt liver trauma;

▶ cholangitis;

▶ chronic malnutrition;

▶ granulocyte dysfunction;

▶ sickle cell disease, thalassemia; or

▶ congenital or acquired immunosuppression.

° Overwhelming postsplenectomy infection 

▶ Diagnosis is often delayed because of a low index of 

suspicion.

▶ Signs and symptoms are rare and develop slowly. They 

include

▷ fever (often prolonged),

▷ abdominal pain,

▷ hepatomegaly, and

▷ nausea, vomiting, anorexia, and weight loss.

▶ Laboratory studies are generally not helpful in diagnosis.

▷ About 50% of patients will show mild leukocytosis. 

▷ Inflammatory markers (eg, C-reactive protein) will

be elevated.

▶ Bacteriology

▷ The most important pathogen is Streptococcus 

pneumoniae, but Haemophilus influenza and Neisseria 

meningitidis are also significant. 

▷ Anaerobes may also be responsible for infection.

▶ Peripheral blood cultures are generally not helpful; 

they are often negative or do not reflect bacteriology of

hepatic abscesses.

▶ Diagnose using ultrasound and CT scan. 

▶ Treatment

▷ Administer broad-spectrum antibiotics for a minimum 

4 weeks total: 2 to 4 weeks parenteral antibiotics, then 

oral antibiotics for the remainder of the course.

▷ Perform image-guided (ultrasound, fluoroscopy) 

drainage.
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Pediatric Surgery and Medicine for Hostile Environments 

▷ Surgically drain if the infection does not respond to 

the above measures. 

▷ Surgically drain multiloculated abscesses.

• Amebic abscess

° Etiology

▶ Poor sanitation and crowded conditions can lead to 

fecal-oral transmission.

▶ Emtamoeba histolytica is the most common organism 

responsible. 

▶ Colitis is a major causative factor in pediatric diarrhea 

deaths in developing countries.

▶ Signs and symptoms include

▷ fevers, chills;

▷ right upper quadrant pain that may radiate to the 

shoulder or have a pleuritic quality;

▷ nausea, weight loss, recent history of diarrhea; and

▷ abdominal distention, hepatomegaly.

▶ Diagnose with ultrasound, CT scan, and serologic 

testing.

▶ Treatment

▷ Give oral metronidazole (30–50 mg/kg/day divided 

3 times per day for 7–10 days).

▷ Drainage and surgery are not indicated unless the 

abscess is at risk for rupture or treatment failure (ie, 

if the patient has fever and pain after completing 3–5 

days of medical therapy).

▶ Complications

▷ Intraperitoneal rupture carries up to a 75% mortality 

rate.

▷ Rupture can also occur into the chest, pericardium, 

and surrounding intraabdominal organs.

▷ Hematogenous spread may infect the central nervous 

system and skin. 

• Hydatid cysts

° Etiology: Echinococcus granulosis, the larval stage of the dog 

tapeworm. Ingested ova burrow through the intestinal 

mucosa and become trapped in the liver (60%), lung (20%), 

and other organs (20%).

° Hydatid cysts are usually solitary.
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Hepatobiliary Tract

▶ A pericyst develops around the hydatid cyst.

▶	 Calcifications may be present in the cyst rim.

▶ Hydatid cysts may develop daughter cysts.

° Rupture may initiate an anaphylactic reaction.

° The cyst may become secondarily infected.

° Diagnose using ultrasound, CT scan, and serologic testing.

° Treatment

▶	 Surgery is definitive.

▷ Pack off the liver to protect the remainder of the

abdomen; avoid spillage-induced anaphylaxis.

▷ Aspirate the cyst.

▷ Open the cyst to excise the remaining contents and 

surrounding pericyst.

▶ Perioperative use of anthelmintic drugs decreases 

incidence of recurrence.

• Masses

° Benign masses include hemangioma, arteriovenous 

malformation, mesenchymal hamartoma, biliary 

cystadenoma, hepatocellular adenoma, focal nodular 

hyperplasia, teratoma, inflammatory pseudotumor, and

nonparasitic cysts.

° Malignant masses include hepatoblastoma, hepatocellular 

carcinoma, sarcoma, and metastatic disease.

° The majority of pediatric liver masses require resection 

and possibly chemotherapy. These lesions should therefore 

be referred to tertiary treatment centers, as successful 

treatment in the hostile environment is unlikely.

Biliary Tract

Trauma

• Nonoperative management of blunt biliary tract trauma carries 

a 4% risk of persistent bile leak.

° Diagnose using radionuclide scanning, if available.

° Treat with endoscopic retrograde cholangiopancreatography 

(ERCP) and stent placement, if available. 

° Perform cholecystectomy for traumatic gallbladder injuries.

° Incomplete common bile duct injuries may be repaired over 

a T-tube.
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Pediatric Surgery and Medicine for Hostile Environments 

° For extensive extrahepatic biliary tract injuries, use tube 

choledochostomy for damage control and hepaticojejunostomy or choledochoduodenostomy for definitive repair. 

Gallbladder Disease

• In developing countries, hemolytic disease, such as hereditary 

spherocytosis, sickle cell disease, thalassemia major, and 

hemolytic anemia, is the most likely etiology of cholelithiasis. 

The nature of the underlying hemolytic disease will vary with 

geography. 

• Treatment

° Perform cholecystectomy for acute calculous cholecystitis 

and symptomatic cholelithiasis, and consider it for 

asymptomatic patients with an underlying hemolytic 

condition, especially if the patient will be undergoing 

splenectomy.

° Placement of a cholecystotomy tube instead of a cholecystectomy may be appropriate depending on the condition 

of the patient and available resources.

° Careful perioperative management of hemolytic disorders 

may avoid associated medical crisis.

▶ Avoid elective surgery in patients with active infection.

▶ Use simple transfusion to achieve a hemoglobin level of 

10 g/dL.

° Higher hemoglobin levels can increase blood viscosity.

° Higher-risk patients should be evaluated by a hematologist.

▶ Keep the patient adequately hydrated and oxygenated.

▶ Avoid intraoperative hypothermia and acidosis due to 

hypovolemia.

° Ensure adequate postoperative hydration, provide 

supplemental oxygenation as required, and monitor pulse 

oximetry to maintain a level of at least 94% saturation.

Acalculous Cholecystitis/Hydrops

• Acalculous cholecystitis and hydrops are associated with 

sepsis, multisystem trauma, burns, total parenteral nutrition, 

and Kawasaki disease.

• Symptoms include fever, right upper quadrant tenderness, 

guarding, and leukocytosis.
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Hepatobiliary Tract

• Sonography will show gallbladder distension and echogenic 

debris (“sludge”). Radionuclide scanning is also useful for 

diagnosis, if it is available.

• Treatment

° Initially, treat conservatively with antibiotics and reinstitute 

enteral feedings when appropriate.

° Perform cholecystectomy, or cholecystostomy in patients 

unable to tolerate cholecystectomy.

Choledocholithiasis

• Symptoms include increased direct (conjugated) bilirubin, 

abdominal pain, fever, and nausea. If amylase is also increased, 

consider choledocholithiasis with pancreatitis.

• Treat with

° Endoscopic retrograde cholangiopancreatography (ERCP) 

preoperatively, if available.

° Intraoperative cholangiogram.

° Open or laparoscopic exploration.

° Cholecystotomy (in certain circumstances).

Choledochal Cyst

• Diagnosis, treatment, and long-term management of this 

condition may be challenging in the hostile environment. 

Strongly consider referring the patient to a tertiary care facility.

• A choledochal cyst involves a cystic dilatation of the biliary 

tree.

• Etiology is not fully understood.

• Symptoms include the classic triad: right upper quadrant pain, 

jaundice, and a palpable mass.

• 	Classification

° Type I: dilation of the common bile duct.

°	 Type II: diverticulum coming off of the common bile duct.

° Type III: choledochocele.

° Type IV: intra- and extrahepatic dilation of the biliary tree.

° Type V: single or multiple intrahepatic cysts (Caroli 

disease).

• Treatment

° Provide treatment to alleviate obstructive symptoms and 

decrease long-term risk of malignant changes.
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Pediatric Surgery and Medicine for Hostile Environments 

° Type I: cystectomy with hepaticojejunostomy or 

hepaticoduodenostomy.

° Type II: simple excision of the diverticulum.

° Type III: marsupialization of the cyst via ERCP or 

transduodenal incision.

° Type IV: excise the dilated extrahepatic biliary tree and 

reconstruct by performing a hepaticojejunostomy or 

hepaticoduodenostomy.

°	 Type V: segmental resection if disease is confined to one

portion of the liver or for possible liver transplantation. 

(The remaining biliary conditions are unlikely to be encountered in 

the hostile environment and should be referred to tertiary care centers 

if encountered.)

Biliary Atresia

• Biliary atresia is a rare obstructive disease of the biliary tract 

that causes persistent jaundice beginning in the neonatal 

period; no clear etiology has been identified.

• Physical examination will show

° jaundice (should be considered pathologic when the direct 

fraction of bilirubin remains elevated beyond 7–10 days of 

life);

° light (acholic), gray-colored stools due to the absence of 

bile pigment;

° dark urine due to increased bilirubin excretion; and

° hepatomegaly.

• Laboratory tests will show direct (conjugated) hyperbilirubinemia (more than 3 mg/dL for patients 2 weeks of age and 

older). Biliary atresia is the most common cause of conjugated 

hyperbilirubinemia in a 1-month-old infant.

• Diagnosis is made by ultrasonography, magnetic resonance 

and CT cholangiography, radionuclide studies, intraoperative 

cholangiogram, and liver biopsy.

• Treatment in a hostile environment is not appropriate; patients 

should be expeditiously referred to a pediatric center for 

evaluation and treatment, if available. Hepatoportoenterostomy 

(Kasai procedure) is the initial surgical treatment; up to twothirds of patients will ultimately require liver transplantation.
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Hepatobiliary Tract

Biliary Hypoplasia

• Biliary hypoplasia is not a specific disease entity, but a 

manifestation of a variety of hepatobiliary disorders including

° neonatal hepatitis,

° alpha-1 antitrypsin deficiency,

° early intrahepatic biliary atresia, and

° Alagille syndrome (arteriohepatic dysplasia).

• Diminutive ducts will be seen on cholangiography.

• Manage nonoperatively with choleretics (eg, ursodeoxycholic 

acid, phenobarbital).

Inspissated Bile Syndrome

• Inspissated bile syndrome may result from massive hemolysis 

due to Rhesus factor and ABO incompatibility (resulting in 

obstruction from sludge in the biliary tract), total parenteral 

nutrition (TPN)-associated cholestasis, or cystic fibrosis.

• Treat with choleretic agents and cholangiogram via the 

gallbladder with irrigation of the biliary tree.

Biliary Ascites

• Biliary ascites is seen in infants after perforation of extrahepatic 

bile duct.

• Diagnosis is made by radionuclide scanning, if available.

• Treat via cholecystostomy with drainage of the porta hepatis. 

Suture repair of the perforation is not recommended. 

Postoperative cholangiogram can be performed via a 

cholecystostomy tube to confirm healing priorto tube removal.
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Pediatric Surgery and Medicine for Hostile Environments 
365

Pancreas and Spleen

Chapter 23

Pancreas and Spleen

Injury to the pancreas and spleen may result from blunt or 

penetrating forces. Treating major pancreatic trauma, and its 

frequent complications, is often problematic in even the bestequipped medical facilities. A “damage control” approach should 

be practiced in echelons of care below those of a full-service 

hospital. While operations for “splenic salvage” are preferred 

where feasible, this is a dangerous approach in an environment 

where blood product transfusion may be limited and when 

patient evacuation may occur in the early postoperative period. 

Under these circumstances, splenectomy constitutes the most 

prudent procedure.

Pancreas

Congenital Variations

• Ectopic pancreatic tissue

° Pancreatic tissue may be functional and the patient may 

demonstrate adverse symptoms. 

° If a Meckel’s diverticulum contains pancreatic tissue, 

diverticulitis or painless, bright red bleeding from adjacent 

intestinal mucosa may be manifest.

▶ Exocrine function remains normal.

▶ Treatment: diverticulectomy or sleeve resection of the 

ulcerated bowel if the patient is symptomatic. 

• Annular pancreas

° Anatomy: pancreatic tissue circumferentially surrounds 

the second portion of the duodenum at the region of the 

sphincter of Oddi.

° Parenchymal and ductal structures are usually normal.

° Symptoms
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Pediatric Surgery and Medicine for Hostile Environments 

▶ Associated atresia or stenosis of the underlying 

duodenum.

▶ Vomiting (may or may not be bilious) in newborns.

° Diagnosis: upper gastrointestinal study.

° Asymptomatic cases do not require treatment. For 

obstructive symptoms:

▶ Use right upper quadrant transverse incision.

▶ Perform side-to-side duodenoduodenostomy (transverse 

incision in proximal duodenum, longitudinal incision in 

distal duodenum), as in correction of duodenal atresia.

▶ Alternately, perform duodenojejunostomy.

▶ Avoid gastrojejunostomy.

Pancreatic Trauma

• Pancreatic trauma is often caused by blunt trauma (especially 

associated with impact with bicycle or motorcycle handlebars; 

the body of the pancreas may be transected when crushed 

over the anterior bodies of the lumbar spine).

• Diagnosis

° Focused assessment with sonography for trauma (FAST) 

examination.

° Computed tomography (CT) scan with oral and intravenous 

(IV) contrast.

° Persistent elevation of amylase: magnetic resonance 

cholangiopancreatography (MRCP), or endoscopic 

retrograde cholangiopancreatography (ERCP) to rule out 

ductal injury (CT scan may be normal).

• Nonoperative management

° Nonoperative management should be used when the 

patient is hemodynamically stable, transfusion requirement 

is less than 50% of estimated blood volume (ie, < 40 mL/kg) 

and there is no transection of the pancreatic duct.

° Admit patient to a treatment facility.

° Place patient under the care of a surgeon.

° Ensure the operating room and personnel are immediately 

available.

° Monitor serial hematocrit levels (initially every 4 hours).

° Ensure there are adequate units of cross-matched blood 

available in the blood bank.
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Pancreas and Spleen

° Enforce bed rest for 48 hours.

° Restrict the patient’s physical activity for 1 month.

° Perform an ultrasound based on clinical course and during 

follow-up for development of a pseudocyst.

• Operative management

° Injury to the body of the pancreas or pancreatic duct 

requires drainage; even if a ductal injury is not identified, 

it should be presumed and drained using a closed drainage 

system.

° Debride clearly nonviable tissue.

° Treat transection or near-transection of the pancreatic duct.

▶ Over sew or staple the distal end of the proximal 

pancreas.

▶ Perform distal pancreatectomy (usually with 

splenectomy) if injury is in the tail.

▶ Drain the distal segment of the pancreas by Roux-en-Y 

anastomosis to the jejunum.

Pancreatitis

• Alcohol and biliary tract disease, common causes of 

pancreatitis in adults, are uncommon in children.

• Pathophysiology is characterized by autodigestion (autolysis).

° Exocrine enzymes are stored in inactive forms in protective 

zymogens.

° The alkaline pH of exocrine glands and protease inhibitors 

provide protection.

° Pancreatic injury (trauma, obstruction, inflammation) 

can rupture protective membranes within the gland and 

activate digestive enzymes, resulting in autodigestion.

• Symptoms: abdominal pain typically radiating to the back, 

and increased serum amylase. 

• Diagnosis

° A ratio of amylase to creatinine clearance greater than 6% 

indicates pancreatitis.

urine amylase × serum creatinine × 100

serum amylase × urine creatinine

▶ Laboratory tests: serum amylase and lipase.
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Pediatric Surgery and Medicine for Hostile Environments 

▶ Imaging methods: ultrasound, magnetic resonance 

cholangiopancreatography, and endoscopic retrograde 

cholangiopancreatography (contraindicated in acute 

pancreatitis).

• Etiology

° The most common cause in children is blunt abdominal 

trauma.

° The most common cause of nontraumatic pancreatitis is 

idiopathic.

° Medications (eg, steroids, chemotherapy), infections, viral 

infections such as mumps, cystic fibrosis, underlying biliary 

tract disease, hemolytic disease resulting in stones (eg, 

spherocytosis, sickle cell disease), or cholelithiasis.

• Treatment

° Medical

▶ Discontinue offending medications.

▶ Control infection.

▶ Give nothing by mouth. Insert nasogastric tube if the 

patient is vomiting, administer total parenteral nutrition, 

and give analgesics (eg, meperidine, not morphine). 

Replace fluid volume.

▶ Antibiotics, H2-blockers, and/or somatostatin are 

administered only if indicated for treatment of sepsis 

(antibiotics), or in severe/refractory cases. 

▶ Monitor arterial blood gasses for impending respiratory 

failure.

▶ Monitor lactate dehydrogenase and serum glutamic 

oxaloacetic transaminase, which indicate tissue necrosis. 

▶ Monitor serum calcium for hypocalcemia (due to 

saponification); prescribe calcium gluconate as indicated.

▶ Monitor serum glucose for hyperglycemia; prescribe 

insulin as indicated.

▶ Monitor hematocrit for hemoconcentration or bleeding.

° Surgical

▶ Debride obviously necrotic tissue.

▶ Drain (especially fluid in lesser sac).

▶ Perform cholecystectomy for stones after resolution of 

the acute episode.
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Pancreas and Spleen

Pseudocysts

• Trauma is the most common etiology in children.

• Cyst walls are composed of inflammatory tissue (not 

epithelium) and are usually located in the lesser sac.

• Symptoms include pain, compression or erosion of 

surrounding organs, secondary infection, hemorrhage, and 

perforation.

• Diagnosis

° Ultrasound.

° CT with oral and IV contrast will show anterior and 

superior displacement of the stomach and downward colon 

displacement. 

• Treatment

° Medical

▶ 50% of cases may resolve spontaneously in 3 to 4 weeks.

▶ Endoscopic drainage.

▶ Nothing by mouth.

▶ Total parenteral nutrition.

° Surgical

▶ Surgery is indicated in the case of persistence (> 6 wk) or 

recurrence, and when pseudocyst communicates with a 

major duct.

▶ Provide external drainage (if infected).

▶ Provide internal drainage by Roux-en-Y cystenterostomy 

(unless the area is infected).

▶ Perform distal pancreatectomy if pseudocyst is in tail.

▶ Perform cystogastrostomy (open or endoscopic) if the 

pseudocyst is in the pancreatic body or adherent to 

the stomach (bleeding after operation is a common 

complication resulting from stomach acid).

▶ Perform Roux-en-Y cystjejunostomy if the pseudocyst 

is located at the head of the pancreas or not adherent to 

the stomach.

Spleen

The thymus is the primary lymphatic organ during intrauterine 

life. The spleen is the major site of hematopoiesis from birth 

to 6 months of age, when hematopoiesis is taken over by the 

bone marrow. It produces immunoglobulin M (IgM) antibodies 
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Pediatric Surgery and Medicine for Hostile Environments 

against encapsulated bacteria (eg, pneumococcus, Haemophilus, 

meningococcus), and tuftsin and properdin, which enhance 

phagocytosis and stimulate production. Humoral immunity 

in neonates is transferred through the placenta (except 

immunoglobulin M).

Congenital Anomalies

• Asplenia (Ivemark syndrome) is the complete absence of the 

spleen. It is also called asplenia syndrome or heterotaxia. It can 

be associated with situs inversus (with or without malrotation 

or volvulus), cardiac anomalies (which are associated with a 

high mortality rate), and three-lobed lungs.

° Symptoms include cyanotic heart disease, shortness of 

breath, and congestive heart failure.

° Diagnosis

▶ Howell-Jolly bodies present in a peripheral smear.

▶ Ultrasound.

• Polysplenia

° Multilobed spleen with 2 to 9 equal portions.

° Associated with situs inversus, cardiac anomalies, and 

biliary atresia.

° Normal splenic function.

• Accessory spleen

° Small nodules of splenic tissue form apart from a normalsized spleen.

° Usually located in the splenic hilum (gastrosplenic 

ligament).

° Nodules must be removed when a splenectomy is performed 

for hypersplenia to prevent persistent hematologic disease.

• Cysts

° Congenital cysts are rare. Epidermoid cysts are the most 

common type in pediatric patients.

° Symptoms: hemorrhage, left upper quadrant pain, and 

infection.

° Echinococcal cysts: most common type worldwide.

° Differential diagnosis is made by history, serology, and 

scan.

° Diagnosis is confirmed with ultrasound, spleen scan, or CT 

scan.
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Pancreas and Spleen

° Treatment: partial cyst wall resection/marsupialization, 

rather than hemisplenectomy.

Trauma

• Diagnosis (see Pancreatic Trauma, above).

• Nonoperative management (see Pancreatic Trauma); patients 

who cannot be observed continuously in an intensive care unit 

or who will be evacuated through multiple levels of care are 

not candidates for conservative management.

• Indications for operative management include:

° Transfusion requirement of more than 50% blood volume 

(~ 40 cc/kg).

° Persistent hypotension despite volume resuscitation, or 

evidence of continued hemorrhage.

° Associated significant injuries.

° Abdominal distension and shock (immediate laparotomy 

is necessary).

• Treatment

° Splenorrhaphy is often possible.

° Perform splenectomy in an unstable patient with multiple 

injuries, one who will not be continuously observed in an 

intensive care unit setting, or one who will be transferred 

through multiple levels of medical care within 72 hours of 

operation.

° Provide immunizations to protect against pneumococcus 

and vaccines to protect against Haemophilus influenzae and 

Neisseria meningitidis; give penicillin prophylaxis until the 

patient reaches 18 years of age.

Inflammation

• Acute inflammatory splenomegaly

° Most commonly caused by infection.

° Treat the source of infection (do not perform splenectomy).

• Abscess

° Gram-negative anaerobic Staphylococcus is the most 

common cause of an abscess.

▶ Hemoglobinopathy is associated with Salmonella.

▶ Leukemia is associated with Candida.
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Pediatric Surgery and Medicine for Hostile Environments 

° Other causes include:

▶ trauma,

▶ infarction,

▶ bacteremia, and

▶ immunosuppression.

° Symptoms include fever, left upper quadrant tenderness, 

and left shoulder pain.

° Diagnosis is made by ultrasound or CT scan (best modality).

° Treatment consists of IV antibiotics, percutaneous aspiration 

and drainage for large abscesses, and splenectomy (in the 

case of persistent infection).

Hematologic Disorders

• Red blood cells (RBCs)

° Hereditary spherocytosis (autosomal dominant)

▶ RBC membrane is abnormal, which prevents RBCs from 

assuming a discoid shape; deformity results in small, 

round, fragile RBCs.

▶ Symptoms include anemia, jaundice, splenomegaly, and 

gallstones (gallstones occur in 75% of these patients).

▶ Laboratory: anemia, increased bilirubin, increased 

reticulocyte count, spherocytes, and increased osmotic 

fragility.

▶ Treatment: splenectomy (deferred until age 3–4 years; 

most common indication) and cholecystectomy if stones 

are present on preoperative ultrasound.

▶ If hemolysis recurs or if no Howell-Jolly bodies are seen 

in a peripheral smear post-operatively, suspect residual 

accessory splenic tissue.

° Elliptocytosis is rarely associated with RBC destruction 

sufficient to require splenectomy.

° Sickle cell anemia

▶ Homozygous sickle cell gene produces severe, chronic, 

hemolytic anemia.

▶ Hemoglobin (HgB) levels in individuals with sickle cell 

anemia are as follows:

▷ HgB S: 90%

▷ HgB F: 5%

▷ HgB A2: normal
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Pancreas and Spleen

▷ HgB A: absent

▶ Sickling results in occlusion of small vessels (“sickle cell 

crisis”).

▶ Etiology may include infection, dehydration, hypoxia, 

and acidosis.

▶ Vaso-occlusive crisis is a potential complication 

characterized by stroke, pain and swelling in the hands 

and feet (“hand/foot syndrome”), acute abdominal pain, 

and pulmonary infarction.

▶ Sequestration results in acute trapping of RBCs in 

the spleen, which leads to anemia, hypotension, 

and splenomegaly (if recurrent severe episodes 

[resulting in shock] occur, splenectomy is indicated after 

administration of polyvalent pneumococcal vaccine and 

Haemophilus influenzae type B vaccine).

▶ Eventually the spleen becomes small, fibrotic, and 

infarcted (functional asplenia); the most common 

infections are pneumococcal and Salmonella osteomyelitis.

▶ Laboratory indicators:

▷ HgB: 6 to 8 g/dL.

▷ Smear will show sickle, target, and nucleated 

RBCs; Howell-Jolly bodies; 5% to 15% reticulocytes; 

increased white blood count; and increased platelets.

▷ Liver function tests will be abnormal.

▷ Diagnosis in made by hemoglobin electrophoresis.

▶ Treatment consists of hydration, packed red blood cell 

transfusion to decrease HgB S to less than 40% (20 cc/kg 

type-specific Rh[–] packed RBCs) from the usual 90%, 

and analgesics.

• White blood cells

° Leukemia

▶ Splenomegaly secondary to leukemic infiltrate is the 

most common cause of splenic rupture.

▶ Splenectomy is not indicated.

° Platelets

▶ Idiopathic thrombocytopenic purpura (ITP): antiplatelet 

antibodies attach to platelets, making the platelets more 

susceptible to destruction in the spleen.

▶ Spleen is normal-sized, platelets are normal shape.
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Pediatric Surgery and Medicine for Hostile Environments 

▶ Usually occurs in children (especially females) under 10

years old, typically a few weeks after a mild viral illness.

▶ Symptoms: petechiae, bruising, and bleeding (worse if 

purpura is in the central nervous system).

▶ 75% of cases undergo spontaneous remission.

▶ Provide medical treatment for chronic or persistent ITP 

(see Chapter 32, Hematology and Oncology). 

▶ Indications for splenectomy include the following:

▷ an acute bleeding episode (especially in the central 

nervous system or intraabdominal space), and

▷ failure of medical management.

▶ Splenectomy is curative in more than 90% of patients 

with ITP; however, if accessory splenic tissue is missed, 

symptoms may recur.

▶ If the platelet count is less than 50,000, platelet transfusion 

should be given only after the splenic artery is ligated, 

at which time the platelet count will start to rise.

▶ If postoperative thrombocytosis occurs (platelets number 

more than 1,000,000), prescribe aspirin.

• Hypersplenism

° Pancytopenia (decreased white blood cells, RBCs, 

or platelets) may be primary or secondary to portal 

hypertension, inflammatory diseases, storage disease, 

chronic hemolytic disease, myeloproliferative disorder, or 

neoplastic disease.

° Hypersplenism is associated with sickle cell crisis.

° Treat primary hypersplenism with splenectomy; however, 

splenectomy is not indicated for secondary hypersplenism 

resulting from Hodgkin disease, sarcoid, leukemia, or 

portal hypertension.

• Wandering (ectopic) spleen

° Anatomy: ligamentous attachments are absent, and the 

spleen is attached only by its hilar vessels; torsion may 

occur, leading to abdominal pain and possible splenic 

infarction.

° Most common in male infants.

° Diagnosis is made by ultrasound.

° Treatment: splenopexy (if the spleen is not infarcted).

• Splenectomy
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Pancreas and Spleen

° The most common indication for splenectomy is ITP.

° Preoperative preparation

▶ Immunize the patient with polyvalent capsular 

polysaccharide antigens of pneumococcal vaccine, 

ideally administered more than 3 weeks before elective 

splenectomy, and Haemophilus influenzae type B vaccine. 

Pneumococcal vaccine (pneumococcal polysaccharide 

vaccine [PSV23]) is only effective against 80% of 

organisms (it may be less effective in children younger 

than 2 y old) and provides protection for children 4 to 5 

years old. 

▶ Administer prophylactic antibiotics before, during, and 

after operation, and prophylactically until the patient is 

18 years old.

▷ Use ampicillin in children under 10 years old.

▷ Use penicillin if the patient is older than 10 years.

▶ Administer an intraoperative stress dose of steroids (100 

mg hydrocortisone IV) if the patient was treated with 

steroids immediately before the operation.

° Operative procedures

▶ Place a nasogastric tube to prevent gastric distension 

and dislodgement of ties on the short gastric vessels.

▶ Make a laparoscopic, upper midline, or left subcostal 

incision.

▶ Mobilize by incising posterior, lateral peritoneal 

reflection.

▶ Suture ligate and divide short gastric vessels.

▶ Suture ligate and divide the splenic artery, then the 

splenic vein.

▶ Avoid injury to the tail of the pancreas. If injury has 

occurred or is suspected to have occurred, closed 

drainage of the bed of the spleen should be performed.

▶ Search for and resect accessory splenic tissue. All splenic 

tissue must be removed for hematologic reasons or the 

disorder will recur.

° Postoperative considerations

▶ Sepsis: overwhelming postsplenectomy infection. 

▷ 50% mortality, especially in children under 2 years 

old.
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Pediatric Surgery and Medicine for Hostile Environments 

▷ Risk is greatest in infancy, decreasing with age. The 

risk is twice as great in children younger than 2 years 

old, least when splenectomy is done for trauma, and 

greatest when splenectomy is done for thalassemia 

and other hematological indications.

▷ Incidence is approximately 5%, with 80% of infections 

occurring within 2 years of splenectomy.

▷ Symptoms are extremely rapid in onset and 

progression and include nausea and vomiting, 

confusion, seizures, shock, disseminated intravascular 

coagulation, and coma. 

▷ The most common organism responsible is 

Pneumococcus. 

▷ Prevent with polyvalent pneumococcal vaccine. 

▶ Laboratory tests

▷ Peripheral blood smear will show the following 

cytoplasmic inclusions: Heinz bodies, Howell-Jolly 

bodies, and siderocytes.

▷ White blood cell count will be increased. 

▶ Thrombocytosis 

▷ A platelet count less than 1,000,000 requires no 

treatment.

▷ Platelet count may be greater than 1,000,000 10 days 

after operation; treat with aspirin (80 mg/day).

▷ Thrombotic complications (eg, portal vein thrombosis, 

diagnosed by ultrasound) are rare.
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377

Chapter 24

Genitourinary Tract 

Introduction

The majority of pediatric patients with genitourinary trauma 

will have concomitant injuries (abdomen, thorax, spine, pelvis, 

femur). Managing genitourinary injuries in children is similar 

to management in adults. This chapter focuses primarily on 

the differences in management and also addresses some of the 

unique congenital and medical genitourinary conditions that 

may be encountered in pediatric patients.

Trauma

Renal Injuries

• Children are more susceptible to renal injury than adults due 

to thinner body habitus, less renal protection from the thorax, 

and less secure tissue attachments, resulting in higher mobility 

of the kidneys within the retroperitoneum.

• Preexisting renal anomalies (ureteropelvic junction [UPJ] 

obstruction, hydroureteronephrosis, horseshoe kidney) are 3 

to 5 times more common in children undergoing evaluation 

for renal trauma than in adults.

• Children with preexisting renal anomalies frequently have 

hematuria out of proportion to the injury; however, the degree 

of injury is comparable to that in those without anomalies.

• Significant renal injury may be present in children without 

hematuria; up to 70% of children with grade 2 or higher renal 

injury will not have hematuria.

• Indications for renal imaging after abdominal trauma include:

° Significant deceleration injury, such as

▶ high-speed motor vehicle accident,

▶ pedestrian struck by a car,
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378

▶ fall from greater than 15 ft, and

▶ striking of flank with a foreign object.

° Associated injuries, such as

▶ fractures of the thoracic rib cage, spine, pelvis, or femur;

▶ bruising of torso or perineum;

▶ peritoneal signs; and

▶ gross hematuria.

° Microscopic hematuria with systolic blood pressure less 

than 90 mmHg at any time.

° Any penetrating trauma.

• Imaging

° Computed tomography (CT) scan

▶ Stabilized patient: triphasic CT (scan precontrast, 

immediately following injection, and 15–20 min 

delayed).

▶ Labile patient: single-phase CT immediately 

following injection will miss ureteral injury or urinary 

extravasations.

▶ Severely unstable patients: intraoperative CT. Verify the 

presence of a functioning contralateral kidney prior to 

performing a trauma nephrectomy.

▶ Obtain a single shot intravenous (IV) pyelogram using 2 

mL/kg IV contrast; perform a radiograph of the kidneys, 

ureters, and bladder at 10 to 15 minutes. 

° Focused assessment with sonography for trauma (FAST) 

examination.

▶ FAST provides 95% specificity, but only 33% to 89% 

sensitivity and only 50% negative predictive value.

▶ FAST tends to detect only higher grade injuries and 

intraperitoneal fluid.

▶ Use FAST sparingly if CT is available. 

• Management

° Determine grade of kidney injury.

° Indications for nonsurgical management:

▶ Patient is hemodynamically stable, grade 1 or 2, with or 

without associated abdominal injury.

▶ Isolated grade 3 or 4, provided the distal ureter is intact.

▶ A hemodynamically stable, grade 5 injury.

• Treatment
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379

° Monitor patient on bed rest (urine output, vital signs) until 

the patient is able to ambulate from associated injuries 

and hematocrit has stabilized. There is no benefit from 

maintaining bed rest until hematuria clears.

° Perform serial physical examinations and hematocrit 

measurements.

° Clear guidelines for antibiotics use are not established.

▶ Grade 1 to 3 injuries do not likely benefit from antibiotics. 

▶ In grade 4 to 5 injuries with urinary extravasation, 

consider antibiotics until the extravasation resolves. 

▶ Two to three days after injury, reimage (ultrasound 

or CT) grade 3, 4, and 5 injuries that were managed 

nonoperatively.

° Relative indications for operative intervention include:

▶ persistent hemorrhage (consider embolization), and

▶ extravasation of urine, progressive pain or ileus.

▷ Consider a ureteral stent or percutaneous drainage 

of a urinoma, which will often successfully treat 

persistent urinary extravasation.

▷ Pediatric ureteral stents, cystoscopic instrumentation, 

or fluoroscopy are frequently unavailable in an 

austere environment.

▷ Within 2 weeks, 80% of urinary extravasation will 

resolve without intervention, even in grade 4 and 5 

injuries.

° Absolute indications for operative intervention include:

▶ hemodynamic instability due to a renal source,

▶ expanding or pulsatile retroperitoneal hematoma,

▶ unsuccessful attempt at angioinfarction,

▶ coexisting abdominal injuries and grade 3 or greater 

renal injury (if expanding hematoma), and

▶ an unstable patient with inadequate preoperative 

staging and a finding of retroperitoneal hematoma at 

exploration.

° Principles of renal exploration

▶ Verify function of the contralateral kidney by pyelography 

before exploration.

▶ Obtain control of the renal vessels prior to exploration.

▶ Repair the renal injury.
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380

▷ Hemostatic agents, such as GelFoam (Pfizer, Inc, 

New York, NY), Floseal (Baxter International, Inc, 

Deerfield, Ill), and Surgicel (Ethicon, Inc, Somerville, 

NJ) are useful adjuncts.

▷ V-Loc sutures (Coviden Inc, Dublin, Ireland) hold 

well in renal parenchyma.

▷ Close collecting system defects with fine absorbable 

suture (eg, 5-0 or 6-0 polydioxanone).

▷ Route drainage devices away from coexisting 

injuries.

▷ Separate intraabdominal and retroperitoneal injuries 

using omentum.

Ureteropelvic Junction Disruption

• CT scan findings include:

° good renal contrast excretion with medial perirenal 

extravasation,

° no parenchymal laceration, and

° nonvisualization of ipsilateral ureter on delayed images 

(Figure 24-1).

• Treatment

° Obtain a retrograde pyelogram to evaluate the extent of the 

UPJ disruption, if possible.

° If the UPJ is intact and there is a renal parenchymal or 

pelvic laceration, place a ureteral stent; nephrostomy may 

be indicated. Consider Foley catheter drainage as well.

° If the UPJ is disrupted and the problem is diagnosed within 

5 days, perform immediate surgical repair.

▶ Debride devitalized tissue.

▶ Spatulate the ureter and connect it to the renal pelvis 

with fine, absorbable suture over a ureteral stent (5–6 

French size [Fr]) or feeding tube.

▶ Place an intraoperative nephrostomy tube if ureteral 

stent cannot be placed.

▶ Place a retroperitoneal drain.

▶ Mobilize the kidney for a tension-free anastomosis, if 

necessary.

▶ If the UPJ is disrupted and problem is diagnosed after 

5 days:
Genitourinary Tract

Figure 24-1. Ureteropelvic junction disruption. Note medial extravasation of 

contrast.

381

▷ Perform nephrostomy.

▷ Reassess after 12 weeks.

▷ Perform a retrograde pyelogram or CT urogram and 

functional imaging (MAG3 renal scan with Lasix 

[Sanofi SA, Paris, France] washout).

Ureteral Injury

• Ureteral injury accounts for less than 4% of penetrating injuries 

in children; it is extremely rare with blunt trauma.

• Its mortality rate of more than 30% is related to concomitant 

injuries.

• Two-thirds of cases do not have hematuria.

• High-velocity injury produces a blast effect.

• The ureter may appear intact at exploration.

• Delayed necrosis leads to urinary extravasation.

• Ureteral injury presents with urine output from surgical drains 

3 to 5 days after injury, fevers, flank, or lower abdominal pain, 

or intestinal ileus.

• Management

° Within 5 days of injury, perform a primary repair.
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382

° Remove devitalized tissue.

° In general, spatulate and perform a tensionless anastomosis 

over a stent with a fine, absorbable suture (eg, 5-0 or 6-0 

Vicryl [Ethicon, Inc, Somerville, NJ]).

° Mobilize the kidney or raise a bladder flap to relieve 

tension.

° In an unstable patient or in the presence of extensive injury, 

occlude the ureter with a large clip at the proximal end 

and place a nephrostomy tube or an externalized ureteral 

stent using a 5 or 8 Fr feeding tube and prepare for delayed 

repair.

° The type of repair will depend on level of the injury.

▶ Istal ureter: ureteral reimplant with or without psoas 

hitch of bladder.

▶ Mid ureter: ureteroureterostomy possible, possible psoas 

hitch and ureteral reimplant.

▶ Extensive ureteral loss: proximal ureter ureteroureterostomy, ureteropyelostomy, Boari flap/

transuretereroureterostomy/ureteral replacement 

(ileum). 

Bladder Injury

• Bladder injury is frequently associated with multiorgan 

trauma and pelvic fractures.

• Absolute indications for surgical repair include:

° all intra-peritoneal injuries, and

° severe gross hematuria or clot retention and pelvic fracture 

with known extraperitoneal injury.

• Relative indications for surgical repair include:

° persistent urinary extravasation despite adequate catheter 

drainage (extraperitoneal), and

° large extraperitoneal injury in addition to presence of 

external pelvic fixation devices. 

Bladder Neck Injury

• Image using cystogram (Figures 24-2 and 24-3).

° Instill contrast agent at a volume of at least 1/2 of the 

estimated bladder capacity under gravity via urethral 
Genitourinary Tract

Figure 24-2. Computed tomography cystogram showing intraperitoneal 

bladder rupture.

383

catheter (bladder capacity in milliliters = [age + 2] × 30), 

or if under 1 year old (5–7 cc/kg). Refer to Table 24-1 for 

estimation of urethral catheter size.

° Standard cystogram

▶ Abdominal plain film (scout).

▶ Anterior-posterior (A-P) plain film and oblique after 

instillation of contrast.

▶ Postcontrast drainage film.

° CT cystogram

▶ Only requires fill film.

▶ Dilute contrast to 1/4 to 1/3 of its full concentration using

sterile saline.

▶ Must fill bladder (not just clamp) catheter during contrast 

abdominal CT (fill per description above).

• Treatment

° Administer antibiotics until 48 hours after the catheter is 

removed.
Pediatric Surgery and Medicine for Hostile Environments

Figure 24-3. Computed tomography cystogram showing extraperitoneal 

bladder rupture.

384

Table 24-1. Urethral Catheter Size Estimation*

Age Size†

Newborn 5

3 mo 8

1 y 8–10

3–6 y 10

8 y 10–12

10 y 12

12 y 12–14

Teenager 16+

*In males, use a tube that fits the meatus, the narrowest part of the male 

urethra.

†

French feeding tube or Foley catheter. A French-sized feeding tube may 

be used if a Foley catheter is unavailable or if the Foley catheters that are 

available are too big.
Genitourinary Tract

385

° Small children, particularly boys, will need a large-caliber 

suprapubic tube (SPT); a small urethral catheter will not 

drain clots.

° Once repaired, drain 7 to 10 days, then reimage with a 

cystogram.

° If no bone spicules are evident and bladder neck injury 

is ruled out, place an indwelling catheter and observe 

extraperitoneal injuries; reimage in about 2 weeks.

° Identify and avoid disruption or occlusion of the ureteral 

orifices.

° Use absorbable suture in two-layer closure if possible, 

though one layer heals fine in almost every instance.

° Check for coexisting ureteral injury (ensure clear efflux if 

possible, consider IV methylene blue).

° Consider perivesical drain if closure was tenuous.

° Bladder injury is twice as likely to involve the bladder neck 

in children as it is in adults.

▶ If bladder neck is not repaired, the patient will likely 

sustain persistent urinary extravasation.

▶ Bladder neck injury increases the risk for incontinence.

▶ Suspect a bladder neck injury if there is contrast 

extravasation and an incompetent bladder neck is 

apparent on cystogram.

° Repairing bladder neck injury

▶ Open bladder at dome.

▶ Use care to avoid disrupting a pelvic hematoma.

▶ Use an intravesical closure (absorbable) suture in 

multiple layers with suprapubic and urethral catheter 

drainage.

▶ Avoid iatrogenic injury to the ureters. Place temporary 

ureteral catheters (feeding tubes) if needed.

▶ Close cystotomy per routine above.

Urethral Injury

• Urethral injury differs in children from that in adults.

° Pelvic fracture is more likely to be unstable in children than 

in adults, displacing the prostatic urethra.

° Complete posterior urethral disruption is more common 

in boys than men.
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386

° There is a 20% incidence of both bladder and urethral 

injuries in children.

° Prepubertal girls are four-fold as likely to have urethral 

injury with a pelvic fracture as adult women.

• Imaging

° Indications

▶ perineal/penile hematoma,

▶ blood at meatus/introitus,

▶ inability to void,

▶ one or more pubic rami factures or symphysis diastasis,

▶ evidence of bladder neck injury on CT, and

▶ inability to pass a urethral catheter.

▷ Males: Perform retrograde urethrogram. Insert a 6 Fr 

or 8 Fr Foley catheter, with balloon gently inflated 

with approximately 1 cc, in the fossa navicularis and 

perform retrograde instillation of 10 to 15 cc contrast 

with an oblique film, visualizing contrast into the 

bladder.

▷ Females: Anesthetize patient and perform 

vaginoscopy or cystoscopy. For prepubertal girls, 

use a nasal speculum, cystoscope, or ureteroscope.

° Urethral injury combined with pelvic fracture mandates a 

rectal examination.

▶ Blood in stool indicates a potential occult rectal injury.

▶ Consider rigid proctoscopy. Rigid scopes are the 

standard of care in trauma because of their ease of use 

in an unprepped patient, availability, and speed, and 

because they do not require a high-intensity light source. 

▶ Treat the rectal injury with a sigmoid colostomy.

° Urethral injury in boys is frequently associated with a pelvic 

fracture. Most are bulbomembranous urethral disruptions 

but prostatic urethral disruption from the bladder neck can 

occur in young boys with severe trauma.

▶ Perform a retrograde urethrogram (RUG) by inserting 

a 6 Fr or 8 Fr Foley catheter, with t h e balloon 

gently inflated with approximately 1 cc, into the fossa 

navicularis and perform retrograde instillation of 10 to 

15 cc of water-soluble contrast and obtain an oblique 

film, visualizing the flow of contrast in the urethra and 

bladder.
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387

▶ If RUG demonstrates the presence of, or is suspicious 

for, a complete urethral disruption, then:

▷ Divert urine per below and prepare for delayed repair 

in 3 to 6 months.

▷ Immediate repair is associated with worse outcomes 

with respect to stricture, erectile dysfunction, and 

incontinence.

▶ Injuries to the anterior urethra can be repaired primarily 

in the absence of large amounts of devitalized tissue. 

With blast injuries and massive tissue loss, debride and 

divert urine and plan for delayed reconstruction.

° Urethral injury in girls

▶ Invariably associated with a pelvic fracture. 

▶ 75% are associated with a vaginal injury, 30% are 

concurrent with rectal injury.

▶ Treatment

▷ Administer broad-spectrum antibiotics.

▷ Assess bladder neck.

▷ Establish urinary drainage with a urethral catheter 

or SPT; vesicostomy is a diversion option in infants 

and small children. Make a small transverse incision 

between the pubis and the umbilicus, mobilize and 

open the dome of the bladder, and mature stoma 

(evert and sew down along the edge of the bowel) to 

rectus fascia and skin.

▷ Encourage gentle passage of urethral catheter (if 

disruption is not complete) to establish continuity; 

abort if passing the catheter is difficult.

▷ If the urethra is repaired or a catheter is placed across 

an incomplete urethral disruption, leave the catheter 

in place for 3 weeks then perform a pericatheter 

RUG or voiding cystourethrogram prior to catheter 

removal.

▷ Repair small lacerations of the anterior urethra with 

fine, absorbable suture in multiple, nonoverlapping 

layers, if possible.

▷ If there is a large injury or complete disruption, close 

likely vaginal laceration and divert urine for delayed 

reconstruction of urethra.
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388

External Genital Injuries

• Management of penile, scrotal, and testicular injuries is 

equivalent to that of adults.

• Evaluate for concomitant rectal injury in the presence of 

penetrating scrotal or vulvar trauma.

• Perform meticulous examination under anesthesia to assess 

depth and extent of the wound, debridement of nonviable 

tissue, and evidence of concomitant injuries.

° Even the smallest penetrating blast wound on the scrotum 

can be associated with testicular rupture; there is a low 

threshold to explore surgically if physical examination is 

not completely normal.

° Scrotal ultrasound can be useful in helping decide on the 

need for surgical exploration.

• In the presence of associated hematuria or blood on rectal 

examination, evaluate for urethral injury or rectal injury, 

respectively.

• Repair injuries with appropriately sized fine absorbable 

suture.

• If there are concerns for nonviable tissue, debride on multiple 

occasions prior to considering reconstruction.

• Meticulous closure of the tunica albuginea of the testis in the 

presence of testis rupture is important; doing so may reduce 

inflammation and the production of antisperm antibodies, 

which can affect future fertility.

Conditions of the Genitourinary Tract

Urinary Tract Infection

• Diagnosis

° Neonates: symptoms include jaundice, failure to thrive, 

and fever.

° Older children: symptoms include dysuria, urgency, 

frequency, enuresis.

° A positive urine culture using urine taken from a 

collecting bag should be confirmed by a specimen 

obtained by suprapubic aspiration or sterile transurethral 

catheterization. Urinary tract infection (UTI) manifests as 

more than 105 colonies/mL of a single bacterial species.
Genitourinary Tract

389

° Accuracy is 80% in a bagged specimen, 95% in a catheterized 

specimen, and 99% in a specimen obtained from suprapubic 

aspiration.

▶ White blood cells in urine are suggestive of UTI (usually 

leukocyte esterase positive).

▶ Perform a nitrite test. Nitrate that is normally present in 

urine is converted to nitrite by bacteria.

° Classification

▶ Upper tract infection (pyelonephritis)

▷ Symptoms: fever, flank pain or tenderness, increased 

white blood cell count.

▷ Imaging: ultrasound/CT scan to rule out a perinephric 

abscess.

▷ Treatment: IV antibiotics for at least 14 days.

▶ Lower tract infection: diagnosis is made by suprapubic 

aspiration or catheterized specimen.

° Pathophysiology

▶ Protective factors include:

▷ regular complete bladder emptying (avoid urine 

stasis),

▷ antimicrobial activity of urothelium (urothelial cells 

secrete a mucopolysaccharide coating, which traps 

bacteria), and 

▷ acid pH and high urinary osmolality.

▶ Potentiating factors include urinary stasis, vesicoureteral 

reflux, urolithiasis, obstruction, periurethral colonization 

(usually with gut flora), and phimosis.

▶ Bacterial factors

▷ O (lipopolysaccharide), K, H antigens;

▷ hemolysins; and

▷ urease produces alkalization of urine, resulting in 

stone formation.

° Laboratory findings

▶ 50% of patients under 12 years old with a UTI have 

associated urinary tract abnormalities.

▶ If a culture from urinary analysis is positive, proceed 

to renal and bladder ultrasound, especially if UTI is 

associated with fevers. 

▶ If patient has had multiple UTI episodes or ultrasound 

is abnormal, consider voiding cystourethrogram.
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390

▶ Nuclear medicine studies, such as a dimercaptosuccinic 

acid renal scan, are in the algorithm for febrile UTI 

work-up in children, but this modality is not likely to 

be available in an austere environment.

° Treatment

▶ Multidrug-resistant organisms can be highly prevalent 

even in austere environments (eg, there is a high 

prevalence of extended spectrum beta-lactamase 

multidrug resistant E coli in Afghanistan).

▷ If antimicrobial resistance profiles are available for 

your area, chose therapies accordingly.

▷ Use ampicillin plus gentamicin for the majority of 

gram-negative organisms, third- or fourth-generation 

cephalosporin, extended spectrum penicillin for 10 to 

14 days.

▶ Provide adequate hydration.

▶ Consider Foley catheter drainage during the acute phase 

of infection.

▶ Consider drainage of any potentially obstructed regions 

of the urinary tract (SPT or Foley catheter for bladder 

outlet obstruction, percutaneous nephrostomy or 

ureteral stent for upper tract obstruction).

Penis

• Foreskin retractility

° In a term newborn, the foreskin is usually not retractile 

(physiologic phimosis). At 6 months old, it is about 20% 

retractile; by 6 years old, it is 40% retractile; and by 13 years 

old, it is 100% retractile.

° High-potency steroid ointments (eg, clobetasol or 

betamethasone 0.05%) applied twice a day for 6 weeks, 

along with manual retraction, can resolve clinically 

significant phimosis in lieu of circumcision. 

• Hypospadias

° Hypospadias describes the condition when the urethral 

meatus opens onto the ventral surface of the penis, proximal 

to the end of the glans.

° Associated anomalies include inguinal hernia and 

undescended testicles (UDTs), disorders of sexual 

differentiation.
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391

° Hypospadias is usually repaired in the first year of life.

° Hypospadias commonly involves the distal penis (glanular 

or coronal).

° It may be associated with ventral curvature (ie, chordee).

° Avoid circumcision to facilitate later reconstruction, if 

desired. 

° Distal hypospadias without chordee does not generally 

affect voiding or fertility and does not need repair, 

especially in an austere environment.

° Repair of more proximal hypospadias should be performed 

by a surgeon with advanced training in pediatric genital 

reconstruction because of the risk of potential complications.

• Epispadias 

° Epispadias describes the condition in which the urethral 

meatus opens onto the dorsal surface of the penis, proximal 

to the end of the glans (Figure 24-4).

° It is usually also associated with bladder exstrophy.

° Repairing bladder exstrophy or epispadias is a major 

undertaking.

▶ In developing countries, exstrophy and epispadias 

are often either not repaired or are addressed 

with some form of urinary diversion (cystectomy, 

ureterosigmoidostomy).

▶ Bladder closure usually requires osteotomy with 

prolonged hospitalization and is not advisable in an 

austere environment. 

▶ Isolated epispadias is rare but can be repaired on an

outpatient basis.

• Phimosis

° Phimosis manifests on physical examination when the male 

foreskin cannot be fully retracted behind the head of the 

penis (this normal in infancy; Figure 24-5).

° It is congenital or acquired secondary to recurrent infections 

of the glans penis (balanitis) or foreskin (posthitis), or 

following local trauma. 

° Complications include impairment or obstruction to 

urinary flow with ballooning of the foreskin upon voiding 

and paraphimosis.

° Treatment is circumcision or a 6-week trial of high-potency 

steroid ointment (betamethasone 0.05% or clobetasol 0.05% 
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392

Figure 24-4. Bladder exstrophy with epispadias. 

Figure 24-5. Phimosis.
Genitourinary Tract

393

ointment) applied twice a day with manual retraction of 

foreskin (over 80% success rate).

• Paraphimosis 

° Paraphimosis is evident on physical examination when 

the foreskin becomes trapped behind the glans penis and 

cannot easily be pulled back to its normal position. This is 

usually associated with remarkable edema of the foreskin 

and glans by the time of presentation (Figure 24-6).

° Complications include constriction of blood supply to the 

glans.

° Treatment options

▶ Compress the glans and move the foreskin back to its 

normal position. This can almost always be done but 

requires very aggressive compression of the glans and 

foreskin and may require at least conscious sedation.

▶ Make a dorsal slit in the foreskin or perform circumcision.

Figure 24-6. Paraphimosis.
Pediatric Surgery and Medicine for Hostile Environments

394

▶ Under topical (lidocaine/prilocaine cream) or regional 

anesthesia (penile block), use a syringe needle to make 

multiple punctures in the edematous foreskin, express 

the edema fluid, then compress as described above. 

° To prevent recurring paraphimosis, pull the foreskin back 

over the glans after it has been retracted (eg, for insertion 

of a Foley catheter).

• Circumcision

° Surgical indications for circumcision include:

▶ Definite: phimosis that is not responsive to medical 

therapy (steroid ointment), paraphimosis, and recurrent 

balanitis.

▶ Relative: recurrent UTI (may only reduce infection risk 

in the first year of life).

° Techniques (YouTube videos are very instructive for those 

unfamiliar with the use of any of these devices):

▶ Freehand using sleeve technique.

▶ PlastiBell (Hollister, Inc, Libertyville, Ill).

▶ Gomco clamp.

▶ Mogen clamp.

° Complications include bleeding, infection, urethral injury, 

and removal of too much or too little foreskin.

Testicular and Scrotal Conditions

• Retractile testis

° In a term male infant, both testes are normally present 

within the scrotum.

° A retractile testes appears to be undescended and can be 

brought down into the scrotum by careful manipulation, 

and will remain there when the child is calm.

° Retractile testes are usually bilateral and result from an 

overactive cremaster muscle, which becomes less active 

with age.

° Testes normally remain in the scrotum after the onset of 

puberty.

• Cryptorchidism

° In ectopic cryptorchidism, the testis is located in an 

abnormal position (thigh, groin). This results from 

abnormally positioned gubernaculum and puts the patient 

at an increased risk of trauma.
Genitourinary Tract

395

° Anorchism/Vanishing Testis

▶ Anorchism: testis is absent due to prenatal torsion or 

infarction. 

▶ Diagnose with laparoscopy and groin exploration. Do 

not rely on ultrasound findings.

▶ Bilateral anorchism: requires a lifetime of endocrine 

support at expected onset of puberty.

° An undescended testicle (UDT) is associated with 

abnormal spermatogenesis and an increased risk for future 

development of testicular cancer. The higher the position 

of the testis, the more abnormal, and the more difficult to 

reposition into the scrotum. In most cases, the testis fails 

to reach scrotum because the gonadal artery is too short. 

UDT may be located anywhere from the renal hilum to the 

external inguinal ring.

▶ Smaller, softer, and more elongated than a normal testes.

▶ 80% to 90% have an associated hernia sac.

▶ Testicular degeneration begins after the second year of 

age.

▶ May produce autoantibodies that injure the other testis.

▶ Incidence (similar to inguinal hernias)

▷ Right side: 50%.

▷ Left side: 25%.

▷ Bilateral: 25%.

▷ 10-fold more common in premature infants.

▷ About 4% of full-term newborn male infants will have 

a UDT.

▷ About 75% will descend in the first 6 months of life 

such that about 0.8% to 1% of males beyond 6 months 

of life have a UDT.

▶ Operation is indicated for the following reasons:

▷ Improved spermatogenesis. Cryptorchid testis 

is exposed to increased temperature, resulting 

in decreased spermatogenesis. Determinants of 

the degree of testicular damage include length of 

exposure and degree of nondescent.

▷ Unilateral UDT, which is associated with 

approximately normal fertility if corrected before 2 

years of age.
Pediatric Surgery and Medicine for Hostile Environments

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▷ Potential for malignant change, which results in 10- 

to 20-fold increased risk for testis cancer if it is not 

corrected. The sooner the testis is positioned into 

the scrotum, the more the risk for cancer is reduced. 

Risk is not completely absolved with orchiopexy, but 

detection is much easier if testis is in scrotum.

▷ Decreasing the high possibility of trauma and torsion 

in UDT.

▷ For repair of associated hernia.

▷ For cosmetic and psychological considerations.

▶ Perform an orchiopexy by 6 months to 2 years of age. 

Orchiopexy in older children is possible and indicated, 

but outcomes are poorer. Beyond approximately 14 years 

of age, orchiectomy with orchiopexy of the contralateral 

testis is usually recommended, provided contralateral 

testis is normal.

▷ To treat surgically, free the testis and spermatic cord 

structures from the attached cremasteric fibers and 

place into a dartos pouch within the scrotum. The 

length of the gonadal artery may be a limiting factor. 

If testis is not palpable, first perform a diagnostic 

laparoscopy, if possible.

▷ When testis are found to be intraabdominal, use firststage Fowler-Stephens orchiopexy (laparoscopic). 

Ligate (clip) the spermatic artery and vein high in the 

retroperitoneal space; the testicular blood supply is 

then derived from vessels to the vas, deep epigastric 

collaterals, and processes vaginalis. Second stage 

Fowler- Stephens can be performed at 6 to 12 months 

after the first stage by bringing the testicle down into 

the scrotum (usually laparoscopically) on its new 

collateral blood supply.

▷ Single-stage laparoscopic orchiopexy without vessel 

ligation can sometimes be performed.

▷ Single-stage Fowler-Stephens orchiopexy is also 

an option with higher risk of postoperative testis 

atrophy.

▷ Testes absent (“anorchia” or “vanishing”): diagnose 

by identifying a blind-ending vas and vessels (using 

laparoscopy), then close.
Genitourinary Tract

397

▷ Atrophic/dystrophic testes: orchiectomy, especially if 

contralateral testis is normal.

▷ Vas and vessels exiting internal ring: perform 

groin exploration and orchiopexy (less likely) or 

orchiectomy (most likely). Usually an atrophic scrotal 

“nubbin” can be found in this instance.

▷ Testis palpable in canal: perform orchiopexy.

▷ Results include injury to vas (uncommon); injury to 

gonadal vessels, which may cause atrophy; invariably 

infertility in patients with uncorrected bilateral UDT 

(70% of patients with bilateral UDT corrected prior 

to 2 years of age are fertile).

Acute Conditions of the Scrotum

• Torsion

° Torsion is the most common genitourinary emergency of 

childhood.

° It usually occurs in late childhood to early adolescence, 

peaking at age 14, but can occur at any age.

° Torsion is the twisting of the testicle on its blood supply, 

which may result in infarction.

° Differential diagnosis

▶ Major

▷ Torsion of testis.

▷ Torsion of appendix testis or epididymis.

▷ Epididymitis.

▷ Orchitis.

▷ Trauma.

▷ Tumor.

▷ Hemorrhage.

▶ Minor

▷ Idiopathic scrotal edema.

▷ Hernia/hydrocele.

° Types of torsion

▶ Neonatal torsion/extravaginal

▷ Occurs in the perinatal period due to poor fixation of 

the tunica vaginalis to the overlying dartos.

▷ True torsion of the spermatic cord.
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▷ Usually results in complete infarction by the time of 

presentation, requiring orchiectomy.

▷ Probable etiology of “vanishing testis” syndrome 

(unilateral anorchia).

▷ Need for contralateral orchiopexy to prevent 

metachronous torsion is controversial, but probably 

not harmful.

▶ Intravaginal or bell clapper deformity

▷ Abnormally high reflection of the tunica vaginalis 

upward from its usual, more equatorial position about 

the testicle to a level of attachment to the spermatic 

cord itself.

▷ Leaves the testicle hanging (like the clapper of a bell) 

within the tunica vaginalis, able to spin freely around 

the long axis of the spermatic cord.

▶ Typical adolescent torsion.

° Symptoms of torsion

▶ Scrotal pain

▷ Abrupt onset suggests testicular torsion; acute scrotal 

pain must be considered torsion of the testicle until 

proven otherwise.

▷ Gradual (12–24 h) onset suggests torsion of the 

appendix testis or infectious case; pain radiates 

upward toward groin and lower abdomen.

▷ Nausea and vomiting are predictive of testicular 

torsion and the absence of these symptoms makes 

torsion less likely; lower abdominal pain can also be 

present.

▷ History will consist of prior transient episodes 

of testicular pain with spontaneous resolution 

(intermittent torsion).

▷ Will present with red, painful, tender scrotum; testis 

will be enlarged, tender, and elevated within scrotum.

▷ Pain is increased (or not decreased) when scrotum is 

lifted (negative Prehn’s sign).

▷ Differential diagnosis: localization of tenderness to 

particular scrotal structures.

° Laboratory tests

▶ Complete blood count may show increased white blood 

cell count.
Genitourinary Tract

399

▶ Urinary analysis will show increased white blood cell 

count.

▶ Diagnose using Doppler ultrasound to assess blood flow 

to the testicle and differentiate ischemia (torsion) from an 

inflammatory process (epididymitis). Epididymitis and 

torsion of appendix testis will show markedly increased 

blood flow to the affected side.

° Treatment

▶ Sedate the patient and attempt manual detorsion.

▷ Torsion will usually (but not always) occur in a medial 

direction.

▷ Detorsion should be attempted by twisting the testicle 

laterally (like opening a book).

▷ Even if detorsion is successful, immediate orchiopexy 

is still recommended. Perform prompt bilateral 

orchiopexy using midline scrotal raphe incision. 

Detorse testis and assess viability (cover in warm 

soaked gauze and assess with Doppler, if needed). If 

viable, suture tunica albuginea to scrotal wall using 3 

to 4 nonabsorbable or long-lasting absorbable sutures. 

If torsion is present for more than 12 hours or is 

necrotic, consider performing orchiectomy (necrotic 

testes may produce autoimmune antibodies). DO 

NOT forget to perform orchiopexy on the contralateral 

testis, regardless of the outcome of the affected testis. 

If torsion is present at birth, stabilize the baby before 

exploration (salvage is rarely possible).

° Prognosis

▶ Patient will have an increased risk of impaired 

spermatogenesis and infertility.

▷ Up to 6 hours: 90% chance of salvage.

▷ 6–12 hours: 75% chance of salvage.

▷ 12–24 hours: 50% chance of salvage.

▷ Over 24 hours: less than 10% chance of salvage.

• Torsion of appendix testis or appendix epididymis

° Transillumination may reveal the “blue dot” sign.

° Treatment

▶ Keep patient on bed rest with scrotal support and 

provide analgesics.
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400

▶ Operative intervention is rarely needed unless severe 

symptoms persist more than 2 to 3 days.

▶ If torsion of the testis cannot be distinguished from 

appendix testis by physical examination or Doppler 

ultrasound, prompt surgical exploration is indicated.

• Epididymitis

° Epididymitis is reflux of urine from the vas to the 

epididymis, inciting an inflammatory response, usually 

due to excessive urine holding or dysfunctional voiding. 

It can also be a result of a sexually transmitted disease 

(usually Neisseria gonorrhoeae or Chlamydia trachomatis). 

Viral syndromes are also possible.

° Symptoms

▶ Pain is decreased when the scrotum is lifted (Prehn’s 

sign).

▶ Urinary tract symptoms associated with epididymitis 

(usually seen in postpubertal boys) include urinary 

frequency, dysuria, and pyuria.

° Diagnosis and laboratory tests

▶ Urinary analysis will reveal bacteria.

▶ Send urine for culture, if possible.

▶ Test for sexually transmitted diseases in sexually active 

males.

▶ If urine culture is positive in a nonsexually active male, 

rule out congenital urinary tract anomaly (meatal 

stenosis, urethral stricture, delayed presentation of 

posterior urethral valves, etc).

▶ In recurrent cases, perform renal ultrasound to rule out 

hydronephrosis. Screen for ureteral ectopia.

▶ Consider performing voiding cystourethrography to 

rule out bladder outlet obstruction in recurrent cases.

▶ Noninvasive urinary flow testing (flow-rate) is also 

helpful, if available.

° Treatment

▶ If patient is sexually active, give antibiotics for chlamydia 

(doxycycline or azithromycin).

▶ If patient is not sexually active, give fluoroquinolone (short 

courses are sufficient in children), oral cephalosporin, or 

sulfamethoxazole/trimethoprim for 14 days.

▶ Use analgesics.
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401

• Orchitis

° Orchitis is usually due to a viral infection (eg, mumps).

° Scrotal skin is erythematous and edematous on physical 

examination, white blood cell count is increased, urinary 

analysis is normal, and ultrasound shows good blood flow 

to testis.

° Treatment consists of bed rest and observation.

° Orchitis is associated with decreased fertility.

• Varicocele

° Varicoceles occur most commonly on the left (left spermatic 

vein drains into the left renal vein).

° When idiopathic, they result from incompetent venous 

valves. They can often occur due to renal vein obstruction 

(renal vein thrombosis, retroperitoneal tumor; suspect 

obstruction in right-sided varicoceles).

° Symptoms include pain, testicular atrophy or hypotrophy, 

and decreased fertility (due to increased ambient 

temperature).

° Diagnosis is made by physical examination and confirmed 

with ultrasound, which will show dilated veins (“bag of 

worms”) superior to testis that increase with Valsalva 

maneuver and decrease when patient is supine.

° Treatment

▶ Measure dimensions of the testicle; atrophy more than 

20% compared to contralateral testis and pain are the 

primary indications for operation.

▶ If there is no significant atrophy and no pain, observe 

the patient.

▶ Perform laparoscopic, retroperitoneal ligation of the 

spermatic veins and artery, or inguinal or subinguinal 

varicocele ligation; all approaches are viable and 

effective.

• Tumor

° The most common testicular tumors in childhood include 

teratomas, yolk sac tumors, rhabdomyosarcoma, and 

lymphoma.

° A solid scrotal mass will be evident on physical examination.

° Diagnosis is made by ultrasound; elevated serum levels 

of α-fetoprotein, β-human chorionic gonadotropin, 
Pediatric Surgery and Medicine for Hostile Environments

402

lactate dehydrogenase; or visible mass lesion on the CT of 

abdomen and pelvis, if available. 

° Treatment consists of radical orchiectomy.

▶ Use inguinal incision; never approach through a scrotal 

incision.

▶ Do not perform a percutaneous biopsy.

▶ Clamp and individually ligate cord structures at the 

internal ring.

▶ Deliver testicle.

▶ Perform high inguinal orchiectomy if a neoplasm is 

present.

▶ The most common tumors (yolk sac and teratoma) 

usually have a benign course in prepubescent children 

and orchiectomy is curative.

▶ If patient is an adolescent child going through puberty, 

treat as though the patient were an adult.

▶ The need for adjuvant therapy is based on pathology 

results, tumor marker response, and axial imaging.

° Renal tumors 

▶ Treat and cure congenital mesoblastic nephroma in 

newborns with nephrectomy. 

▶ Wilms tumor occurs most commonly in 3- to 4-year-olds.

▷ Usually presents as a palpable flank mass or gross 

hematuria.

▷ Diagnose using ultrasound or CT scan.

▷ Staging and decision of surgical versus chemotherapy 

is complicated and should be researched prior to 

deciding on a treatment plan.

▷ General US practice is to perform initial radical 

nephroureterectomy with lymph node biopsy for 

lower stage tumors.

▶ Clear cell sarcoma of the kidney and renal cell carcinoma 

usually result in poor prognosis in older children. 

Consider whether definitive pathology results will 

be available before performing surgery for suspected 

malignancy. If you do not have access to pathology 

services but the patient can be transferred to a treatment 

facility where these services are available, it is often 

better to leave the tumor in the patient for excision at 
Genitourinary Tract

403

the receiving facility rather than risk losing the specimen 

in transit. Pathology results are critical in determining 

follow-up care and surveillance regimens.

Vaginal Conditions

• Labial fusion (labial adhesions)

° Etiology: chronic irritation, lack of estrogen stimulation.

° Symptoms include difficulty urinating, UTI, and pain.

° Physical examination will show fused labia minora.

° Treat as follows:

▶ Perform incision or separation under general anesthesia.

▶ Prescribe topical estrogen cream and/or high potency 

steroid ointment twice a day for 14 days.

▶ Perform gentle separation in office after applying 

lidocaine jelly or lidocaine/prilocaine cream.

° To prevent labial fusion, the patient must maintain good 

hygiene. Liberally apply petroleum jelly after separation 

for several weeks to prevent recurrence.

• Vaginitis

° Etiology

▶ When the patient is in prepuberty, allergy or irritation 

due to bubble bath or laundry detergent is most 

common, poor hygiene is also very common. Vaginal 

voiding with chemical irritation from urine is another 

potential cause.

▶ When the patient has reached puberty, the most likely 

cause is infection. 

▶ Ensure child has not been abused.

▶ Foreign body may also be to blame. 

° Diagnosis using vaginoscopy.

° Treatment

▶ Remove foreign body or irritant.

▶ Give antibiotics for infection (consider antifungals).

▶ Recommend sitz baths and improved hygiene.

▶ Change voiding behavior to prevent vaginal 

contamination (legs far apart, rock pelvis forward, or 

sit on toilet backwards).

• Urolithiasis
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404

° In the austere environment and in developing countries, 

renal and bladder stones are extremely common in both 

adults and children.

° Stones are a significant source of pain, UTI, and progressive 

renal failure.

° Urolithiasis is due to a poor, grain-based diet; overly 

prolonged breast-feeding; and generalized dehydration. 

Check serum calcium and uric acid, and perform a stone 

analysis.

° Endoscopic management of urolithiasis is very dependent 

on advanced urologic instrumentation and best left to a 

surgeon with specific urologic training.

° Bladder stones are easily treated with an open cystotomy 

incision, stone removal, and bladder closure.

▶ Leave an indwelling catheter (Foley or SPT) in place for 

7 to 10 days. 

▶ Close bladder in 2 or 3 layers using absorbable suture.

° Renal stones can be treated with open pyelolithotomy or 

anatrophic nephrolithotomy.

▶ If open stone surgery is performed, leaving a 

percutaneous nephrostomy tube or indwelling ureteral 

stent is recommended if possible, with removal in 7 to 

10 days to decrease the risk of urine leak and urinoma.

▶ Decrease warm ischemia with iced saline slush (if 

available) when performing anatrophic nephrolithotomy.

▶ Poorly functioning kidneys filled with stones are 

best treated with nephrectomy, especially when the 

contralateral kidney is normal.

▶ Advanced reading on the surgical steps is recommended 

prior to proceeding with open stone surgery, as most 

surgeons rarely perform these procedures even outside 

of an austere environment.
 Basic Fluid and Electrolytes

405

Medicine
Pediatric Surgery and Medicine for Hostile Environments

406
 Basic Fluid and Electrolytes

407

Chapter 25

Basic Fluid and Electrolytes

Introduction

Infants and young children have a greater need for water and are 

more vulnerable to alterations in fluid and electrolyte imbalances 

than adults. Water and electrolyte imbalances occur more 

frequently and more rapidly in children. In addition, children 

adjust less promptly to those disturbances because infants and 

children also have a greater proportional amount of extracellular 

fluid volume.

Normal Distribution of Body Water and Electrolytes

Total body water (TBW) varies with an individual’s age and 

amount of muscle mass and body fat.

• 80%–85% of a premature infant’s body weight is attributed to 

water.

• About 70% of a full-term infant’s body weight is attributed to 

water.

• Body weight attributed to water in young adults differs 

between males and females:

° Males: approximately 65% total body weight.

° Females: approximately 52% of total body weight.

• During infancy, a larger proportion of body water is 

extracellular.

Changes in Fluid Composition and Distribution During Critical 

Illness

Critically ill infants and children tend to retain fluids because 

of increased secretion of antidiuretic hormone (ADH) and 

aldosterone.
Pediatric Surgery and Medicine for Hostile Environments

408

• Catecholamine release, hypotension, fright, and pain stimulate 

the release of ADH, renin, and aldosterone.

• ADH release is also stimulated by any condition that reduces 

left atrial pressure (eg, hemorrhage, positive-pressure 

ventilation, or severe pulmonary hypertension), general 

anesthetics, morphine, and barbiturates.

• Critically ill pediatric patients often exhibit decreased urine 

volume and increased urine concentration in the presence of 

dilution of intravascular space.

• A newborn’s kidney has a limited ability to concentrate urine 

(< 600 mOsm/L); a neonate may have decreased urine volume 

and only moderate urine concentration.

Administering Maintenance Fluid

Fluid administration must be tailored to prevent fluid overload 

or sodium imbalance (Tables 25-1 and 25-2).

• Fluid and electrolyte losses in urine most closely resemble 

0.45 normal saline (1⁄2NS); insensible losses are more similar 

to 0.2 NS.

• Daily sodium requirement: 3 mEq/kg/day.

• 1⁄2NS is usually administered with 5% or 10% glucose immediately 

postoperatively to replace insensible and urine losses.

• Excessive gastrointestinal losses are generally replaced with 

1⁄2NS or NS.

Table 25-1. Pediatric Daily Maintenance Fluid Requirements

Goal Calories

Age/Weight Fluid (kcal/kg) Dextrose*

Infants (> 1 100–120 mL/kg ~ 120 5%–10%

month old)

< 10 kg 100 mL/kg ~ 110 5%

10–20 kg 1,000 mL + 50 ~ 80 5%

mL/kg > 10 kg

> 20 kg 1,500 mL + 20 ≥ 45 5%

mL/kg > 20

*Percent of dextrose in water.
 Basic Fluid and Electrolytes

409

Table 25-3. Differentiating Sources of Sodium Disturbances

Intravascular

Condition Volume Status Serum Sodium Urine Volume Urine Sodium Net Sodium StatusHyponatremic dehydration i	 i	 i i iSIADH Normal or h	 i i 	 h NormalCSW i	 i	 h	 h	 ii: decreasedh: increased

Table 25-2. Pediatric Daily Electrolyte Requirements

CSW: cerebral salt wastingSIADH: syndrome of inappropriate antidiuretic hormone

*

Age Sodium Potassium Magnesium† Calcium† Phosphorus†Infants/Children 3.0 mEq/kg‡ 2.0 mEq/kg 0.25 mEq/kg 1.0 mEq/kg 0.50 mEq/kgAdolescents 2.0 mEq/kg 1.0 mEq/kg 0.25 mEq/kg 0.25 mEq/kg 0.25 mEq/kg*A standard pediatric fluid is D5 1⁄2NS with 20 mEq of KCl. (Some experts now recommend using normal saline as a base intravenous fluid in pediatrics to avoid 

iatrogenic hyponatremia.)

†Consider adding if using intravenous fluids for more than 3 to 5 days.‡1 mEq potassium phosphate = 0.68 mMol phosphorus (1 mEq sodium phosphate = 0.75 mMol phosphorus).
Pediatric Surgery and Medicine for Hostile Environments

410

• All infusions should be connected to a constant infusion pump.

• Specific electrolyte needs and therapies require different 

concentrations.

° D10 with 1⁄2NS: neonates; D5

 with 1⁄2NS: older infants and 

children.

° Add potassium (20 mEq/L) if urine output is adequate, or 

if serum creatinine and potassium levels are normal.

° Some experts now recommend using NS as a base 

intravenous (IV) fluid in pediatrics to avoid iatrogenic 

hyponatremia.

° Monitor urine volume closely, using a Foley catheter if 

necessary. 

▶ The average is greater than 1 mL/kg/h if fluid volume 

is adequate.

▶ If fluid is severely restricted, urine volume may average 

0.5 to 1 mL/kg/h.

• Fluid deficit replacement can be calculated using the following 

formula:

% deficit × weight (grams) = fluid deficit in mL

For example, 10% dehydration of a 7-kg infant would be 

calculated as follows:

10% × 7,000 g = 700 g or 700 mL

Add deficit to maintenance fluids of 700 mL to give 1,400 mL 

for the day.

• See Chapter 6, Hemodynamics and Shock, Table 6-1, for 

clinical features to help assess the severity of hypovolemic 

shock.

• To calculate hourly maintenance fluid rate, give 4 mL/kg/h for 

the first 10 kg body weight, an additional 2 mL/kg/h for the 

second 10 kg body weight, and 1 mL/kg/h for every kg above 

20 kg.
 Basic Fluid and Electrolytes

411

Electrolyte Management

Hypokalemia

• Commonly seen with use of loop and thiazide diuretics.

• Also found following vomiting, diarrhea, intestinal fistulas, 

ileostomy drainage, or gastric suctioning.

• Excessive renal excretion of potassium is associated with metabolic 

alkalosis, renal tubular acidosis, and diabetic ketoacidosis.

• Cardiac dysrhythmias occur infrequently unless the 

hypokalemia is severe (serum K+ < 2.3 mEq/L).

• Electrocardiogram (ECG) findings include low-voltage, 

flattened T waves, and prolonged QT interval.

• Management

° Use IV potassium replacement if the child is nauseated 

and vomiting; continuous replacement is preferred over 

potassium chloride “bolus” therapy.

▶ Potassium chloride infusions should not exceed 1 mEq/

kg and should not be delivered faster than over 60 to 90 

minutes (maximum 25 mEq KCl). 

▶ Patient should be observed closely on a cardiac monitor.

▶ Peripheral veins will routinely tolerate up to 40 mEq/L 

KCl in IV fluids.

° Consider adding potassium chloride supplements to enteral 

feeds in the absence of vomiting.

▶ No oral potassium should be given 1 hour before or 

after an IV potassium bolus. 

▶ Administer 1 mEq/kg/dose added to formula or with 

a meal 3 to 4 times daily, depending on the degree of 

hypokalemia.

▶ Do not exceed 1 mEq/oz of enteral formula during tube 

feeds.

Hyperkalemia

• Etiologies include excessive potassium administration, 

acidosis, significant cell destruction, and reduced renal 

excretion of potassium.

• Common signs include generalized muscle weakness and 

flaccidity (K+ > 6.2 mEq/L).
Pediatric Surgery and Medicine for Hostile Environments

412

• ECG findings include a tall, peaked T wave on ECG initially, 

followed by widened QRS, ST segment depression, and 

increasing R wave amplitude.

• As serum potassium level rises, PR interval prolongs, and 

ventricular fibrillation may occur.

• Management includes frequent assessments and careful 

monitoring of input and output (ie, fluids in and urine and 

drainage out).

• Emergent management should be performed rapidly and 

sequentially. 

° If the patient is not already fluid overloaded, rapidly 

reexpand intravascular volume with NS 10 to 20 mL/kg.

° Administer calcium gluconate 100 mg/kg over 5 minutes 

(maximum dose is 2 g). Give IV calcium through a central 

line, if available. Calcium preparations can cause skin burns 

if the peripheral IV is infiltrated; flush with NS before giving 

bicarbonate.

° Use sodium bicarbonate (1 mEq/kg over 5 min) in the 

presence of metabolic acidosis.

° Glucose and insulin therapy is very effective in children; 

give 0.5 g/kg of glucose (5 cc/kg of D10) and 0.1 unit/kg of 

insulin over 30 minutes, simultaneously but in separate 

drips. 

° Administer sodium polystyrene sulfonate 1 g/kg/dose 

(maximum dose 30 g, onset of action 1–2 hours) diluted in 

3 to 4 mL of water every 6 hours orally, nasogastrically, or 

rectally.

° Consider giving an inhaled albuterol treatment, which will

begin to lower the serum potassium level in 30 minutes.

° Consider furosemide 0.5 to 1 mg/kg IV to augment

potassium losses in urine. 

Hyponatremia

• Common etiologies include hyponatremic dehydration

due to excessive sodium loss or diuretic use; syndrome of 

inappropriate antidiuretic hormone (SIADH), and cerebral salt 

wasting syndrome. This can be seen with major head trauma 

or meningitis (Table 25-3). 
 Basic Fluid and Electrolytes

413

Na+ deficit = (140 – serum Na+) × weight (kg) × 0.6

° Checking urine sodium and osmolality and assessing 

hydration status will determine the underlying 

pathophysiology of the disorder.

° Hyponatremic dehydration can be corrected over 24 hours, 

with half the deficit replaced in the first 8 hours.

° Sodium (Na+

) deficit can be calculated as follows:

▶ Add the deficit sodium and water to the daily 

maintenance sodium and water to derive the most 

appropriate fluid (at least 1⁄2NS, more likely NS).

▶ Serum sodium should not rise more than 0.5 mEq/L/h. 

▶ Potassium chloride (20 mEq/L) may be added when the 

patient voids.

° Managing SIADH involves relative fluid and free water 

restriction; use NS to avoid giving free water.

° Managing cerebral salt wasting involves aggressively 

replacing ongoing salt and water loss with frequent 

monitoring of serum sodium levels (every 4 hours) during 

acute management.

▶ Replace sodium deficit with a combination of NS and 

3% hypertonic saline, ideally through a central line; 

maximum infusion rate 2 mL/kg/h (1 mEq/kg/h). 

▶ If no central line is available, a 1:1 mixture of NS and 

3% hypertonic saline can be safely infused peripherally. 

Hypernatremia

• Etiologies include hypernatremic/hypertonic dehydration 

and diabetes insipidus.

• Checking urine concentration, sodium, and osmolality and 

assessing hydration status will help determine the underlying 

pathophysiology of the disorder.

• Management of hypernatremic dehydration, like all severe 

hypertonic states (eg, diabetic ketoacidosis) requires a slower 

correction, usually over 48 to 72 hours, depending on the 

duration and severity of the hypernatremia (eg, a 10-day-old 

breast-fed infant whose serum sodium rose to 165 mEq/dL 

over many days).
Pediatric Surgery and Medicine for Hostile Environments

414

• Calculating the sodium deficit can be complex; if all volume 

lost is assumed to be 140 mEq/L, the most likely calculation 

error will be avoided. 

° For severe hypernatremic dehydration (Na+ ≥ 165), do not 

use anything less tonic than NS for at least the first 12 h.

° Sodium level should not fall more than 0.5 mEq/L/h.
415

Respiratory Emergencies

Chapter 26

Respiratory Emergencies

Introduction

Breathing should be effortless, and individuals should exhibit 

respiratory rates and tidal volumes appropriate for their ages 

(normally 5 mL/kg in spontaneously ventilating infants and 

children; Table 26-1). A comprehensive equipment table in 

Appendix C of this book contains weight-based recommendations 

for all equipment needed to mechanically ventilate an infant or 

child.

Table 26-1. Pediatric Respiratory Rates

Age (y) Respiratory Rate (breaths per min)

< 1 30–60

1–3 24–40

4–5 22–34

6–12 18–30

> 12 12–16

Work of Breathing

• Evidence of increased work of breathing in a child may include 

the following:

° tachypnea;

° retractions (intercostal, subcostal, or suprasternal);

° use of accessory muscles;

° head bobbing;

° open-mouth breathing;

° nasal flaring; and

° grunting (an ominous sign!).
416

Pediatric Surgery and Medicine for Hostile Environments 

• Appropriate tidal volume should be judged by thoughtful 

analysis during auscultation (ie, does the breath sound normal, 

small, or excessive?).

° Stridor is an abnormal breath sound that signifies upperairway obstruction. It is caused by a foreign body, infection, 

congenital airway anomalies, upper-airway edema, mass 

effect on the airway, or vocal cord impairment.

° Grunting is a short, low-pitched sound during exhalation 

and is an ominous sign.

▶ Grunting requires immediate intervention with 

supplemental oxygen, bag-mask ventilation, or 

intubation.

▶ It is the child’s attempt to keep his or her lungs open 

and sustain oxygenation by maintaining positive endexpiratory pressure.

▶ Grunting may be present in a variety of conditions, 

including pneumonia, pulmonary contusion, and acute 

respiratory distress syndrome. 

° Wheezing is typically a musical expiratory sound associated 

with lower-airway obstructive disorders.

▶ Asthma and bronchiolitis typically manifest with diffuse 

polyphonic wheezing, signifying the closure of many 

airways at different times. Treatment differs for asthma 

and bronchiolitis (see below).

▶ Central airway collapse disorders, such as tracheomalacia 

or bronchomalacia, typically manifest with monophonic 

wheezing (the same noise can be heard throughout the 

chest).

▶ In younger children (9–36 months), unilateral wheezing 

appreciated on examination may indicate partial airway 

obstruction or retained foreign body.

° Crackles/rales are inspiratory sounds typically associated 

with airway or alveolar disease and collapse (pneumonia, 

atelectasis, pulmonary edema).

° Pulse oximetry

▶ 94% SaO2 and above is normal for a child.

▶ Must be checked on warm, well-perfused extremity.

▶ Less than 90% SaO2 despite 100% oxygen administration 

may predict impending respiratory failure.
417

Respiratory Emergencies

▶ Less than 90% SaO2 requires consideration of previously 

undiagnosed congenital cyanotic heart disease in infants 

and children who present with minimal respiratory 

distress and cyanosis that does not improve despite 

oxygen.

Status Asthmaticus

• Status asthmaticus is characterized by respiratory distress due 

to airway obstruction from bronchospasm, excess mucous 

production, and airway inflammation.

• The following plan can be used for all acutely symptomatic 

asthma exacerbations (Tables 26-2–26-4): 

° Rapidly categorize severity based on presenting signs and 

symptoms.

° Use time-based management (see Tables 26-3–26-5), 

depending on severity.

° Evaluate disposition based on response to prompt therapy.

• Admit the patient for management if he or she cannot take 

medications or fluids orally, cannot maintain saturation at 

or above 91% SaO2 on room air, requires bronchodilators 

more often than every 3 to 4 hours, or if the patient is rapidly 

deteriorating (see Table 26-5).

• Watch for toxicities and side effects of medications (Table 26-6). 

° For example, extreme tachycardia can be seen when 

albuterol, ipratropium inhalation, and terbutaline are used 

in combination.

° An infant or toddler will tolerate a heart rate of 180 beats 

per minute, but an adolescent will not.

Managing Chronic Asthma

• Optimal long-term management of asthma leads to fewer 

acute exacerbations, minimal use of medications (short-acting 

b-agonists and oral corticosteroids), fewer restrictions on 

activity, and preservation of lung function. The following steps 

provide a framework for long-term asthma management: 

° Classify asthma severity. 

▶ Although spirometry provides an objective means for 

evaluating lung function, it is unlikely to be available. 
418

Pediatric Surgery and Medicine for Hostile Environments Table 26-2. Acute Asthma Severity Category Imminent Respiratory Signs and Symptoms Mild Moderate Severe Failure Respiratory rate 30% above mean 30%–50% above mean > 50% above mean > 50% above mean, or very slow Alertness Normal Usually agitated Agitated Drowsy, confused Dyspnea Mild Moderate Severe Severe Color Good Pale May be cyanotic Cyanotic Accessory muscle use Mild Moderate Severe Paradoxical thoracoabdominal movements Auscultation End-expiratory Inspiratory and Inaudible wheezing Inaudible wheezing, minimal wheeze expiratory wheezing breath sounds PEFR (% of predicted) 70%–90% 50%–70% < 50% < 20%

Air movement Good Fair Poor Poor/absentPaCO2 < 35 mmHg < 40 mmHg > 40 mmHg > 40 mmHgPEFR: peak expiratory flow ratePaCO2: partial pressure of carbon dioxide in arterial bloodAdapted from: National Institutes of Health, National Heart, Lung, and Blood Institute. Guidelines for the Diagnosis and Management of Asthma. Bethesda, MD: NIH; 1991.
419

Respiratory Emergencies

▶ Classifying asthma severity using an age-based table can 

help guide initial management (Table 26-7).

° Control precipitating factors and comorbid conditions.

▶ Identification and avoidance of known triggers, along 

with aggressive use of rescue medications, can help 

minimize symptoms. 

Table 26-3. Acute Asthma Treatment for Mild to Moderate 

Attacks

Timeframe Treatment

Presentation Check vitals and pulse oximetry; take brief history and 

perform PE, administer supplemental oxygen for sat ≤ 

90%, preferably keeping sat ≥ 94%

10–20 min Administer an immediate β-agonist (eg, albuterol):

MDI with spacer 4–8 puffs 

OR 

Albuterol (nebulized) 2.5–5 mg

Reassess and repeat q10–20min; consider adding 

ipratropium to subsequent nebulizer 0.25–0.5 mg

30 min Consider steroids:

Oral prednisone 1 mg/kg

OR

Methylprednisolone sodium succinate (IV or IM) 1 mg/

kg if unable to tolerate PO, max dose 60 mg

60 min Consider MgSO4:

50 mg/kg over 20 min and reassess (maximum single 

dose 2 g)

120–240 min Patient may be discharged if clinically improved with 

sat ≥ 94% and reliable follow-up established

IM: intramuscular

IV: intravenous

MDI: metered-dose inhaler 

MgSO4: magnesium sulfate 

PE: physical examination

PO: per os (by mouth)

sat: saturation

SQ: subcutaneous
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Pediatric Surgery and Medicine for Hostile Environments 

▶ Common triggers include upper respiratory infections, 

inhaled allergens (eg, pollen, dust mites), and irritants 

(eg, tobacco smoke, perfumes). 

▶ Comorbid conditions, such as rhinitis, reflux, obesity, 

and stress, are known to worsen asthma symptoms and 

should be treated.

° Provide asthma education. 

▶ Education should focus on the appropriate use of 

medications (proper use of inhaler, chamber, and 

spacer), avoiding environmental exposures, recognizing 

worsening symptoms and adjusting medications, and 

seeking appropriate medical care when needed. 

Table 26-4. Acute Asthma Treatment for Severe Attacks

Timeframe Treatment

Presentation Check vitals and pulse oximetry; take brief history and 

perform PE, administer supplemental oxygen for sat 

≤ 90%, preferably keeping sats ≥ 94%

10–20 min Administer an immediate β-agonist:

Albuterol (nebulized) 2.5–5 mg. Reassess and repeat 

q10–20min

OR

Terbutaline or epinephrine (1:1,000) 0.01 mg/kg (SQ) 

if unresponsive to albuterol or not moving air; may 

repeat in 15 min; max dose 0.3 mg

Add ipratropium to subsequent nebulizer 0.25–0.5 mg

30 min Steroids:

Methylprednisolone sodium succinate 1–2 mg/kg IV 

and reassess

60 min MgSO4 50 mg/kg over 20 min and reassess (max single 

dose 2 g)

Continue nebulizer as necessary

120–240 min Admit or transfer for ICU care if not improved

IV: intravenous

MgSO4: magnesium sulfate 

PE: physical examination 

PICU: pediatric intensive care unit 

sat: saturation 

SQ: subcutaneous
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Respiratory Emergencies

Table 26-5. Asthma Inpatient Management Plan

Ward Pediatric Intensive Care Unit

If O2 sat ≥ 94% on ≤ 50% FiO2 If patient remains in distress, use 

requires ≤ q2–3h albuterol albuterol continuously (0.6 mg/kg/h, 

PRN (MDI with spacer or range 10–40 mg/h) with O2 to keep O2

nebulized) sat ≥ 94% (always use humidified O2)

Use prednisone 2 mg/kg/day Use terbutaline drip as adjunct, bolus 

or methylprednisolone with 10 μg/kg over 10 min, then run 

sodium succinate 2–4 drip .1 μg/kg/min, titrating q15–

mg/kg/day ÷ q6h 30 min, up to max of 4 μg/kg/min 

Consider ipratropium neb Use methylprednisolone sodium

0.25–0.5 mg q4–6h succinate 4 mg/kg/day ÷ q6h

Consider MgSO4 50 mg/kg Ipratropium neb 0.25–0.5 mg q4-6h

IV q6h (if not already given)

Consider temporary NPO Consider repeating MgSO4 25–50 mg/

status with maintenance kg IV q6h

IVFs if in distress

Discharge patient to home if Consider temporary NPO status with 

clinically improved with maintenance IVFs if in distress, 

O2 sat ≥ 94%, and reliable especially if intubation is possible 

follow-up established Other options include: Heliox 70:30

Ketamine sedation 0.5–1 mg/kg/dose 

for agitation out of proportion to 

respiratory distress. CAUTION: may 

cause respiratory depression

Inhaled anesthetics

FiO2: fraction of inspired oxygen 

IV: intravenous

IVF: intravenous fluid

MDI: metered dose inhaler

MgSO4: magnesium sulfate

neb: nebulized

NPO: nil per os (nothing by mouth)

PRN: pro re nata (as needed)

sat: saturation
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Pediatric Surgery and Medicine for Hostile Environments 

▶ A written asthma action plan is a validated educational 

tool.

Other Common Respiratory Emergencies

• Anaphylaxis

° Several organ systems may be involved, including 

the skin, respiratory tract, cardiovascular system, and 

gastrointestinal tract.

° If not recognized and promptly treated, anaphylaxis may 

lead to death from respiratory or cardiovascular collapse.

° Causes can include foods, drugs, and hymenoptera venom.

▶ Foods: peanuts, tree nuts, milk, eggs, fish, shellfish, 

fruits, grains.

▶ Drugs: penicillins, cephalosporins, sulfonamides, 

nonsteroidal antiinflammatory drugs, opiates, insulin, 

local anesthetics.

▶ Hymenoptera venom: honeybee, yellow jacket, wasp, 

hornet, and fire ant venom. 

▶ Other: latex, exercise, vaccinations.

Table 26-6. Asthma Medication Toxicity Profile

Medication Toxicity

Albuterol Tachycardia, hypokalemia, tremors

Ipratropium Dry mouth, tachycardia, dry secretions

Terbutaline Tachycardia, arrhythmias, hypokalemia, muscle 

twitching, increased muscle CPK, headache, 

seizure

Steroids Hyperglycemia, gastritis, CNS stimulation, 

hypertension, immune suppression

Magnesium Hypotension, weakness, nausea, flushing, 

diarrhea

Ketamine Potent sialogogue, respiratory depression, 

emergence phenomena, tachyphylaxis

Inhaled anesthetics Hypotension, apnea, myocardial depression

CNS: central nervous system 

CPK: creatine phosphokinase
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Respiratory Emergencies

° Evaluation should proceed as follows:

▶ History should include investigations into interaction 

with anaphylaxis-associated allergens via contact, 

ingestion, inhalation, or medication administration; 

inquiries into previous history of anaphylaxis; and past 

medical history.

▶ Review of symptoms and physical examination should 

check for the following:

▷ Dermatologic: urticaria, angioedema, pruritus, 

flushing, or warmth.

▷ Oropharynx: swelling of the lips, tongue, or mouth.

▷ Throat: hoarseness, cough.

▷ Pulmonary: dyspnea, wheeze.

▷ Gastrointestinal: nausea, vomiting, diarrhea, or 

Table 26-7. Chronic Asthma Severity and Suggested Treatment

Severity Intermittent Mild Moderate Severe

Frequency of < 2/wk > 2/wk Daily Throughout

symptoms (not daily) day

Nighttime None 1–2/mo 3–4/mo > 1/wk

awakenings

Impairment None Minor Moderate Extremely 

limited

Treatment Albuterol Low-dose Low- or Medium- or

PRN ICS or medium- high-dose

LTRA and dose ICS ICS + LABA

albuterol + LABA or LRTA

PRN or LTRA and

and albuterol

 albuterol PRN

PRN Consider 

systemic 

 corticosteroids

ICS: inhaled corticosteroid

LABA: long-acting beta-adrenoceptor agonist

LTRA: leukotriene receptor antagonist

PRN: pro re nata (as needed)
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Pediatric Surgery and Medicine for Hostile Environments 

abdominal pain.

▷ Cardiovascular: hypotension, dizziness, syncope, or 

cardiovascular collapse.

° Treatment is as follows:

▶ Immediate 

▷ Check airway, breathing, and circulation. 

▷ Administer epinephrine 0.01 mg/kg (1:1,000) 

intramuscular (IM): 

▷ Maximum single dose: 0.3 mg.

▷ Repeat every 15 minutes as needed.

▷ Auto injectors: epinephrine 0.15 mg (10–25 kg) or 

epinephrine 0.3 mg (> 25 kg).

▷ Obtain intravenous (IV) access, administer 100% 

oxygen, observe cardiac monitor and pulse oximetry.

▷ Bolus normal saline (NS) 20 cc/kg, repeat as needed 

for hypotension.

▶ Therapy after epinephrine

▷ H1 antagonist (diphenhydramine 1–2 mg/kg PO/IM/

IV), maximum single dose 50 mg.

▷ Corticosteroids (prednisone 1–2 mg/kg PO or 

methylprednisolone 2 mg/kg IV).

▷ Consider nebulized albuterol 1.25 to 2.5 mg every 20 

minutes for bronchospasm.

▷ Consider an H2 antagonist (ranitidine 2 mg/kg PO or 

IV).

° Disposition

▶ Following initial stabilization, observe patient at least 4 

hours (may have biphasic response).

▶ Discharge patient with 72 hours of antihistamine and 

corticosteroids (albuterol if bronchospasm is present).

▶ Prescribe an epinephrine auto injector (use age-based 

dosing).

▶ Educate patient on anaphylaxis trigger avoidance and 

proper use of epinephrine auto injector.

• Bronchiolitis

° Bronchiolitis is an acute, infectious, inflammatory disease of 

the upper and lower respiratory tracts leading to coughing, 

wheezing, and respiratory distress. Most cases are mild 

and self-limiting; however, inpatient mortality can be 
425

Respiratory Emergencies

significant.

° Causes: bronchiolitis is most often caused by respiratory 

syncytial virus, but other viruses and mycoplasma have 

been implicated. Premature, chronically ill, or malnourished 

infants are at higher risk for severe disease.

° Evaluation

▶ Bronchiolitis may present with a low-grade fever 

and nasal congestion that can progress to lower tract 

symptoms with cough, dyspnea, wheezing, and feeding 

difficulties.

▶ Severe cases can manifest with respiratory distress, 

tachypnea, nasal flaring, retractions, irritability, and 

cyanosis.

▶ Biphasic wheezing and crackles during auscultation are 

common.

▶ Hypoxemia on pulse oximetry is the best predictor of 

severe illness and correlates with a respiratory rate 

greater than 50 breaths per minute.

▶ Patients can present with otitis media, myocarditis, 

dysrhythmias, and syndrome of inappropriate 

antidiuretic hormone.

▶ A significant number of young or premature infants will 

have apnea.

▶ Chest radiograph, although not necessary, will 

show hyperexpansion and diffuse bilateral perihilar 

peribronchial cuffing.

° Treatment

▶ Admit patient for respiratory distress, room air 

saturation values less than 92% SaO2, dehydration, 

apnea, or hypothermia.

▶ Therapy is supportive, using oxygen and IV fluids in 

infants who are hypoxemic and cannot take oral liquids. 

▶ Excess fluid administration may exacerbate pulmonary 

edema.

▶ Some infants may experience short-term symptom relief 

with nebulized albuterol or racemic saline. 

▶ Mild nasal decongestants or bulb suctioning are more 

likely to be of symptomatic benefit than nebulized 
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Pediatric Surgery and Medicine for Hostile Environments 

albuterol or reacemic saline.

▶ Antibiotics are not indicated unless there is a strong 

suspicion of a secondary bacterial process.

▶ If mechanical ventilation becomes necessary, use 

synchronized intermittent mechanical ventilation with 

pressure support and positive end-expiratory pressure, 

ventilating at relatively slow rates to allow adequate 

exhalation time.

• Croup

° Laryngotracheobronchitis is an infection of the upper 

airway characterized by inspiratory stridor, cough, 

wheezing, and hoarseness.

° Causes include the following:

▶ The etiology is predominately viral infection 

(parainfluenza, respiratory syncytial virus, adenovirus).

▶ Often occurs during winter or cooler months.

▶ Measles can be a cause in unimmunized populations. 

° Evaluation

▶ Children ages 3 to 36 months typically present with 

gradually developing symptoms, including a barky 

cough, hoarse voice, inspiratory stridor, tachypnea, and 

retractions (usually worse at night).

▶ Significant hypoxia, biphasic stridor, change in mental 

status, poor air movement, or apparent fatigue may 

suggest impending respiratory failure and require 

urgent management.

▶ Chest radiograph will demonstrate laryngeal narrowing 

or “steeple sign.”

° Treatment

▶ Urgent treatment includes rapid-acting nebulized 

racemic epinephrine (0.25–0.5 mL) of 2.25% solution 

diluted to 3.0 cc with NS, repeated as needed.

▷ Rapid onset, short duration (about 2 h).

▷ Patients should be monitored closely for rebound 

symptoms 2 hours after nebulized treatment; 

tachyphylaxis may occur with repeated dosing.

▷ If racemic epinephrine is unavailable, use 

l-epinephrine (0.5 mg/kg, maximum dose 5 mL of 
427

Respiratory Emergencies

1:1,000 solution).

▶ Corticosteroids are the mainstay of treatment to decrease 

airway edema.

▷ Onset of action is around 6 hours.

▷ Dexamethasone: 0.6 mg/kg IV/IM/PO (IV formulations 

can be given orally once, max dose 16 mg),

OR

▷ Prednisolone: 2 mg/kg/day IV divided bid for 2 to 3 

days,

OR

▷ Prednisone: 4 mg/kg PO (equivalent to 0.6 mg/kg 

dexamethasone).

▶ Management includes supplemental oxygen and 

supportive measures, including IV fluids and humidified 

air.

• Epiglottitis (see also Chapter 16, Face and Neck)

° Epiglottitis is a rapidly progressive bacterial infection of 

the epiglottis, aryepiglottic folds, and surrounding tissues 

that leads to edema, airway compromise, and respiratory 

failure.

° Causes

▶ More common in unimmunized populations due to 

Haemophilus influenzae type b.

▶ Rare causes in immunized populations include: 

Pneumococcus, Staphylococcus aureus, group A b-hemolytic 

streptococci (GABHS), and nontypeable H influenzae.

° Evaluation

▶ Children ages 1 to 5 years old can present with a rapid 

progression from minimal symptoms to fever, sore 

throat/dysphagia, inability to manage secretions, and 

toxic appearance.

▶ Airway compromise appears rapidly with respiratory 

distress; patient may exhibit a muffled “hot-potato” 

voice (sounds like a person speaking with a hot potato 

in his or her mouth) and abnormal positioning (tripoding 

or leaning forward with mouth open) to maintain 

maximum airway patency.

▶ Hoarseness and stridor are typically absent or mild.
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Pediatric Surgery and Medicine for Hostile Environments 

▶ Work of breathing is normal to minimally elevated.

▶ Clinical diagnosis is based on high index of suspicion; 

cherry-red epiglottis may be seen on passive visualization 

without instrumentation.

▶ Aggressive attempts to visualize the airway should 

be avoided until skilled personnel are present (ie, 

an anesthesia professional and a surgeon capable of 

performing emergent pediatric tracheostomy) and 

prepared to intervene.

▶ Lateral neck radiographs should be obtained with 

caution in children with airway concerns; however, the 

enlarged epiglottis can be visualized (it appears as the 

so-called “thumb sign” on the lateral neck). 

° Treatment

▶ Total airway obstruction may occur due to the massively 

enlarged epiglottis.

▶ Management includes intubation, by the most 

experienced provider, with an endotracheal tube 0.5 to 

1.0 size smaller than that routinely used for a child of 

that age and size.

▶ Simple bag-valve mask ventilation may be successful if 

absolutely necessary.

▶ Once the child is intubated, it is critical to secure the 

endotracheal tube and sedate the child sufficiently to 

avoid a potentially catastrophic self-extubation.

▶ Treatment includes broad-spectrum IV antibiotics (do 

not exceed maximum adult dose).

▶ Oxacillin/nafcillin (150–200 mg/kg/day divided four 

times daily),

OR

▶ Cefazolin (75–100 mg/kg/day divided three times daily),

OR

▶ Clindamycin (30–40 mg/kg/day divided three times 

daily),

PLUS

▶ Third-generation cephalosporin (ceftriaxone 75–100 mg/

kg/day divided twice daily).
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Respiratory Emergencies

▶ Cover for methicillin-resistant S aureus in endemic area.

• Bacterial Tracheitis

° Symptoms: similar to croup but with high fever, toxic 

appearance, and progressive airway obstruction.

▶ Tendency to have insidious onset, which may differentiate 

this illness from epiglottitis.

▶ Copious purulent secretions arise from the trachea; the 

child may expectorate these and the secretions will make 

frequent suctioning necessary. 

° Etiology: usually S aureus, also GABHS, Haemophilus 

influenzae type b, or S pneumonia.

° Diagnosis: clinical; trachea may appear “shaggy” on 

radiograph.

° Treatment

▶ Intubate and ventilate patient for 5 to 7 days (usually 

needed for pulmonary toilet).

▶ May require flexible or rigid endoscopy for secretion 

removal.

▶ Administer nafcillin, cefazolin, cefuroxime, or ampicillin/

sulbactam, all IV.

▶ Cover for methicillin-resistant S aureus in endemic areas.
430

Pediatric Surgery and Medicine for Hostile Environments 
431

Cardiology

Chapter 27

Cardiology

History

• In newborns, exercise tolerance is approximated by asking 

caregivers about feeding difficulties, specifically tachypnea, 

cyanosis, and diaphoresis during feeding.

• In infants, failure to thrive (gain weight at an appropriate rate) 

warrants consideration of congenital heart disease.

• Children with other congenital anomalies are more likely to 

have congenital heart disease, particularly defects along the 

midline or involving other solid organs. Family history should 

focus on family members with heart disease (congenital or 

acquired), sudden unexplained deaths, and arrhythmias.

Examination

• Blood pressure should be measured in both of the patient’s 

arms and one leg to evaluate for coarctation of the aorta (in 

normal patients without coarctation, blood pressure should 

be slightly higher in the leg). 

• Murmurs are noted in more than 90% of all children at some 

time in their lives. Most murmurs are harmless. Characteristics 

concerning for a pathologic murmur include associated cardiac 

symptoms, a loud or harsh-sounding systolic murmur (> 3/6 

or with a palpable thrill), a diastolic murmur, abnormal heart 

sounds, presence of a click, and weak or absent peripheral 

pulses.

• Electrocardiograms (ECGs) are helpful if they are available 

(consult The Harriet Lane Handbook for help interpreting an ECG).
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Pediatric Surgery and Medicine for Hostile Environments 

Evaluating the Cyanotic Newborn, Infant, and Child

• Central cyanosis is universally consistent with hypoxemia and 

is best appreciated in the oral mucosa, conjunctivae, and the 

tip of the tongue.

• The most common cause of cyanosis in newborns, infants, and 

children is respiratory compromise from a host of pulmonary 

diseases.

• Cyanosis from congenital heart disease is typically due to 

a right-to-left intracardiac shunt and persists beyond the 

newborn period.

• Evaluation

° Initial evaluation should include pulse oximetry and 

measurement of the partial pressure of oxygen in arterial 

blood (PaO2) by blood gas to confirm hypoxemia. The PaO2

in a normal, 1-day-old newborn may be as low as 60 mmHg.

° Primary pulmonary processes are associated with 

tachypnea, increased work of breathing, and dyspnea; 

congenital cyanotic heart defects are generally associated 

with effortless tachypnea (often described as “comfortable 

tachypnea”).

▶ If a cyanotic heart defect is suspected, perform chest 

radiograph, ECG (if available), and a hyperoxitest.

▶ Ultimately, the diagnosis of congenital cyanotic heart 

disease is made by echocardiography. 

▶ The hyperoxitest compares PaO2 and pulse oximetry 

values after a 100% oxygen challenge as a means of 

differentiating pulmonary from cardiac causes of 

hypoxemia.

▷ Arterial blood gas samples should be taken from the 

right upper extremity.

▷ PaO2 and pulse oximetry values are taken while the 

newborn is breathing fraction of inspired oxygen 

(FiO2) of 0.21, and after FiO2 is increased to 1.00 for 

10 minutes.

▷ Care should be taken to get the FiO2 as close as 

possible to 1.00. 

▷ Pulmonary disease: PaO2 greater than 150 mmHg 

and pulse oximetry equal to 100% arterial oxygen 

saturation, with FiO2 equal to 1.00. 
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Cardiology

▷ Cardiac disease: PaO2 less than 150 mmHg and pulse 

oximetry less than 90% Arterial Oxygen Saturation, 

with FiO2 equal to 1.00.

• Treatment

° Although some children with cyanotic heart defects can 

survive past infancy (eg, most commonly those with mild

forms of tetralogy of Fallot), definitive treatment of cyanotic 

heart defects requires surgical correction.

° In the newborn period, if surgical intervention is a feasible 

option, a prostaglandin E1 (PGE1) intravenous (IV) infusion 

can be started to maintain patency of the ductus arteriosus; 

however, this medication is unlikely to be on standard Role 

3 formularies.

▶ Currently, there are no alternative drugs to PGE1.

▶ The starting dose of PGE1 is 0.05 to 0.1 μg/kg/min and 

may be titrated up to 0.4 μg/kg/min.

▶ Clinical evidence of the ductus reopening, typically 

within 1 to 2 hours, will include improved pulse 

oximetry, perfusion, blood pressure, and urine output, 

as well as improved arterial pH and partial pressure of 

oxygen. Once the ductus is reopened the dose can be 

reduced and the infusion continued until balloon atrial 

septostomy or cardiac surgery is performed.

▶ Common side effects include flushing, apnea, 

hypotension, fever, and seizure-like activity; be prepared 

to intubate when starting PGE1.

Arrhythmias

• See Pediatric Advanced Life Support resuscitation algorithms 

on the card located inside the front cover of this book.

Bradycardia 

• The most common cause of true bradycardia in infants and 

children is hypoxia, usually due to respiratory compromise.

• Sinus bradycardia can be normal in adolescents and athletes.

• Bradycardia can also be caused by increased vagal tone, 

increased intracranial pressure, hyperkalemia, hypercalcemia, 

hypothyroidism, hypothermia, long QT syndrome, and drugs 

(eg, digoxin, β-blockers, calcium channel blockers, lithium).
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Pediatric Surgery and Medicine for Hostile Environments 

• In newborns, physiological stresses (eg, hypoxia, cold, 

hypoglycemia) are often manifest as bradycardia (but manifest 

as tachycardia in older children and adults).

• Bradycardia can also occur as a result of heart block.

• Management

° Treat the underlying cause.

° A hemodynamically unstable patient with underlying 

bradycardia requires emergent attention.

° Begin with effective oxygenation and ventilation via bagvalve mask, if necessary.

° Epinephrine IV or intraosseous is the drug of choice after 

oxygen; dose 0.01 mg/kg (0.1 mL/kg) of 1:10,000 repeat 

every 3 to 5 min.

° Atropine should be considered a second-line agent, 

unless vagal stimulation is thought to be the source of the 

bradycardia. Dose 0.02 mg/kg (minimum dose 0.1 mg, max 

1 mg); may be repeated once. 

Tachycardia

• The most common cause of tachycardia in pediatric patients 

is sinus tachycardia, which can be caused by hypovolemia, 

hemorrhage, hypoxia, anemia, fever, sepsis, shock, congestive 

heart failure, myocardial disease, anxiety, and drugs (eg, 

β-agonists, atropine).

• Management requires distinguishing sinus tachycardia from 

supraventricular tachycardia (typically narrow QRS complex) 

and ventricular tachycardias (wide QRS complex). 

° Sinus tachycardia is almost always accompanied by a 

history that explains it (volume loss, fever, hemorrhage, etc). 

° Maximum heart rates for infants and children can be 

surprising:

▶ Infants: up to 220 beats per minute (bpm).

▶ Children: 210 bpm.

▶ Adolescents: 200 bpm.

• Treatment involves correcting the underlying causes.

• Supraventricular tachycardia is the most common 

tachyarrhythmia seen in children, with increased ventricular 

rates (often > 220 bpm).

° P waves, if visible, are usually abnormal.
435

Cardiology

° This typically manifests as a paroxysmal start/stop, rather 

than a warm-up and cool-down.

° Heart rate is regular, rapid, and monotonous, with minimal 

variation.

° Narrow QRS complexes are typical.

° Supraventricular tachycardia can be associated with 

congenital heart disease (eg, Ebstein’s anomaly, 

transposition) and preexcitation syndromes, like WolffParkinson-White syndrome.

° It is most often idiopathic.

° Treatment includes vagal maneuvers (ice to the face, 

blowing through a straw, or Valsalva) and adenosine 

(initially 0.1 mg/kg/dose) IV administered quickly, followed 

immediately by a flush of 5 to 10 cc normal saline; given 

its short half-life, adenosine may be repeated at 0.2 mg/kg 

if necessary.

° If the patient is unstable, perform synchronized 

cardioversion (0.5–1 J/kg).

Atrial Flutter

• Atrial flutter is very rare in children without structural heart 

disease and is usually associated with a narrow complex 

tachycardia (unlike in adults) secondary to excellent 

conduction through the atrioventricular node.

• Acute treatment of unstable patients requires synchronized 

cardioversion or overdrive pacing; medical therapy including 

anticoagulation, digoxin, procainamide, and short-acting 

β-blockers may be started in consultation with a pediatric 

cardiologist.

Atrial Fibrillation

• Atrial fibrillation is very rare in children and may be hereditary 

or associated with structural heart disease.

• It is defined as an irregular-appearing and fast atrial rate 

(350–600 bpm), narrow QRS complexes, and an irregular 

ventricular response rate of 110 to 150 bpm.

• Anticoagulation may be necessary if atrial fibrillation is 

present for more than 48 hours. 
436

Pediatric Surgery and Medicine for Hostile Environments 

• Acute treatment of unstable patients requires synchronized 

cardioversion; medical therapy including anticoagulation, 

calcium channel blockers, and β-blockers may be started in 

consultation with a pediatric cardiologist.

Ventricular Dysrhythmias

• Premature ventricular contraction (PVC)

° PVC is typically benign; multifocal PVCs are more 

concerning.

° Causes of PVCs include myocarditis, cardiomyopathy, 

congenital and acquired heart disease, long QT syndrome, 

hypokalemia, hypoxemia, hypomagnesemia, anxiety, 

and drugs (eg, digitalis, catecholamines, caffeine, and 

anesthetics).

° Treatment is only necessary if the PVCs are associated 

with symptoms, hemodynamic changes, underlying heart 

disease, high frequency (> 25% of total beats), or are made 

worse with exercise.

° Treatment can include β-blockers and other antiarrhythmic 

drugs or catheter ablation.

• Ventricular tachycardia (VT) and ventricular fibrillation (VF)

° VT and VF represent the initial arrest rhythm in only 10% of 

pediatric cardiopulmonary arrests, but will appear in up to 

25% of resuscitations (see Samson, et al, in Further Reading).

° For stable VT, consider a slow load of amiodarone 5 mg/kg 

IV, but be prepared to cardiovert or defibrillate if necessary.

° For pulseless VT and VF, treat with immediate 

cardiopulmonary resuscitation, defibrillate 2 to 4 J/kg, and 

administer IV epinephrine 0.01 mg/kg then either lidocaine 

(1 mg/kg) IV or amiodarone (5 mg/kg) IV bolus. 

Congestive Heart Failure

• Congestive heart failure (CHF) can be caused by a variety of 

congenital or acquired medical conditions.

• By far, the most common cause of CHF in infancy is congenital 

heart disease.
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Cardiology

° Volume overload lesions (left to right anatomic shunts), 

such as ventricular septal defect, patent ductus arteriosus, 

and endocardial cushion defects are most common.

° Tachyarrhythmias and heart block can cause heart failure 

at any age, including in utero.

° Acquired heart diseases become more common as children get 

older. These conditions include myocarditis, acute rheumatic 

carditis, rheumatic valvular diseases with significant mitral 

or aortic regurgitation, dilated cardiomyopathy, metabolic 

abnormalities, endocrinopathies, and severe anemia.

• Diagnosis

° Infants present with tachycardia, hepatosplenomegaly, 

poor feeding, tachypnea that worsens during feeding, poor 

weight gain, and diaphoresis, particularly with feeding.

° Older children may report dyspnea (particularly 

with activity), orthopnea, easy fatigability, abdominal 

discomfort, and swelling of the eyelids, feet, and hands.

° Like in adults, the following are common physical exam 

findings consistent with but not specific to CHF:

▶ wheezes or crackles,

▶ tachycardia,

▶ gallop rhythm,

▶ displaced point of maximal impulse,

▶ weak pulses,

▶ hepatosplenomegaly, and

▶ extremity and eyelid edema.

° Unlike in adults, jugular venous distention is not a common 

finding.

° Cardiomegaly is almost always seen on a chest radiograph.

• Management

° Address the underlying etiology, provide support, and 

control underlying heart failure state.

° Supportive measures include providing adequate calories 

given fluid restrictions (for infants with volume overload 

lesions, this may be > 140–150 kcal/kg/day, often given via 

nasogastric tube; see Schwarz, et al, in Further Reading). 

° Medical management includes a combination of inotropic 

agents, diuretics, and afterload-reducing agents.
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Pediatric Surgery and Medicine for Hostile Environments 

Acquired Heart Disease

Rheumatic Heart Disease 

• Acute rheumatic fever is a common cause of heart disease in 

underdeveloped countries.

• Pathophysiology includes a postinflammatory reaction 

affecting the whole body.

° Rheumatic heart disease is believed to be immunologically 

mediated following a group A streptococcal infection of the 

pharynx.

° Other streptococcal infections, like impetigo, do not 

typically cause acute rheumatic fever. 

° Most cases occur in children between 6 and 15 years 

old (peak incidence at 8 years old), 1 to 5 weeks after 

streptococcal pharyngitis, with nonspecific symptoms of 

malaise, fatigue, abdominal pain, and pallor; there may be 

a positive family history of rheumatic fever.

° The diagnosis is ultimately made using the revised 

Jones Criteria (Exhibit 27-1) and requires two major 

manifestations or one major and two minor manifestations, 

in addition to evidence of an antecedent streptococcal 

pharyngitis by either throat culture or serology.

Exhibit 27-1. Diagnostic Criteria for Rheumatic Fever: 

Jones Criteria

Major Criteria Minor Criteria

Carditis Fever

Chorea Arthralgia

Polyarthritis Elevated ESR or CRP

Erythema marginatum Prolonged PR interval (ECG)

Subcutaneous nodules

CRP: C-reactive protein

ECG: electrocardiograms

ESR: erythrocyte sedimentation rate
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Cardiology

• While rheumatic fever is systemic inflammatory disease, the 

major long-term consequences are due to rheumatic heart 

disease caused by a pancarditis.

° Pancarditis involves the pericardium, myocardium, 

endocardium, and epicardium.

° Valvulitis is commonly present. 

• In the acute phase, mitral regurgitation (regurgitant systolic 

murmur) with or without aortic insufficiency (diastolic 

murmur) is the most common cardiac manifestation. 

• Carditis should also be suspected in the presence of new onset 

CHF or pericardial friction rub in a patient with a murmur 

and suspicious clinical history.

• Clinical examination is the basis of diagnosing rheumatic fever 

and carditis, but echocardiography, if available, would be 

supportive. See Chapter 29, Infectious Diseases, for treatment 

regimens.

Kawasaki disease

• Kawasaki disease is an acute, febrile vasculitis of unknown

etiology, with a predilection for the coronary arteries.

• It is the most common cause of acquired heart disease in 

developed countries and seen almost exclusively in children 

less than 8 years old.

• Diagnosis is clinical and based on a history of high fever lasting 

5 days or more, plus four of the following five criteria: 

° bilateral bulbar conjunctivitis without exudates;

° erythema of the mouth and pharynx, strawberry tongue, 

or red and cracked lips;

° nonspecific polymorphous exanthema; 

° swelling of the hands and feet, with erythema of the palms 

and soles; and

° cervical lymphadenopathy (> 1.5 cm), usually single or 

unilateral.

• Additional associated features include extreme irritability, 

abdominal pain, vomiting, diarrhea, and skin changes 

(particularly desquamation of the hands, feet, and perineal 

region), usually after the fever ends.
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Pediatric Surgery and Medicine for Hostile Environments 

• Laboratory findings include elevated erythrocyte 

sedimentation rate (ESR) and C-reactive protein, leukocytosis 

with left shift, normocytic anemia, thrombocytosis, sterile 

pyuria, and elevated liver enzymes.

• If left untreated, there is a 15% to 25% risk of coronary artery 

aneurysm and subsequent coronary artery thrombosis and 

stenosis, although aneurysms can develop elsewhere in the 

body.

° Rarer complications include carditis, valve regurgitation, 

pericardial effusion, and CHF.

° Treatment

▶ Administer one dose of IV immunoglobulin (2 g/kg over 

12 h).

▶ Give high-dose aspirin (80–100 mg/kg/day divided into 

four doses) per os (PO) until the fever resolves, followed 

by 3 to 5 mg/kg/day of aspirin PO once a day for 6 to 8 

weeks when an echocardiogram demonstrates normal 

coronary arteries and the ESR and platelet count have 

returned to normal.

Infective Endocarditis Prophylaxis

• The use of antibiotic prophylaxis to prevent bacterial 

endocarditis was greatly changed in 2007. Under current 

guidelines, prophylaxis is recommended for only the 

following procedures:

° Dental procedures that involve manipulation of gingival 

tissues, the periapical region of teeth, or perforation of oral 

mucosa.

° Procedures on the respiratory tract involving incision of 

the respiratory tract mucosa.

° Procedures on infected skin, skin structures, or 

musculoskeletal tissue.

• Prophylaxis is no longer recommended for procedures 

involving the gastrointestinal or genitourinary tracts.

• Cardiac conditions for which endocarditis antibiotic 

prophylaxis is indicated include:

° prosthetic cardiac valve;

° unrepaired cyanotic heart disease;

° congenital heart defects completely repaired with a 
441

Cardiology

prosthetic material or device (placed surgically or by 

catheter) during the first 6 months after the procedure;

° repaired congenital heart defects with residual defects at the 

site or adjacent to the site of a prosthetic patch or prosthetic 

device;

° cardiac transplantation recipients with cardiac valvulopathy; 

and

° previous infective endocarditis.

• Medication and dosing administered as a single dose 30 to 60 

min before the procedure:

° Amoxicillin: 50 mg/kg PO to a max dose of 2 g.

° Ampicillin: 50 mg/kg IV to a max dose of 2 g.

° Azithromycin: 15 mg/kg to a max dose of 500 mg.

° Clindamycin: 20 mg/kg PO or IV to a max dose of 600 mg.

° Cephalexin: 50 mg/kg to a max dose of 2 g.

° Ceftriaxone 50 mg/kg to a max dose of 1 g.

° Vancomycin: 15 mg/kg to a max dose of 1 g.

Cardiac Syncope

• Although syncope is usually the result of vasovagal and 

orthostatic mechanisms, cardiac causes of syncope include: 

° Obstructive heart lesions, such as:

▶ aortic stenosis,

▶ severe pulmonary stenosis, and

▶ hypertrophic cardiomyopathy.

° Coronary artery abnormalities.

° Arrhythmias.

• Red flags during the evaluation of syncope include:

° exercise-induced syncope;

° preceding chest pain;

° associated seizure-like activity;

° absence of prodromal symptoms, such as tunnel vision, 

seeing spots, and muffled hearing; 

° physical examination suggestive of cardiac disease;

° abnormal ECG; and

° unexplained death or aborted sudden death in a family 

member under age 40.
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Pediatric Surgery and Medicine for Hostile Environments 

Chest Pain and Myocardial Infarction

• Chest pain is a frequent chief complaint among children 

and adolescents, but it is rarely due to any underlying 

cardiovascular cause. The most common etiologies of chest 

pain among pediatric patients are:

° Musculoskeletal pain from muscle strain, chest wall 

deformities like pectus excavatum, costochondritis, or 

precordial catch syndrome (localized chest wall pain at 

rest lasting seconds to minutes and made worse with deep 

inspiration). 

° Respiratory conditions, such as:

▶ pneumonia,

▶ cough and asthma.

° Gastrointestinal disease, specifically esophagitis related to 

gastroesophageal reflux disease.

° Psychogenic etiologies, including anxiety.

• Red flags for underlying cardiovascular disease include:

° exertional chest pain not consistent with asthma symptoms;

° pain that radiates down the left arm or up the neck, jaw, 

or into the back;

° associated presyncope or syncope;

° palpitations; and 

° dull, squeezing, or heavy chest pain (as opposed to sharp or 

pinpoint pain that is often reproducible, worse with taking 

a deep breath, and worse on palpation). 

• Cardiac causes of chest pain include:

° obstructive congenital heart conditions that put additional 

strain on the myocardium, such as aortic stenosis, subaortic 

stenosis, coarctation of the aorta, and pulmonary stenosis;

° cardiomyopathy;

° coronary artery abnormalities;

° aortic dissection or aneurysm;

° pericarditis;

° myocarditis; and

° arrhythmias.
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Cardiology

Myocardial Infarction

• Myocardial infarction is rare in children.

• Predisposing conditions include history of Kawasaki disease, 

anomalous origin of a left coronary artery, congenital heart 

disease, and dilated cardiomyopathy.

• Diagnosis and management are similar to that used in adults.

Further Reading

1. Robertson J, Shilkofski N. The Harriet Lane Handbook: A Manual for 

Pediatric House Officers. 17th ed. Philadelphia, PA: Elsevier Mosby; 

2005.

2. Park MK. Pediatric Cardiology for Practitioners. 4th ed. St Louis, MO: 

Mosby; 2002.

3. Keane JF, Lock JE, Fyler DC. Nadas’ Pediatric Cardiology. 2nd ed. 

Philadelphia, PA: Saunders Elsevier; 2006.

4. Samson RA, Nadkarni VM, Meaney PA, Carey SM, Berg MD, Berg 

RA. Outcomes of in-hospital ventricular fibrillation in children. N 

Engl J Med. 2006;354:2328–2339.

5. Schwarz SM, Gewitz MH, See CC, et al. Enteral nutrition in infants 

with congenital heart disease and growth failure. Pediatrics. 1990 

Sep;86(3):368–373.
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Pediatric Surgery and Medicine for Hostile Environments 
445

Gastroenterology

Chapter 28

Gastroenterology

Intestinal Infection

• Acute gastroenteritis is the most common cause of infant 

mortality worldwide.

• Viral gastroenteritis is usually associated with small bowel 

disease, presenting with 5 to 10 watery, large-volume episodes 

per day.

° Rotavirus: lasts 5 to 7 days; symptoms include fever, 

vomiting, and profuse diarrhea.

° Adenovirus: milder than rotavirus, but lasts 8 to 12 

days.

° Norovirus, calicivirus, and astrovirus: mildest, lasting 

1 to 3 days.

• Bacterial gastroenteritis usually starts watery; stool may 

become mucousy or blood-tinged.

° Bacterial gastroenteritis may transition to colitis or 

dysentery.

° Colitis/dysentery signs include frequent episodes (10–20/

day); mucousy, bloody stools; and positive hemoccult test.

° Species include Salmonella, Shigella, Escherichia coli 

(enterohemorrhagic or enteroinvasive), Campylobacter, 

Yersinia, and Clostridium difficile.

° Enterotoxigenic E coli and cholera only cause watery 

diarrhea.

° Treatment is largely supportive by way of oral or IV 

rehydration. Always treat Shigella and cholera. Other 

bacteria may be self-limited, but should be treated 

in the setting of outbreaks to decrease spread, or in 

particularly severe cases. Azithromycin or trimethoprimsulfamethoxazole is frequently used pending stool culture 

result. 
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Pediatric Surgery and Medicine for Hostile Environments

• Protozoal gastroenteritis can be dysenteric (Entamoeba 

histolytica) or consist of more chronic loose stools (eg, Giardia, 

Cryptosporidium, etc).

° Treat symptomatic (dysenteric) amebiasis with 

metronidazole; however, metronidazole does not 

eradicate the ameba from the intestine. For eradication, use 

paromomycin or diloxanide. Eradication therapy for local 

personnel is not recommended; indigenous personnel will 

likely be quickly recolonized.

° Treat Giardia with tinidazole or nitazoxanide. If those are 

unavailable, use metronidazole. 

° Many countries have a quinolone (eg, norfloxacin) and 

metronidazole combination drug that comes in a pediatric 

solution. It can be used to empirically treat to dysentery in 

the absence of diagnostics. 

° Cryptosporidium and other parasites can be treated with 

nitazoxanide, tinidazole, and others. NOTE: paromomycin, 

diloxanide, nitazoxanide, and tinidazole are unlikely to be 

available in a deployed setting.

Osmotic Diarrhea

• Osmotic diarrhea usually indicates an injury to the small 

bowel mucosa and can be seen transiently in postinfectious 

diarrhea.

• Treat by feeding with soy or other lactose-free formula 

until healed.

° Rice formula is not recommended because it mainly 

consists of carbohydrates and lacks the protein and 

fat that the bowel needs to promote rapid healing and 

epithelial cell growth.

° Juice is not recommended.

Allergic Colitis

• Allergic colitis is seen mostly in infants.

° It usually presents at age 6 to 8 weeks.

° It is often diagnosed after clinical presentation of bloodtinged, mucousy diarrhea.

° Babies usually outgrow typical allergic colitis by 12 months 

of age.
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Gastroenterology

• Children with allergic colitis often appear well otherwise, but 

can present with malnutrition, protein-losing enteropathy, or 

anemia.

• Skin manifestations are typically absent, especially in 

younger infants, because the colitis is frequently due to 

an immunoglobulin G-mediated allergy (rather than an 

immunoglobulin E-mediated one).

• To treat: remove all cow’s milk protein from the patient’s diet.

° If the baby is not severely ill, try feeding with soy 

formula.

° If the infant’s mother can breast-feed, continue breastfeeding, but remove all cow’s milk from the mother’s diet.

° If the baby is severely ill and semi-elemental based formulas 

are not available, continue treating with soy formula or 

breast-feeding with maternal milk elimination diet.

° Semi-elemental formula: Nutramigen (Enfamil, Mead 

Johnson & Company, LLC, Glenview, IL) or Alimentum 

(Similac, Abbott Nutrition, Columbus, OH). Consider 

amino-acid based formulas as well. 

Malabsorption

• Malabsorption disorders in infants are usually manifestations 

of chronic duodenal infection, such as those that occur with 

parasites.

• Malabsorption may also be caused by genetic disorders 

that lead to fat malabsorption (cystic fibrosis is the common 

etiology for fat malabsorption in the first year of life).

• In the second year of life, infection is still a likely cause 

of malabsorption, but celiac disease also becomes more 

prevalent.

° Celiac disease is an autoimmune disorder that requires

gluten, a byproduct of wheat-containing foods, to manifest 

itself (thus, it is less common in certain areas of the world).

° Treatment is a gluten-free diet for the patient’s lifetime.

• In older children showing evidence of malabsorption, infection 

and inflammatory bowel disease are the two most likely 

causes. Inflammatory bowel disease is an autoimmune 

disorder that is rarely seen in underdeveloped countries.
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Pediatric Surgery and Medicine for Hostile Environments

• Protein-losing enteropathy presents with diarrhea and edema 

and has many etiologies.

° Begin by ruling out allergic colitis, infection, and other 

inflammatory conditions.

° In remote locations, the diagnosis can be made by evidence 

of protein malnutrition, low serum albumin, and urinalysis 

that is clear of protein.

° The differential also includes primary protein malnutrition 

from deficient dietary protein; a dietary history is essential 

in any child with diarrhea.

° Treatment of protein malabsorption requires determining 

the etiology.

▶ Meanwhile, use an amino acid-based formula or a 

formula that is as elemental as possible (eg, breast milk 

from a mother who has removed dairy from her diet).

▶ Some children need total parenteral nutrition for 

nutritional rehabilitation if feeding exacerbates the 

symptoms.

Constipation

• Functional constipation usually begins at age 18 months to 2 

years old, when toilet training begins.

• It manifests as infrequent, large, hard stools, sometimes 

predisposing to anal fissures.

• Encopresis (overflow of bowel movement into the underwear) 

or intermittent overflow diarrhea can occur in severe cases.

° Treatment: clean out (typically administered over 2–3 days) is 

usually required first because megarectum tends to develop 

following chronic retention.

° Administer enema once a day for 2 days, followed by 

bisacodyl (5 mg tablet orally [PO] or 10 mg suppository 

every day for 1–2 days).

▶ When used in an enema or for a child dose, halve the 

adult size (60 cc of phosphosoda).

▶ Never give a young infant less than 6 months old or 

any child with a suspected rectal outlet obstruction 

(eg, Hirschsprung’s) an electrolyte solution, such 

as phosphosoda enemas; this type of treatment has 

been reported to cause severe electrolyte disturbances 

(hyperphosphatemia) and death in infants.
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Gastroenterology

° Mineral oil enemas are sometimes effective (1–2 cc/kg as 

single dose).

° Recommended daily medications are as follows:

▶ Polyethylene glycol at a dose of 1 capful mixed with 

water, juice, or poured on soft food, given 1 to 3 times 

per day; this treatment has largely replaced the other 

daily medications listed below and should be tried first.

▶ Milk of magnesia: 1 to 2 cc/kg/day (max 60 mL 

daily).

▶ Mineral oil: 1 to 2 cc/kg/day.

▶ Lactulose: 1 to 2 cc/kg/day, up to 30 mL.

• Some organic disorders cause constipation.

° Hirschsprung’s disease usually presents with obstructive 

symptoms and no bowel movement in the first 24 hours of 

life, but can also present later in infancy.

▶ Take abdominal films prior to rectal examination, flat 

plate then prone, cross-table lateral with hips slightly 

flexed (ie, “butt up”).

▶ These show distended loops of bowel, but also the 

absence of air in the area that should be the rectal vault.

▶ Because rectal air will be expelled with a digital rectal 

examination, films must be taken first.

▶ Bowel movements are usually explosive and watery, 

which can be documented on a digital rectal examination 

(in which forceful expulsion of soft stool occurs on 

extraction of the examiner’s finger).

▶ The physical examination reveals a long, tight sphincter 

canal.

▶ Follow this with a contrast enema to rule out etiologies 

besides Hirschsprung’s, such as microcolon and 

imperforate anus.

▶ Confirmatory diagnosis is only made by rectal biopsy.

▶ Treatment is surgical, but can be temporized by frequent 

rectal washings with normal saline (5–10 cc every 3 h) 

via a rectal tube (10–12 Fr red rubber catheter inserted 

a few centimeters from the anus).

° When a newborn does not stool in the first 24 hours of 

life, obstructive lesions are possible, but also consider 

meconium plug syndrome.
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Pediatric Surgery and Medicine for Hostile Environments

▶ Meconium plug syndrome is usually benign.

▶ Symptoms are relieved after contrast enema or serial 

rectal washings.

▶ Meconium plug syndrome may indicate cystic fibrosis, 

but is not pathognomonic.

• Anatomical defects

° Some anatomical defects that can result in constipation 

include:

▶ Anorectal malformations, such as imperforate anus, 

rectal stenosis, and anterior displaced anus.

▶ Microcolon (especially in infants of diabetic 

mothers).

▶ Obstructive intestinal lesions, such as ileal atresia.

▶ Neurological disorders, such as caudal regression 

syndrome.

° Treat first with oral hyperosmotic agents, such as lactulose 

or milk of magnesia; eventually administer enemas 

as needed (patients with these conditions do not have 

adequate sensation to have a bowel movement).

Vomiting and Gastroesophageal Reflux

• If vomiting is bilious, an upper gastrointestinal (GI) series is 

imperative to rule out malrotation with volvulus, duodenal 

atresia, or atresia of the small intestine.

• For nonbilious vomiting in an infant 4 to 6 weeks old, consider 

hypertrophic pyloric stenosis.

• If vomiting is chronic, consider gastroesophageal reflux 

disease.

° Gastroesophageal reflux in children may present as 

respiratory disease (either apnea and bradycardia in infants 

or asthma in older children).

° Severe vomiting with failure to thrive, lethargy, or 

delayed development can be a sign of metabolic disease 

in infancy.

• Another etiology of chronic vomiting in infants and children is 

peptic ulcer disease (especially if accompanied by abdominal 

pain), with or without Helicobacter pylori; and urinary tract 

infection, especially with hydronephrosis.
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Gastroenterology

• Laboratory evaluation for chronic vomiting or vomiting 

causing chronic problems (such as failure to thrive, abdominal 

pain, etc) includes:

° Complete blood count.

° Erythrocyte sedimentation rate and complete metabolic 

panel.

° Amylase.

° Lipase.

° Urinalysis and culture.

° If possible, an upper GI series can also rule out malrotation

in the presence of chronic vomiting.

• Treatment

° Treat gastroesophageal reflux disease in children using any 

of the following:

▶ Ranitidine: 1 to 2 mg/kg twice daily.

▶ Omeprazole: 0.7 to 3 mg/kg/day (capsule can be emptied 

into yogurt or applesauce to encourage ingestion).

▶ Over-the-counter antacids, such as aluminum hydroxide 

with magnesium hydroxide (1–2 cc/kg given frequently 

through the day with feeds; watch for changes in bowel 

movements).

▶ Metoclopramide (0.1–0.2 mg/kg 3–4 times per day prior to 

a meal) may be helpful for infants as well. If possible, 

rule out malrotation with severe gastroesophageal reflux 

before adding this medication (and definitely if the 

emesis is bilious).

• Consider adding erythromycin as prokinetic (3 mg/kg/dose 

four times daily).

° If H pylori is expected, the suggested antibiotics are 

similar to those recommended for adults, including the 

following:

▶ Amoxicillin: 50 mg/kg/day divided twice daily.

▶ Clarithromycin: 20 mg/kg/day divided twice daily.

▶ Metronidazole: 20 mg/kg/day divided three times 

daily.

▶ Proton pump inhibitors: 1 to 2 mg/kg/day at weightappropriate doses for 2 weeks.

▶ The usual choices are amoxicillin, clarithromycin, and 

omeprazole, but that can be altered if the patient is 

allergic to amoxicillin.
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Pediatric Surgery and Medicine for Hostile Environments

Gastrointestinal Bleeding

• To treat GI bleeding, first check airway, breathing, and 

circulation, and perform hemodynamic stabilization if 

bleeding is severe.

• Take a patient history and perform a physical examination 

to determine etiology or source of the bleeding and ongoing 

rate of blood losses.

• Potential laboratory examinations include complete blood 

count, prothrombin time or activated partial thromboplastin 

time, liver function panel, disseminated intravascular 

coagulation panel, electrolyte panel with blood urea nitrogen/

creatinine, blood type and cross-match, and stool guaiac.

• If the patient has bloody diarrhea, send a stool sample for 

fecal leukocytes test and culture.

• Consider blood transfusion.

• Perform gastric lavage if upper GI bleeding is evident.

• Etiologies are based on age.

° Toddlers to children of early school age: painless rectal 

bleeding (either hematochezia or melena) in large 

quantity that drops hemoglobin levels is likely Meckel’s 

diverticulum.

▶ If this is suspected, admit the patient and observe by 

frequently checking hemoglobin levels.

▶ Radiologic diagnosis is made by Meckel’s scan.

▶ Treat with surgical resection of the Meckel’s diverticulum.

° In older children, significant upper GI bleeding is usually 

peptic disease, gastritis, or esophagitis.

▶ Occult liver disease can present as upper GI bleeding 

from esophageal varices in children.

▶ The other “at-risk” population includes patients who 

had omphalitis or umbilical cord catheterization 

complicated by portal vein thrombosis, causing 

portal hypertension.

° Another relatively common presentation of rectal bleeding 

is allergic colitis in an infant 1 to 2 months old.

• The most common cause of lower GI bleeding in the first 

year of age is anal fissure. Treat using warm soaks and stool 

softeners.
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Gastroenterology

Chronic Abdominal Pain

• Warning signs of organic disease include frequent vomiting, 

diarrhea, GI bleeding, weight loss or failure to gain weight 

normally, associated systemic symptoms, nocturnal wakening 

symptoms, localized pain, poor appetite, and early satiety.

• H pylori may cause vomiting associated with upper abdominal 

pain.

• Intussusception presents with severe abdominal pain that 

manifests as colicky pain, followed by bowel movement that 

may appear as melena or bright red blood.

° The classic appearance of the stool in the late stages is 

described as the “currant jelly stool” due to bowel wall 

ischemia.

° In younger infants and children, subjective localized pain 

will be absent.

▶ On physical examination, tenderness can often be 

localized in the right lower quadrant.

▶ This presentation usually occurs in children 6 months 

to 2 years old and is ileocolic.

° A kidney, ureter, and bladder radiograph will show paucity 

of bowel gas in the right lower quadrant, and a barium 

enema can be diagnostic and therapeutic.

▶ The risk of bowel perforation is higher during the 

diagnostic and therapeutic contrast enema if there has 

been a delay from the time of onset of symptoms; exercise 

caution.

▶ Admit and observe the patient; there is significant 

risk of recurrence in the first 24 hours, and fluids and 

electrolytes must be managed.

▶ If the enema does not reduce the intussusception, 

surgery will be needed for manual reduction.

▶ If intussusception occurs in an older child or occurs in a 

less typical location, such as ileal-ileal, be wary of other 

types of lead points, such as polyp disease or cancer 

lesions (as in lymphoma).
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Pediatric Surgery and Medicine for Hostile Environments

Acute Abdominal Pain

• Omental cysts

° Omental cysts may cause abdominal pain.

° They be difficult to diagnose on physical examination 

because of the large size and fluidity of the structure.

° Omental cysts are readily noticeable on ultrasound and 

computed tomography scan of the abdomen.

° Treatment is surgical resection.

• Intraabdominal masses and tumors may cause abdominal 

pain.

° Ultrasound and computed tomography scan of the 

abdomen are sufficient for diagnosis.

° Masses and tumors are sometimes evident on a kidney, 

ureter, and bladder radiograph.

• Peptic disease, celiac disease, esophagitis, and colitis cause 

abdominal pain.

• Nephrolithiasis and hydronephrosis, with or without urinary 

tract infection, can cause severe flank pain.

• Cholelithiasis and cholecystitis are uncommon in children; 

however, children may have congenital lesions that predispose 

them to these diseases. Sickle cell and cystic fibrosis patients 

are also prone to these problems.

Tube Feedings

• See Chapter 36, Nursing Assessment, for advice on enteral tube 

feeding, and comprehensive equipment table in Appendix C 

for age-appropriate nasogastric tube sizes. 
455

Infectious Diseases

Chapter 29

Infectious Diseases

Ocular Infections (see also Chapter 14, Ophthalmology)

Neonatal Conjunctivitis

• Symptoms include profuse purulence or hemorrhage in the 

conjunctivae.

• Etiology includes Neisseria gonorrhoeae, Chlamydia trachomatis, 

and herpes simplex virus (HSV).

• Diagnosis

° Gonococcal: Generally profuse, thick discharge, which may 

be unilateral or bilateral. Perform Gram stain and culture 

on chocolate agar. 

° Chlamydia: Purulence is usually thin, whitish, watery, and 

bilateral. Use nucleic acid amplification tests.

° HSV: Includes a variety of presentations from simple 

eye redness to thick discharge. The eye may also have 

surrounding vesicles. Use viral culture, direct fluorescent 

antibody, or polymerase chain reaction (PCR). In neonates, 

rule out disseminated HSV by evaluating cerebrospinal 

fluid and liver transaminases or HSV deoxyribonucleic 

acid (DNA) PCR, if available.

• Treatment (if laboratory testing is not readily available, 

consider empiric treatment)

° Gonococcus

▶ Administer ceftriaxone (50 mg/kg intravenous [IV] or 

intramuscular [IM] once, with a maximum of 125 mg) or 

cefotaxime twice a day for 7 days if neonate is jaundiced.

▶ Irrigate every 1 to 2 hours with saline.

▶ Topical antibiotics are not recommended.

° Chlamydia

▶ Administer oral (PO) erythromycin (50 mg/kg/day in 4 

divided doses) for 14 days, or azithromycin 20 mg/kg 

daily for 3 days.
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Pediatric Surgery and Medicine for Hostile Environments 

° HSV

▶ Apply topical trifluridine or vidarabine for 7 to 10 days.

▶ Consult an ophthalmologist, if possible.

▶ In severe cases or if infection has disseminated, 

administer IV acyclovir 20 mg/kg/dose three times a day 

for 14 to 21 days.

• Universal neonatal prophylaxis: apply topical 0.5% 

erythromycin ointment (preferred), 1% silver nitrate, or 1% 

tetracycline. 

Trachoma

• Symptoms include:

° chronic, mucopurulent drainage;

° follicular inflammation on the upper eyelid; and

° trichiasis (scarring with lashes turned inward).

• Etiology

° C trachomatis serovars A–C,

° endemic in developing parts of world, and 

° major cause of blindness worldwide.

• Diagnosis is clinical.

• Treatment consists of PO azithromycin (20 mg/kg once; 1 g 

maximum dose).

Periorbital Cellulitis

• Symptoms include erythema and edema surrounding the eye.

• Etiology involves inoculation from trauma or insect bite 

(Staphylococcus aureus or group A streptococcus) or bacteremic 

seeding (Haemophilus influenzae type B [Hib] or Streptococcus 

pneumoniae).

• Diagnosis is made by clinically assessing for normal globe 

movement, lack of proptosis, and lack of pain with extraocular 

muscle use. Blood cultures should be obtained.

• Treatment consists of administering third-generation 

cephalosporin. Add an antistaphylococcal drug (including 

methicillin-resistant Staphylococcus aureus [MRSA] coverage) 

if trauma is suspected or skin is broken.

• Perform lumbar puncture if Hib is suspected or if there is 

evidence of meningitis.
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Infectious Diseases

Orbital Cellulitis

• Symptoms include:

° periorbital edema and erythema;

° proptosis, severe eye pain, vision loss; and

° limitation of extraocular movement in more severe cases.

• Etiology

° underlying bacterial sinusitis,

° S pneumonia,

° Streptococcus pyogenes,

° S aureus,

° H influenzae (nontypable),

° Moraxella catarrhalis, and

° anaerobes in older children.

• Diagnosis is clinical. Computed tomography (CT) scan may 

be used, if available, to assess for abscess.

• Treatment includes IV ceftriaxone and clindamycin; or 

ampicillin (AMP)-sulbactam and vancomycin. Consider 

surgical intervention if condition continues to progress 24 to 

48 hours after treatment or if there is evidence of subperiosteal 

abscess.

Diseases of the Face and Neck

Buccal Cellulitis

• Symptoms include acute cheek edema and erythema anterior 

to parotid, associated with fever.

• Etiology includes Hib. Oral flora will be present if the 

condition is an extension of odontogenic infection.

• Diagnosis is clinical; organism can be obtained by blood

culture. 

• Treatment consists of administering third-generation IV

cephalosporin. 

Epiglottitis (see Chapter 26, Respiratory Emergencies)

Bacterial Tracheitis (see Chapter 26, Respiratory Emergencies)
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Pediatric Surgery and Medicine for Hostile Environments 

Parotitis, Sialadenitis, and Mumps

• Symptoms include painful swelling of the salivary glands 

(parotid, sublingual, or submandibular). Fever and toxicity 

are present with bacterial infection.

• Etiology is viral (usually mumps, human immunodeficiency 

virus [HIV], or enteroviruses) or bacterial (S aureus, gramnegative bacilli, S pyogenes, S pneumoniae).

• Diagnosis is clinical. Bacterial infection manifests with 

purulent drainage from Stensen’s duct. Perform Gram stain 

and culture.

• Treatment

° Bacterial: hydrate and provide parenteral antibiotics (eg, 

ceftriaxone, AMP/sulbactam, or other broad-spectrum 

varieties); cannulate duct or perform surgical drainage 

in severe or refractory cases; cover for MRSA if cultures 

dictate.

° Viral: supportive.

Parapharyngeal Abscess

• Symptoms include preceding adenitis, tonsillitis, or dental 

infection in children 5 years old and above; trismus; and 

parotid-area swelling extending below mandible.

• Etiology includes S pneumoniae, S aureus, group A β-hemolytic 

streptococci, and anaerobes.

• Diagnosis

° Retropharyngeal abscess may have bulging posterior 

pharyngeal wall on plain film.

° Prevertebral soft tissue swelling of greater than 7 mm at 

the level of the second cervical vertebra, or greater than 14 

mm at the level of the sixth cervical vertebra, is suggestive.

° Reversal of the normal cervical curvature may be present. 

Imaging with CT or magnetic resonance is required for 

definitive diagnosis.

• Treatment consists of surgical drainage and appropriate IV 

antibiotic therapy for primary infection (usually ceftriaxone 

and clindamycin).
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Infectious Diseases

Skin, Soft Tissue, Bone, and Joint Infections

In areas with a high prevalence of community-acquired MRSA, 

consider using clindamycin, trimethoprim-sulfamethoxazole 

(TMP/SMX), or vancomycin (IV only) when initiating empiric 

therapy for staphylococcal infections.

Cellulitis and Lymphangitis

• Symptoms include erythema, induration, warmth, tenderness, 

and lymphangitic spread (streaks).

• Etiology is most commonly S aureus, group A streptococcus, 

and Hib in unimmunized toddlers.

• Diagnosis is clinical and includes positive blood culture in 

less than 10% of patients, positive aspirate culture in 50%.

• Treatment consists of oral or IV antibiotics for S aureus and 

group A streptococcus (first-generation cephalosporin, 

antistaphylococcal penicillin, clindamycin). Rapid progression 

may indicate infection in deeper tissue planes, such as 

necrotizing fasciitis.

Cutaneous Candidiasis/Yeast Infections

• Symptoms include painful or itchy erythematous rash, usually 

concentrated in skin folds or covered areas (eg, diaper rash).

• Etiology is Candida species (usually Candida albicans).

• Diagnosis is based on clinical appearance. Erythema with 

sharp borders and smaller satellite lesions are frequently seen 

around the rash border.

• Treatment consists of one dose of fluconazole (10 mg/kg IV/

PO; maximum dose of 150 mg), OR topical antifungals, such 

as clotrimazole or nystatin.

Lymphadenitis

• Symptoms include swollen lymph nodes often associated with 

erythema, warmth, and tenderness.

• Etiology includes S aureus, group A streptococcus, 

mycobacterial species, toxoplasmosis, and many viruses. 

Consider plague in endemic areas.
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Pediatric Surgery and Medicine for Hostile Environments 

• Diagnosis is based on clinical appearance. Depending on 

location, consider throat culture, complete blood count, 

monospot, Gram stain, and a culture of the drainage.

• Treatment consists of empiric antibiotics against S aureus

(including MRSA) and group A streptococcus. Surgically 

drain abscess, if needed. If patient does not improve, consider 

tuberculosis (TB), chronic viral infection (eg, HIV), and 

atypical mycobacteria.

Septic Arthritis

• Symptoms include pain, swelling, erythema, warmth, and 

joint tenderness. Pain may be referred. 

• Etiology is most commonly S aureus, but N gonorrhoeae is 

possible if the patient is sexually active. Other etiologies 

include group A streptococcus, group B streptococcus (in 

neonates), S pneumoniae, Brucella (especially hip or sacrum), 

Hib (if unimmunized), and other gram negatives.

• Diagnosis is made when the following are present:

° elevated white blood cell (WBC) count,

° elevated erythrocyte sedimentation rate (ESR), and

° elevated C-reactive protein (CRP).

° Ultrasound may reveal fluid in joints.

° Perform Gram stain and culture of joint aspirate.

• Treat as follows:

° Drain joint (particularly the hip joint). 

° Empiric IV antibiotics should cover S aureus (first- or 

second-generation cephalosporin, antistaphylococcal 

penicillin; when MRSA is a concern, use vancomycin or 

clindamycin). In Hib, use a third-generation cephalosporin.

° Administer ceftriaxone for N gonorrhoeae.

• Differential diagnosis in children includes toxic synovitis 

(a diagnosis of exclusion), reactive arthritis, and juvenile 

rheumatoid arthritis.

Osteomyelitis

• Symptoms include pain, tenderness over bone (with or 

without swelling), overlying erythema, warmth, and fever.
461

Infectious Diseases

• Etiology is most commonly S aureus. Others include group A 

streptococcus, H influenzae, Kingella, Brucella, and mycobacteria 

species (including TB).

• Diagnosis: Patient will have elevated WBC count, ESR, and 

CRP; take radiographs of the suspected bones. If taken early, 

the radiographs may be normal. 

• Treatment

° Use empiric IV antibiotics against S aureus (first-generation 

cephalosporin, antistaphylococcal penicillin; alternatively, 

use vancomycin, or clindamycin if MRSA is a concern).

° If patient initially presents with a high fever or appears 

very ill, or for patients with sickle cell disease, cover for 

gram-negative organisms with ceftriaxone (or similar).

° Complete 3 to 6 weeks of antibiotics (switch to PO after 

1 week or when CRP and examination are normal and 

compliance with oral medications is ensured).

° Surgical debridement may be necessary if the condition is 

severe or if the patient fails to respond.

° Chronic osteomyelitis may require long-term therapy 

(months to years).

° If the patient fails to respond to antistaphylococcal 

medication, broaden coverage to include gram-negative

organisms.

Pulmonary Infections

Croup (laryngotracheitis/laryngotracheobronchitis; see Chapter 

26, Respiratory Emergencies)

Bronchiolitis (see Chapter 26, Respiratory Emergencies)

Pneumonia

• Symptoms include fever, tachypnea, retractions, and focal

lung findings.

• Etiology

° Bacterial: S pneumoniae, H influenzae, S aureus, Mycoplasma 

pneumoniae, Chlamydia pneumoniae, Bordetella pertussis, 

Mycobacterium tuberculosis, Chlamydia trachomatis (infants), 

and group B streptococcus (infants).
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Pediatric Surgery and Medicine for Hostile Environments 

° Viral: respiratory syncytial virus, influenza, parainfluenza, 

adenovirus, and measles.

° Parasitic/fungal: Pneumocystis carinii/jiroveci (if the patient 

has HIV or is immunosuppressed or malnourished).

• Epidemiology

° Pneumonia can occur in all ages and all seasons, and has 

high morbidity and mortality in children less than 5 years 

old.

° Risk factors include poverty, crowding, environmental 

exposures, prematurity, malnutrition, immunosuppression, 

and lack of breast-feeding.

• Diagnosis

° clinical,

° radiological (take chest radiograph, if available), and

° laboratory (cultures).

• Treatment

° Provide supportive care (eg, IV fluids, oxygen).

° Consider TB skin test in all children.

° Treatment duration is 5 to 10 days for uncomplicated 

infection, 2 to 4 weeks for complicated or severe infection.

• Antibiotics

° Less than 2 months old: IV AMP and gentamicin; OR AMP 

and cefotaxime.

° Greater than 2 months old: IV ceftriaxone or AMP.

° If atypicals are suspected (M pneumoniae or C pneumoniae), 

add azithromycin 10 mg/kg once, followed by 5 mg/kg/day 

for a total of 5 days.

° If HIV is suspected or if the patient is severely malnourished, 

consider TMP/SMX.

° If disease is nosocomial or the patient is immunosuppressed, 

consider broadening coverage with vancomycin, 

antifungals, or TMP/SMX.

° If aspiration is the etiology, provide anaerobic coverage 

(clindamycin or AMP/sulbactam).

• Complications

° Suspect complications in cases of severe pneumonia with 

prolonged fever, septic appearance, slow response to 

antibiotics, and clinical deterioration.

° In the case of a lung abscess: 
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Infectious Diseases

▶ obtain a CT scan, if possible;

▶ include anaerobic coverage; and

▶ extend treatment to 3 to 4 weeks or more.

° In the case of effusion/empyema (suspect this in patients 

with dyspnea and pleuritic pain):

▶ Patients will exhibit dullness to percussion and decreased 

breath sounds.

▶ Take decubitus films, CT scan, and ultrasound, if 

available. 

▶ Use a chest tube rather than thoracentesis to address 

large effusions, if possible.

Whooping Cough/Pertussis

• Symptoms

° Suspect pertussis if a patient exhibits paroxysmal cough, 

facial petechiae, or posttussive emesis, or if patient’s face 

turns red or blue with cough.

° Catarrhal: patient will show mild symptoms of upper 

respiratory infection (URI); antibiotics may ameliorate 

disease and limit spread. Neonates may present with apnea.

° Paroxysmal: patient has paroxysms of cough with 

inspiratory whoop, with or without posttussive emesis.

° Convalescent: patient’s symptoms wane gradually over 

weeks to months (usually afebrile); can last 6 to 10 weeks 

or longer.

• Most severe in children less than 6 months old who may present 

with apnea or elevated WBC count with lymphocytosis.

• Epidemiology

° B pertussis, Bordetella parapertussis.

° Humans are the only hosts.

° Transmitted via aerosolized droplets.

° Adolescents and adults are important infectious sources; 

incidence is increased in conditions of close contact.

• Diagnosis: clinical (culture or PCR, if available).

• Treatment

° Administer macrolides (azithromycin, erythromycin, 

clarithromycin). Use macrolides with caution in infants 

less than 2 months old due to concerns of pyloric stenosis. 

° Provide supportive therapy (eg, IV fluids, rest, oxygen). 
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Pediatric Surgery and Medicine for Hostile Environments 

• Prophylaxis and control can be achieved by:

° immunization, and

° postexposure prophylaxis (same dose and duration as 

treatment).

▶ Erythromycin: 40 to 50 mg/kg/day divided four times 

daily for 14 days (maximum 2 g/day; estolate salt is better 

tolerated).

▶ Azithromycin: 10 to 12 mg/kg once daily for 5 days (do 

not step down doses on days 2 to 5; maximum of 600 

mg/day).

▶ Clarithromycin: 15 to 20 mg/kg/day, divided twice daily 

for 7 days (maximum 1 g/day).

▶ TMP/SMX: if the patient cannot tolerate erythromycin, 

give 8 mg/kg/day TMP component twice daily for 14 

days (contraindicated in infants less than 2 months old 

because of the risk for kernicterus).

Tuberculosis

• Symptoms: fever, weight loss/failure to thrive, cough, night 

sweats, chills.

• Extrapulmonary findings may include meningitis, 

lymphadenitis, and involvement of bones, joints, skin, and 

middle ear or mastoid.

• Epidemiology includes M tuberculosis. Incidence is increased 

in populations with high HIV rates.

• Diagnosis in the low and moderate resource setting is difficult. 

Tuberculin skin tests are unreliable predictors of TB diseases 

due to high rates of latent infection and a high rate of anergy 

in high-risk groups (malnourished and HIV) as well as those 

with active TB disease. 

• Use chest radiograph to evaluate for evidence of active 

pulmonary disease. Careful clinical evaluation may also 

detect extrapulmonary manifestations of tuberculosis, such 

as vertebral TB or TB lymphadenitis.

• Sputum specimens are often difficult to obtain in young 

children but should be pursued. Acid-fast staining is widely 

available but has an unreliable sensitivity in children. Sputum 

culture, though more sensitive, is often not widely available. 

In some regions, World Health Organization (WHO) and 
465

Infectious Diseases

ministry-of-health-supported referral programs have rolled 

out the Xpert MTB/RIF (Cepheid, Sunnyvale, CA), a PCR assay 

designed for use in low-resource settings that can rapidly 

detect the presence of TB in sputum smears as well as genes 

coding for rifampin resistance (which predicts multidrug 

resistance). 

• Treatment should be consistent with the host-nation ministry 

or department of health guidelines. Additional resources for 

WHO diagnosis and treatment guidelines are available at the 

end of this chapter. 

• Due to the resources required, long duration of care, and risk 

of fostering resistance, deployed military forces should be 

reticent to initiate treatment of TB in local populations unless 

there is a capacity to transition care to a functioning ministry 

of health or nongovernmental agency TB program.

• Active disease (see drug dosages below)

° Pulmonary/extrapulmonary (except meningitis) in an HIVnegative child:

▶ 2 months of isoniazid plus rifampin plus pyrazinamide, 

followed by

▶ 4 months of isoniazid and rifampin. 

° Pulmonary/extrapulmonary (except meningitis and 

osteoarticular) in an HIV-positive child or where local rates 

of isoniazid resistance are elevated:

▶ 2 months of isoniazid plus rifampin plus pyrazinamide 

plus ethambutol. Ethambutol can cause optic neuritis, so 

avoid use in young children unless they can cooperate 

with tests for visual acuity and color blindness.

▶ 4 months of isoniazid and rifampin.

° For meningitis and osteoarticular TB:

▶ 2 months of isoniazid plus rifampin plus pyrazinamide 

plus ethambutol.

▶ 10 months of isoniazid and rifampin.

° Steroids are indicated for TB meningitis, pericardial TB, 

and airway obstruction due to TB.

▶ Dexamethasone 0.3 to 0.4 mg/kg/day (IV until the patient 

starts accepting PO, at which time tablets can be used) 

or prednisolone or prednisone 2 mg/kg/day (maximum 

dose 60 mg). Total duration is 6 to 12 weeks based on 

disease severity and includes a 2-week taper. 
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Pediatric Surgery and Medicine for Hostile Environments 

▶ In active pulmonary disease, the WHO does not 

recommend follow-up chest radiographs for those 

patients who are clinically responding well. Resolution 

of radiographic changes will be slow.

° Drug dosages:

▶ Isoniazid: 10 to 15 mg/kg/day (maximum 300 mg/day) 

OR 20 to 30 mg/kg three times weekly.

▶ Rifampin: 10 to 20 mg/kg/day (maximum 600 mg/day) 

OR 10 to 20 mg/kg three times weekly.

▶ Pyrazinamide: 30 to 40 mg/kg/day (maximum 2 g/day). 

▶ Ethambutol: 20 mg/kg/day (maximum 2.5 g/day). 

• In settings with a high HIV prevalence, TB-infected children 

should not be treated with intermittent regimens (ie, two or 

three times per week dosing). During the continuation phase of 

therapy, three-times-per-week regimens can be considered for 

children confirmed to be HIV-uninfected and living in settings 

with well-established, directly observed therapy programs.

° Routine laboratory checks are not recommended by the 

WHO. Assess transaminases in children with hepatomegaly, 

jaundice, right upper quadrant tenderness, or prolonged 

nausea and vomiting.

° Provide B6 (pyridoxine) supplementation for individuals 

who are malnourished or HIV positive to prevent isoniazidinduced neuritis, 1 to 2 mg/kg/day (maximum 50 mg/day).

° Children with TB likely acquired it from an adult, so 

investigate all who have had contact with the infected 

child, looking for the index case as well as for other infected 

children.

° WHO recommendations for assessing case contacts 

in a low- or moderate-resource setting call for clinical 

assessment for illness but do not require a chest radiograph 

or skin test. 

° Preventive therapy for latent TB infection with 6 months of 

isoniazid is recommended by WHO for contacts of TB cases 

who are infected with HIV, or who are under 5 years old.

Urinary Tract Infections and Pyelonephritis

• Symptoms include fever, irritability, foul-smelling or 

discolored urine, urinary frequency and urgency, dysuria, 

emesis, and diarrhea.
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Infectious Diseases

• Urinary tract infection should be considered in any child less 

than 2 years old with unexplained fever, as children this young 

cannot verbalize dysuria complaints.

• Etiology: Gram-negative enteric organisms, especially E coli.

• Diagnosis is made by urinalysis, preferably with corresponding 

culture. 

° Specimens obtained by bag are useful for urinalysis, but 

not for culture because of skin contamination. If culture is 

not available, use a urine dipstick or microscopy. 

° Leukocyte esterase test on a urine dipstick is sensitive, but 

not specific; nitrite is specific for urinary tract infection, but 

not sensitive.

° Greater than 10 WBCs per high-powered field on 

microscopy indicates pyuria.

° Bacteria are also noted.

• Treatment consists of standard first-line therapies in the 

nontoxic child (7-day course):

° Amoxicillin (40 mg/kg/day).

° TMP/SMX (10 mg/kg/day of TMP) or cefixime (8 mg/kg/

day every day).

° Reevaluate in 1 to 2 days.

° If the child appears toxic, IV or IM third-generation 

cephalosporin or an aminoglycoside are preferred.

• Follow-up and prophylaxis 

° If possible, evaluate anatomy with renal ultrasound.

° If it is a recurrent infection, consider prophylactic antibiotics 

(amoxicillin or TMP/SMX at half the usual daily dose, given 

at bedtime) and further evaluation for reflux with voiding 

cystourethrogram.

Diarrhea in a Humanitarian-Assistance Setting

• Symptoms include the following:

° three or more loose or watery stools per day,

° acute diarrhea that starts suddenly and is generally selflimited after several days, or

° persistent diarrhea that starts like acute diarrhea but lasts 

14 days or more.

• Etiology

° Diarrhea is the major cause of morbidity and mortality 

among children worldwide.
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Pediatric Surgery and Medicine for Hostile Environments 

° WHO recognizes acute watery diarrhea and dysentery as 

the two basic types of acute diarrhea.

▶ Acute watery diarrhea in children in low-income countries 

may be caused by rotavirus, Cryptosporidium, Aeromonas, 

adenovirus, and E coli, as well as classic dysentery 

pathogens, such as Salmonella and campylobacter. 

When a patient presents with a high volume of watery 

stools with flecks of mucous (rice-water stools), rule out 

cholera.

▶ Dysentery is defined as bloody, mucoid diarrhea, and 

is usually caused by gram-negative bacteria (Shigella, 

Campylobacter, Salmonella species, and rarely, Clostridium 

difficile). Shiga-toxin producing E coli, associated with 

hemolytic-uremic syndrome, are rare in low-income 

countries.

° Almost all these agents are transmitted by ingesting 

contaminated food or water and by person-to-person 

spread; contact precautions are encouraged.

• Diagnosis: Use clinical diagnosis and empiric treatment for 

most cases. 

° Most cases in infants are of viral etiology (rotavirus). 

Confirm initial cases of cholera and bacillary dysentery 

microbiologically, if possible.

° WHO case definitions for cholera:

▶ any person older than 5 years with severe dehydration 

or death due to watery diarrhea, or

▶ any person older than 2 years with watery diarrhea in 

an area with a cholera outbreak.

• Treatment (derived from WHO guidelines; assumes limited 

resources and limited or no laboratory support):

° assess dehydration (ie, none, some, severe);

° prevent dehydration by increasing fluid intake (use oral 

rehydration solution [ORS] or breast milk);

° treat dehydration;

° provide nutritional support and encourage feeding, support 

breast-feeding;

° use antibiotics selectively;

° avoid antimotility agents; and 

° provide empiric treatment.
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Infectious Diseases

▶ If the patient is not dehydrated, increase fluid intake to 

more than the usual amount.

▶ If the patient exhibits some dehydration, give ORS until 

skin turgor returns to normal and thirst abates; start with 

75 mL/kg in first 4 hours.

▶ In cases of severe dehydration, use IV fluid therapy.

▶ Use a nasogastric tube if an IV cannot be placed within 

30 minutes.

▶ Start ORS as soon as the patient can tolerate it.

▶ Give 30 mL/kg IV bolus, then another 70 mL/kg IV over 

the next 4 to 6 hours.

▶ Zinc supplementation for 10 to 14 days will mitigate 

current illness and decrease the incidence of subsequent 

episodes (10 mg a day for children younger than 6 

months old, 20 mg a day for those older than 6 months; 

check the available zinc salt preparation for zinc content).

▶ Treat with an antibiotic if dysentery is likely (know local 

resistance patterns if possible).

• Antibiotics are not recommended for use in children living in 

low-resource settings with acute watery diarrhea not due to 

cholera. WHO guidelines for empiric therapy of dysentery:

° give ciprofloxacin 500 mg PO bid for 3 days (adults), 15 mg/

kg PO bid for 3 days (off-label use for pediatric patients). 

Significant resistance is developing, especially in Southeast 

Asia; OR

° give azithromycin 10 mg/kg PO for 3 days.

° Resistance rates to TMP/SMX and AMP make them poor 

empiric choices.

° Antibiotics will shorten the duration of cholera symptoms.

▶ In large outbreaks, reserve antibiotics for severe cases.

▶ Administer one dose of doxycycline (300 mg PO; WHO 

guidelines recommend this as off-label use for all 

patients).

° For patients with persistent diarrhea, the priority is to 

improve nutritional intake and provide micronutrient 

supplementation (zinc). In cases of dysentery, two courses 

of antibiotics should be prescribed before empiric therapy 

for amoebiasis. Empiric therapy for giardiasis may be 

considered for persistent nonbloody diarrhea.
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Pediatric Surgery and Medicine for Hostile Environments 

▶ Amoebiasis: symptoms include abdominal pain, fever, 

and diarrhea (usually bloody or mucoid). Right upper 

quadrant abdominal pain may represent amebic abscess.

▷ Etiology: Entamoeba histolytica. 

▷ Diagnosis: Identify trophozoites or cysts on stool 

sample. Rapid antigen tests may be available.

▷ Treatment: Give metronidazole for dysentery and 

abscesses. Administer diloxanide, iodoquinol, or 

paromomycin to eradicate cysts from stool. For 

endemic populations, eradicating cysts from stools 

is not indicated. Chlorinating water will not kill 

Entamoeba; boil water for 1 minute.

▶ Giardiasis 

▷ Etiology: Giardia intestinalis (formerly Giardia lamblia).

▷ Diagnosis: Microscopic identification of trophozoites 

or cysts in stool. Rapid antigen test may also be used.

▷ Treatment: Administer metronidazole, tinidazole, 

imidazole, or nitazoxanide. Paromomycin can be 

used for pregnant women. Chlorinating water will 

kill Giardia; boil water for 1 minute. 

Systemic Conditions

Sepsis and Meningitis

• Symptoms: The clinical case definition of meningitis is sudden 

onset of fever (greater than 38°C) and one of the following:

° neck stiffness in older children,

° altered consciousness, or 

° other meningeal sign, such as:

▶ Kernig sign: flex the patient’s knees and the neck bends 

in response.

▶ Brudzinski sign: flex the patient’s neck and the knees 

bend in response.

° Petechial or purpural rash.

° In patients younger than 1 year old, meningitis is suspected 

when fever is accompanied by a bulging fontanel.

° Neisseria meningitidis also causes meningococcal septicemia 

(severe disease with signs of acute fever, purpura or 

petechiae, and shock). Though less common, the case 

fatality rate is high.
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Infectious Diseases

• Etiology: N meningitidis, S pneumoniae, and Hib account for 

more than 80% of all cases of bacterial meningitis and sepsis 

in unimmunized populations.

• Diagnosis is made by blood culture. Lumbar puncture should

be done as soon as meningitis is suspected and before starting 

antimicrobial treatment, if possible.

° In bacterial meningitis, cerebrospinal fluid is usually cloudy 

or purulent (but may be clear or bloody).

° In malaria-endemic areas, thick and thin smears of blood 

should be made to differentiate meningitis from cerebral 

malaria.

• Treatment

° If bacterial meningitis is suspected, antibiotic treatment 

should be started immediately after a lumbar puncture 

without waiting for the results; treatment should not be 

delayed if lumbar puncture cannot be performed in a timely 

manner (Table 29-1).

° Viral meningitis is rarely serious and requires supportive 

care, but a lumbar puncture is necessary to differentiate it 

from bacterial meningitis.

° During epidemics of N meningitidis among refugees or 

displaced populations, a single-dose IM regimen of oily 

chloramphenicol can be considered. 

▶ Oral chloramphenicol also effectively penetrates the 

central nervous system.

▶ Single-dose ceftriaxone IM or IV (100 mg/kg, maximum 4 

g) is equivalent to a single dose of oily chloramphenicol. 

° Chemoprophylaxis of local civilian contacts is often 

not recommended in emergency situations; however, 

exposed healthcare workers should receive prophylaxis if 

meningococcus is suspected or confirmed. Administer:

▶ Rifampin: 10 mg/kg, maximum 1,200 mg, every 12 hours 

for 2 days.

▶ Ceftriaxone: single dose, 125 mg IM for those up to 14 

years old, 250 mg for those older than 15 years.

▶ Ciprofloxacin: single dose, 500 mg PO for those older 

than 18 years.
472

Pediatric Surgery and Medicine for Hostile Environments Table 29-1. Empiric Therapy for Bacterial Meningitis and Sepsis in Developing Countries Patient Group Likely Etiology Treatment Duration of Therapy

Neurosurgical problems 

and head trauma

Staphylococcus aureusStaphylococcus epidermidisGram-negative organismsStreptococcus pneumoniae

Minimum 3 wk Vancomycin and a thirdgeneration cephalosporin

2 mo–18 y old Haemophilus influenzae

Streptococcus pneumoniaeNeisseria meningitidesSalmonella spp

Ceftriaxone 100 mg/kg q24h 

(if resistant Streptococcus pneumoniae is present, add vancomycin 40 mg/kg/day, divided q6–8h)

Haemophilus influenzae: 10 

days

Streptococcus pneumoniae: 

10–14 days

Neisseria meningitidis: 7 

days

Salmonella spp: 21 days

Immunocompetent children 

< 2 mo old

Group B streptococcusEscherichia coliListeriaSalmonella spp

Ampicillin 200–300 mg/kg/day≤ 7 days ÷ q8h; > 7 days ÷ q6h

PLUS

Gentamicin 2.5 mg/kg q12h

OR ADD

Cefotaxime 50 mg/kg q8h

3 wk
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Infectious Diseases

Acute Rheumatic Fever

• Symptoms: Most commonly presents with arthritis or carditis.

• Etiology: Inflammatory process occurring after pharyngitis 

due to certain group A beta-hemolytic streptococci types.

° In developed countries, there is well-known association 

between acute rheumatic fever and streptococcal 

pharyngitis. In developing countries, the association is less 

clear; fewer than two-thirds of patients remember having 

a sore throat in the months before presenting.

° The disease is common among children aged 6 to 15 years 

old, rare in infants and preschool-aged children, and may 

occur in adults.

• Diagnosis

° Evidence of recent streptococcal infection is required 

(positive throat culture or rapid streptococcal test), recent 

scarlet fever, or positive antibodies (antistreptolysin O or 

deoxyribonuclease B).

° The diagnosis is made using the revised Jones Criteria (see 

Chapter 27, Cardiology, for carditis discussion, and Table 

27-1); the patient must meet two major criteria OR one

major and two minor criteria (chorea and recurrent acute 

rheumatic fever do not require minor criteria for diagnosis).

• Treatment

° Penicillin V 250 mg PO bid for 10 days, or administer 

benzathine penicillin G (0.6 to 1.2 million units IM).

° Administer aspirin (initially 80 to 100 mg/kg/day in four 

doses, decreased to 10 to 15 mg/kg/dose when afebrile) or 

naproxen (15 to 20 mg/kg/day in two doses).

° Preventing recurrence includes administering benzathine 

penicillin G 25,000 units/kg IM every 3 to 4 weeks 

(maximum of 1.2 million units/dose). Alternatively, use 

penicillin VK 250 mg PO bid, OR erythromycin 250 mg PO 

bid for penicillin-allergic patients.

° Recommendations for secondary prophylaxis are to 

continue for 10 years after the last attack, or to age 21 to 

25 years, whichever is longer. In the presence of severe 

residual heart valve disease, prophylaxis is life-long.

Commonly used oral and IM antibiotics can be found in Tables 

29-2 and 29-3.
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Pediatric Surgery and Medicine for Hostile Environments Table 29-2. Common Oral Liquid Antimicrobial Medications Used in Children Generic Strength Average Dose Interval Maximum Name (mg/mL) (mg/kg/day) (h) Dose Amoxicillin 25, 40, 50, 80 Infants < 3 mo old: 20–30 12 2–3 g/day > 3 mo old: 25–50 8–12 Acute OM due to 12 resistant Streptococcus pneumoniae: 80–90 Amoxicillin + 25, 40, 50, 80 Infants < 3 mo old: 30 AMX 12 Use 25 mg/mL (AMX component) clavulanic acid AMX component formulation for infants < 3 mo old Children < 40 kg: 25–45 8–12 Use 4:1 (AMX:CA) formulation (25 or 50 mg AMX component AMX/mL) with tid dosing regiment 120 AMX > 3 mo old and > 40 kg with 12 Use 7:1 (AMX:CA) or ES formulation multidrug-resistant for bid dosing regimen to avoid higher pneumococcal OM 80–90 dose of CA AMX component Azithromycin 20, 40 URI and OM in children 24 500 mg/day for day 1; 250 mg/day for > 6 mo old: 10 on day 1, days 2–5

followed by 5 on day 2–5

OM: 10 for 3 days 24 500 mg/day

or 30 × 1 single dose 1,500 mg/day

Pharyngitis in children 24 500 mg/day

> 2 y old: 12 for 5 days

(Table 29-2 continues)
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Infectious Diseases

Generic Strength Average Dose Interval Maximum

Name (mg/mL) (mg/kg/day) (h) Dose

Cephalexin 25, 50 25–100 6 4 g/dayClarithromycin 25, 50 15 12 1 g/dayClindamycin 15 10–30 6–8 1.8 g/dayNitrofurantoin 5 Children > 1 mo old: 5–7 6 400 mg/day

UTI prophylaxis: 1–2 24 100 mg/day

Penicillin V 25, 50 25–50 6–8 3 g/day

potassium

Sulfamethoxazole 8 TMP + Children > 2 mo old: 12 160 mg TMP component/dose

+ trimethoprim 40 SMX 6–12 TMP component

Serious infection in children 6–8

> 2 mo old: 15–20 TMP component

Sulfasoxazole 100 Children > 2 mo old: 75 for 4–6 6 g/day

initial dose, then 120–150

(Table 29-2 AMX: amoxicillin bid: twice dailyCA: clavulanic acid ES: extra strengthOM: otitis media

continued)

SMX: sulfamethoxazoletid: three times dailyTMP: trimethoprimURI: upper respiratory infectionUTI: urinary tract infection
476

Pediatric Surgery and Medicine for Hostile Environments Table 29-3. Common Intramuscular Antimicrobial Medications Used in Children Change Dose/ Dosage Interval Due Concentration Range (mg/ Interval Maximum to Renal Drug Name (mg/mL) kg/day) (h) Dose Dysfunction Comments Ampicillin 250 50–400 6 12 g/day Yes 3 mEq Na+/1 g ampicillin; use within 1 h of reconstitution Cefazolin 225 or 330* 40–100 6–8 6 g/day Yes 2 mEq Na+/1 g cefazolin Cefepime 280 50–150 8 2 g/dose, Yes No dosage adjustment for burn 6 g/day patients Ceftriaxone 350 50–100 12 2 g/dose, No 3.6 mEq Na+/1 g ceftriaxone 4 g/day May cause primary cholelithiasis, nephrolithiasis, and hemolytic anemia; gallstones resolve after discontinuation Not recommended for neonates with hyperbilirubinemia Gentamicin 40 2.0–3.5 or 8 or 24 According Yes Peak concentration 4–12 μg/mL 5.0–7.5 to serum (2–3 times higher with once-daily

levels dosing regimen)

Trough concentration 0.5–2 μg/mLContains sulfites, which may 

exacerbate asthma symptoms

May cause cochlear and/or 

vestibular ototoxicity

*This concentration is only approved for use with the 1-g vial.
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Infectious Diseases

Miscellaneous and Tropical Diseases

Diphtheria

• Symptoms range from a moderately sore throat to toxic, lifethreatening diphtheria of the larynx or of the lower and upper 

respiratory tracts.

• Throat may be covered by a grey membrane and the patient 

may have a “bull neck” appearance from local edema of the 

neck.

• Nasal mucosa is generally markedly inflamed.

• Disease is often complicated by myocarditis (rhythm 

disturbance due to toxin) and neuritis (toxic damage to 

peripheral nerves).

• Can be fatal; 5% to 10% of diphtheria patients die, even if 

properly treated (untreated patients die in greater numbers).

• Untreated patients are infectious for 2 to 3 weeks.

• Etiology is Corynebacterium diphtheria. In several developing 

countries (particularly Eastern Europe and Asia), diphtheria 

is the leading cause of pharyngitis in unimmunized children 

during an outbreak. It is transmitted by the spread of large 

droplets.

• Diagnosis is clinical and made by culture. A probable case 

definition according to WHO is as follows:

° recent (within 2 weeks) contact with an individual 

confirmed contaminated,

° diphtheria endemic to region,

° stridor,

° swelling/edema of the neck,

° submucosal or skin petechiae,

° toxic circulatory collapse,

° acute renal insufficiency, and

° myocarditis and motor paralysis 1 to 6 weeks after onset.

• Treatment is as follows:

° Administer equine diphtheria antitoxin (20,000 to 100,000 

units, consider test dose prior to treatment) and penicillin 

or erythromycin.

° Obtain cultures before giving antibiotics.

° Monitor contacts closely for disease development.
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Pediatric Surgery and Medicine for Hostile Environments 

° Provide prophylaxis to contacts via 600,000 units penicillin 

(IM) in those younger than 6 years, 1.2 million units (IM) 

in those 6 years and older.

Human Immunodeficiency Virus and Acquired Immunodeficiency 

Syndrome

In deployment settings, it is impossible to properly administer 

antiretroviral therapy. In underdeveloped countries, the rates 

of HIV may be very high, and the provider should always be 

suspicious that an ill or malnourished patient is infected.

• Symptoms

° recurrent or severe pneumonia in infancy (pneumococcus, 

tuberculosis, and Pneumocystic carini/ jiroveci);

° generalized lymphadenopathy;

° enlarged, nontender parotitis;

° failure to thrive;

° mucocutaneous candidiasis; and

° recurrent sepsis.

• Diagnosis is made based on serology, viral load, and clinical 

appearance.

• In the absence of antiretroviral therapy, treatment is supportive 

and may also include chemoprophylaxis for opportunistic 

infections with TMP/SMX or targeted therapy.

Japanese Encephalitis

• Symptoms include headache, fever, meningeal signs, 

stupor, disorientation, coma, tremors, paresis (generalized), 

hypertonia, and loss of coordination.

° Japanese encephalitis cannot be distinguished clinically 

from other central nervous system infections.

° Severe infections are marked by acute onset, headache, high 

fever, meningeal signs, and coma.

• Etiology: 

° Acute, inflammatory, mosquito-borne disease involving 

the brain, spinal cord, and meninges.

° Common and usually asymptomatic.

° Case fatality rate among individuals with clinical disease 

is 25% to 50%.
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Infectious Diseases

° Infants and the elderly are most susceptible to severe 

disease.

° Occurs in east, southeast, and southern Asia.

° Especially associated with rice-growing areas and exposure 

to pigs.

• Diagnosis: demonstration of specific immunoglobulin M in 

acute-phase serum or cerebrospinal fluid.

• Treatment is supportive.

• Prophylaxis and control

° Use protective clothing and repellents to avoid exposure 

to mosquitoes.

° Screen sleeping and living quarters.

° House pigs away from living quarters.

° Effective vaccines are available.

Leptospirosis (Weil’s disease)

• Most infections have mild to moderate nonspecific symptoms 

of fever, headache, and myalgias. Severe disease presents with 

abrupt onset of chills, high fever, jaundice, and renal disease 

(proteinuria, hematuria, azotemia). Petechiae, purpura, or 

pulmonary hemorrhage may also occur.

• Death occurs in 5% to 10% of patients with severe disease.

• Conjunctival suffusion, hemorrhage, ocular pain, photophobia, 

and intense headache may be other clues to diagnosis.

• Acquired from contact with water or soil contaminated with 

urine or tissues of infected animals (often rats, dogs, and cats).

• Diagnosis is typically empiric in most low-resource settings, 

but may be made by finding the spirochetes of Leptospira in the 

blood and urine (culture, PCR) or with acute and convalescent 

serologies.

• Treatment with penicillin (IV if disease is severe) and/or 

doxycycline during the first week of illness will shorten the 

disease duration.

Lyme Disease

• Borrelia species carried by Ixodes ticks found throughout 

Europe, parts of Asia, and pockets of the United States.

• Transmission is via the bite of infected ticks and generally 

requires the tick to be attached for at least 36 hours. 
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Pediatric Surgery and Medicine for Hostile Environments 

• Symptoms: Lyme disease is categorized into three phases, 

characterized by local disease (Bull’s eye rash, see Chapter 

34, Dermatology, Figure 34-6) as well as early and late 

disseminated phases. Meningitis and nerve involvement are 

more common with European strains. 

• For a complete review of the symptoms, diagnosis, and 

treatment for each phase, please see the American Lyme 

Disease Foundation’s website (http://www.aldf.com/raad.

shtml) or the Medscape webpage addressing Lyme disease 

(http://emedicine.medscape.com/article/330178).

• Of note, US antibody detection methods will not diagnose 

Eurasian Lyme strains. A C6 peptide or locally obtained 

diagnostics are required for these strains. 

• Prophylaxis: The risk of infection increases with the duration 

of tick attachment. If a deer tick is found and removed, and 

if the tick has been attached for 36 hours or is engorged, a 

single dose of 200 mg of doxycycline administered within the 

72 hours after removal may reduce the risk of Lyme disease. 

Malaria

• Plasmodium falciparum

° Symptoms include:

▶ anemia that may be severe (hemoglobin less than 5 gm/

dL), particularly in nonimmune and pregnant patients;

▶ hyperparasitemia (more than 5% of red blood cells 

infected on smear);

▶ hyperthermia (body temperature above 41°C);

▶ hypoglycemia and acidosis;

▶ cerebral malaria, marked by seizures or coma (more 

common in children, with mortality rate of 15% to 30%);

▶ renal failure;

▶ pulmonary edema; and

▶ diarrhea (common presenting sign in children).

▶ Plasmodium vivax symptoms include cyclic fevers and 

chills and splenic rupture (late manifestation).

▶ Plasmodium malariae and Plasmodium ovale symptoms 

include few complications due to low-level parasitemia. 

P malariae has been associated with immune complex 

glomerulonephritis.
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Infectious Diseases

• The WHO strongly recommends that parasitologic diagnosis 

of malaria be made prior to treatment to conserve resources 

and reduce expansion of drug resistance resulting from 

indiscriminate use. In high-transmission settings (eg, much 

of sub-Saharan Africa), empiric therapy for children under 5 

years of age with fever can be offered when diagnostic tests 

are not otherwise available. While microscopy has been the 

traditional means of diagnosing malaria, outside of clinical 

trials with expert microscopists, experience has shown that 

in field use, rapid diagnostic tests are typically more sensitive 

and specific than blood smears. Some rapid diagnostic tests 

only test for P falciparum and will miss P vivax and other 

species. Although US-based practice is to perform three rapid 

diagnostic tests with smear microscopy backup, common 

practice in endemic regions is to perform a single test. 

• Treatment medications are the same as for adults and are 

based on the infecting species, possible drug resistance, and 

severity of disease. 

° Use IV therapy only for severe disease.

▶ Artesunate: 2.4 mg/kg/dose IV at 0, 12, 24, and 48 hours. 

This is the WHO first-line therapy, it is currently only 

available in the United States under an investigational 

new drug protocol from the US Centers for Disease 

Control and Prevention (CDC).

▶ Quinidine gluconate: 10 mg/kg loading dose (maximum 

600 mg) by IV infusion over period of 1 to 2 hours. 

Give the first 2 mg/kg as a test dose with continuous 

electrocardiogram monitoring for idiosyncratic 

prolongation of QRS or arrhythmias. Watch for 

hypoglycemia and hypotension. Follow loading dose 

with continuous infusion of 0.02 mg/kg/min to keep 

serum levels at 3 to 7 mg/L. This medication is not 

recommended by the WHO, but may be the only 

parenteral antimalarial medication available to deployed 

forces.

▶ Transition to an oral regimen when parasitemia is less 

than 1% or patient is able to take oral medication. 

° Oral therapy
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Pediatric Surgery and Medicine for Hostile Environments 

▶ Plasmodium with no resistance noted (most 

nonfalciparum species worldwide; falciparum in Central 

America and the Caribbean):

▷ Chloroquine phosphate: 10 mg base/kg (PO; 

maximum 600 mg base) initially, then 5 mg base/kg 

(PO; maximum 300 mg base) at 24 and 48 hours.

▶ Plasmodium with known chloroquine resistance noted:

▷ Artemisinin-based combination therapy is the WHO 

first-line approach. One of the most widely used 

regimens, and one licensed by the US Food and Drug 

Administration, is artemether-lumefantrine (20 mg 

/120 mg). First dose at time 0 and then second dose 8 

hours later; then 1 dose twice daily for a total 6 doses 

over 3 days. Dosages by weight: 5 to 15 kg: 1 tablet 

per dose; 15 to 25 kg: 2 tablets per dose; 25 to 35 kg: 3 

tablets per dose; 35 kg and above: 4 tablets per dose).

OR

▷ Quinine sulfate: 25 mg/kg/day (PO; maximum 2,000 

mg), divided three times daily for 3 to 7 days. 

AND one of the following:

▷ Tetracycline: 20 mg/kg/day (PO; maximum 750 mg) 

divided 4 times a day for 7 days for children older 

than 8 years.

OR 

▷ Clindamycin: 30 mg/kg/day PO divided 3 times a day 

for 5 days.

OR

▷ Atovaquone/proguanil is highly effective but not 

recommended for treatment on a wide scale in 

endemic regions due to concerns of rapid resistance 

emergence. Mefloquine can also be used but is not 

recommended as a first-line drug due to the high rate 

of adverse effects.

° Consult entomology teams for vector control methods.

° Chemoprophylaxis is not recommended for local 

populations in endemic regions.

° Use permethrin-treated bed nets.
483

Infectious Diseases

Measles

• Measles (rubeola) has played a significant role in situations 

involving displaced persons. It can lead to high mortality 

in unimmunized individuals, particularly those who are 

malnourished and very young.

• Symptoms include fever, cough, coryza, conjunctivitis, Koplik 

spots, and cephalocaudal progressive rash.

• Treatment involves recognizing the clinical disease spectrum, 

immunizing, and treating.

° Immunization should target malnourished children in 

displacement situations and those between 6 months and 

5 years old, with an emphasis on the youngest children.

° Rubeola will often unmask vitamin A deficiency; 

prophylactic supplementation should occur as follows:

▶ Less than 12 months old: 100,000 IU (PO) once daily for 

2 days.

▶ Older than 12 months: 200,000 IU (PO) once daily for 2 

days.

• Complications and associated findings:

° cervical adenitis,

° mesenteric issues (abdominal pain, appendicitis),

° upper respiratory tract issues (otitis media, mastoiditis, 

oral ulcers),

° lower respiratory tract issues (croup, bronchiolitis, 

pneumonia),

° bacterial superinfection,

° central nervous system issues (encephalitis),

° malabsorption/malnutrition (significant cause of mortality; 

treat malnutrition aggressively), and

° ocular issues (xerophthalmia/ulcerating keratomalacia in 

those who are vitamin-A deficient). 

° If complications are present, a third dose of vitamin A 

should be given at 2 to 4 weeks after the second dose is 

administered.

• Treat pyogenic complications with antibiotics.

Polio

• Symptoms
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Pediatric Surgery and Medicine for Hostile Environments 

° More than 95% of cases are asymptomatic.

° Others have nonspecific URI.

° A small percentage has aseptic meningitis.

° 0.1% to 2% will develop flaccid paralysis.

• Etiology: Poliovirus (enterovirus) types 1, 2, and 3. Polio is 

still endemic in parts of Africa and Asia, and there have been 

recent epidemics in Afghanistan and Pakistan. 

• Diagnosis is made by viral culture of stool (best), urine, 

pharynx, or cerebrospinal fluid (best if done within 14 days 

of onset of illness) and serology.

• Treatment is supportive.

• Prophylaxis and control consists of vaccinating susceptible 

individuals and identifying all known cases and contacts for 

outbreak control. Reporting to public health officials is vital.

Viral Hemorrhagic Fevers Due to Arenaviruses and Filoviruses

• The survival of viral hemorrhagic fevers due to arenaviruses 

and filoviruses is typically dependent on an animal or insect 

host, called the natural reservoir.

• The more common viral hemorrhagic fevers include Ebola, 

Marburg, dengue, yellow fever, Lassa fever, and hantavirus.

• For a complete list of viral hemorrhagic fever pathogens, their 

areas of distribution, vectors, incubation periods and modes of 

transmission, see the CDC website on viral hemorrhagic fevers 

(http://www.cdc.gov/ncidod/dvrd/spb/mnpages/dispages/

vhf.htm).

• The term “hemorrhagic fevers” is often used to a describe a 

severe multisystem syndrome associated with capillary leak 

or frank signs of bleeding and is applied to members of the 

arenavirus, filovirus, bunyavirus, and flavivirus families. 

° These are severe, life-threatening infections that begin 

with nonspecific symptoms of fever, myalgias, vomiting, 

and diarrhea, which may progress to petechial or purpuric 

rashes. Frank hemorrhage may also occur. Altered mental 

status is a late finding. 

° Patients rarely die of blood loss; rather, they die from shock 

related to dehydration, third-spacing of intravascular fluid, 

or secondary sepsis. 
485

Infectious Diseases

• Human cases or outbreaks of hemorrhagic fevers occur 

sporadically and are not easily predicted. Lassa fever is 

associated with a rodent reservoir. Fruit bats have been 

implicated as a reservoir for Ebola and Marburg; nonhuman 

primates and other forest-dwelling mammals have also been 

infected and may transmit the disease to humans who hunt, 

butcher, or consume undercooked meat from these animals.

• Following single-case infections from animals, nosocomial 

spread within medical facilities or related to funerals serve 

as amplifying events.

• Primary prevention includes:

° Avoidance or control of reservoir hosts (Lassa).

° Avoiding consumption of fruit that has been fed upon by 

fruit bats or “bush-meat” from susceptible animals. 

° Appropriate use of infection prevention and control 

procedures in healthcare settings (Ebola and Marburg). 

• Outbreak control involves:

° Rapid case identification.

° Implementation of expanded infection control procedures 

specific to hemorrhagic fevers.

° Special precautions for safe burial; however, these conflict 

with cultural norms in endemic regions and require close 

coordination with community leaders to garner support. 

° Notifying public health authorities to mobilize a broader 

response (critically important).

• There is no cure or established drug treatment for Ebola or 

Marburg, although experimental treatments are being studied 

as part of the recent Ebola outbreak in West Africa. Current 

management strategies include:

° Intensive fluid and electrolyte support.

° Treatment of comorbid infections due to malaria or 

bacteremia.

° Symptomatic management of pain and fever.

° Ribavirin for Lassa fever cases. 

• Clinicians managing cases of Lassa, Ebola, or Marburg should 

consult current WHO and CDC treatment guidelines for 

details of current management recommendations.
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Pediatric Surgery and Medicine for Hostile Environments 

Dengue and Dengue Hemorrhagic Fever

• Symptoms of dengue include acute onset fever lasting 3 

to 5 days, intense headache, retro-orbital pain, myalgias, 

arthralgias, anorexia, and rash. Petechiae and epistaxis are 

occasionally seen in otherwise mild cases but raise concern for 

progression to severe disease. Thrombocytopenia is common 

in both mild and severe infections. 

• Symptoms of dengue hemorrhagic fever/severe dengue 

include all of the above plus a capillary leak syndrome causing 

shock and multiorgan system failure. This occurs in the 24 

to 48 hours after fever resolution and reflects an immune 

dysregulation phenomenon. Counterintuitively, due to the 

capillary leak, hemoconcentration and rising hematocrit is 

typical. Frank hemorrhage is rare outside of preexisting peptic 

ulcer disease or the use of salicylates or ibuprofen, which may 

cause gastritis and alter platelet function.

• Diagnosis is made by clinical suspicion in most settings, 

serum PCR during the febrile phase, and serology during 

the convalescent phase. Serology may cross react with other 

flaviviruses, such as West Nile, Japanese encephalitis, and 

yellow fever (including recent vaccinations). A positive 

tourniquet test may be used to identify capillary fragility but 

may have low specificity based on the prevalence of other 

endemic diseases.

° Inflate a blood-pressure cuff on the upper arm to a point 

midway between the systolic and diastolic pressures for 5 

minutes.

° A test is considered positive when 10 or more petechiae 

per 2.5 cm2 (1 in.2) are observed after the cuff pressure has 

been released for 2 minutes.

• Treatment of mild cases includes symptomatic care with 

acetaminophen and oral hydration. 

• Managing severe disease consists of meticulously replacing 

isotonic fluids to provide for urine output of 1 to 2 cc/kg/h 

and a gradual reduction in hematocrit back to normal levels. 

Overusing IV fluids leads to iatrogenic morbidity and 

mortality. Platelet transfusion does not impact the disease 

course and is not indicated. In rare cases of severe hemorrhage, 
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Infectious Diseases

red blood cell transfusions are indicated. The WHO publishes 

management algorithms.

• Prevention and control require avoiding bites. This can 

be accomplished by using repellants and destroying or 

larviciding breeding sites (eg, tires, trash, and water cisterns) 

for Aedes aegypti.

Chikungunya Virus

• Etiology/Epidemiology

° Endemic to Africa, Southeast Asia, and the Indian and 

Pacific Oceans. 

° In late 2013, chikungunya virus was found for the first time 

in the Americas on islands in the Caribbean and has since 

become widespread in Central and South America, with 

more than 1.2 million suspected cases reported.

° Vectors: Aedes aegypti and Aedes albopictus mosquitoes. 

These are the same daytime-biting mosquitoes that transmit 

dengue virus.

• Symptoms usually begin 3 to 7 days after being bitten by an 

infected mosquito.

° The most common symptoms are fever and joint pain.

° Other symptoms may include mild headache, muscle pain, 

arthritis of the small joints, and rash.

° Although rarely fatal, the symptoms can be severe and 

disabling. Most patients feel better within a week. In some 

people, the joint pain may persist for months.

• Diagnosis is made by PCR and serology.

• Treatment is solely supportive.

• Control and prevention can be achieved by eradicating and 

larviciding breeding sites and by using personal repellants. 

• Distinguishing chikungunya from dengue can be difficult 

because the symptoms are similar to those of dengue: arboviral 

disease with identical vectors and overlapping geographic 

range.

° Severe manifestations are rare in cases of chikungunya. 

° Capillary leakage or bleeding diathesis points to dengue. 

° Chikungunya joint pain is classically in the small joints 

of the hands and may be frank arthritis, compared to the 

lumbosacral arthralgias and diffuse myalgias of dengue. 
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Pediatric Surgery and Medicine for Hostile Environments 

° When both are suspected, assume dengue. Chikungunya 

is rarely fatal. In contrast, early identification and proper 

clinical management for hospitalized dengue cases can 

reduce the case fatality rate of severe dengue disease from 

10% to less than 0.1%.

Yellow Fever

• Epidemiology: Flavivirus transmitted to humans primarily 

through the bite of infected mosquitoes in certain South 

American and African countries. For list of countries, see 

the CDC webpage on yellow fever (http://www.cdc.gov/

yellowfever/maps/index.html).

• Symptoms

° The majority of those infected have no illness or only mild 

illness. 

° In persons who develop symptoms, the incubation period 

is typically 3 to 6 days. 

° The initial symptoms include sudden onset of fever, chills, 

severe headache, back pain, general body aches, nausea 

and vomiting, fatigue, and weakness. Most people improve 

after initial presentation. 

° After a brief remission of hours to a day, roughly 15% 

of cases progress to develop a more severe form of the 

disease, characterized by high fever, jaundice, bleeding, 

and eventually shock with failure of multiple organs.

▶ In those who become symptomatic but recover, weakness 

and fatigue may last several months. 

▶ Among those who develop severe disease, 20% to 50% 

may die.

• Diagnosis

° Serologies (many cross react with other flaviviruses, such 

as West Nile, Japanese encephalitis, and dengue). 

° PCR can be used if it is still early in the disease course. By 

the time jaundice or organ failure is detected, the PCR will 

be negative.

° Similarly, viral culture can be used but will only test positive 

early in the disease course.

° Immunohistochemical staining of specimens, such as 

those taken from lymph nodes or liver biopsy, may help 

in diagnosis. 
489

Infectious Diseases

• Treatment is supportive. Survivors have life-long immunity 

after recovery.

• Prevention

° Control and prevent mosquitos.

° Provide vaccine (live attenuated virus).

▶ A single dose of vaccine protects against disease for 10 

years or more. 

▶ Serious adverse events can occur following yellow 

fever vaccination. Therefore, persons should only be 

vaccinated if they are at risk of exposure to yellow fever 

virus or require proof of vaccination for country entry. 

Vaccination of immune-compromised individuals is 

contraindicated.

▷ A medical waiver can be given to those with a 

precaution or contraindication to vaccination.

▷ Vaccination requirements and recommendations for 

specific countries are available on the CDC Travelers’ 

Health webpage (http://wwwnc.cdc.gov/travel).

Humanitarian Issues

Children make up a large portion of the people involved in 

refugee and displacement situations. Common illnesses, such 

as diarrheal and respiratory illnesses, may proliferate. The 

majority of respiratory tract infections will be viral in origin and 

do not require antibiotic therapy. Antibiotics should be used 

only for complicated URIs (otitis media or sinusitis with fever, 

or mastoiditis) and all suspected acute lower respiratory tract 

infections (eg, pneumonia).

Limited numbers of trained medical personnel cannot care for 

hundreds or thousands of refugees on an individual basis. It is 

the goal in these settings for medical personnel to give handson training to volunteers from within the refugee population. 

Volunteers should be trained in vitamin-A administration, 

preparation and delivery of WHO rehydration formulas, and 

vaccine administration to prevent disease within the camp. They 

should be given limited training in triage so they can determine 

who should actually receive care from medical professionals. 

Medical professionals should limit their care to those most in 

need of trained providers. Some treatment recommendations 
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Pediatric Surgery and Medicine for Hostile Environments 

may differ slightly in this chapter from other opinions in this 

text because in a refugee situation, resources are often extremely 

limited. In endemic areas consideration should be given to mass 

drug administration for soil-transmitted helminthes to treat and 

prevent iron deficiency (see Chapter 35, Emergency Nutrition, for 

details). See Chapter 43, Humanitarian Operations, for guidance 

on successfully planning and executing large-scale humanitarian 

missions. 

Further Reading 

1. Mèdecins Sans Frontières. Clinical Guidelines: Diagnosis and Treatment 

Manual for Curative Programmes in Hospitals and Dispensaries. 8th ed. 

Paris, France: Mèdecins Sans Frontières; 2013. http://apps.who.int/

medicinedocs/documents/s17078e/s17078e.pdf. Accessed April 30, 

2015. 

2. World Health Organization. Integrated Management of Childhood 

Illness. Geneva, Switzerland: WHO; 2008. http://whqlibdoc.who.

int/publications/2008/9789241597289_eng.pdf. Accessed April 30, 

2015.

3. World Health Organization. Pocket Book of Hospital Care for Children: 

Guidelines for the Management of Common Illnesses With Limited 

Resources. Geneva, Switzerland: WHO; 2013. http://apps.who.int/

iris/bitstream/10665/81170/1/9789241548373_eng.pdf. Accessed 

April 30, 2015.

4. World Health Organization. Guidelines for the Treatment of Malaria. 

2nd ed. Geneva, Switzerland: WHO; 2010. http://whqlibdoc.who.

int/publications/2010/9789241547925_eng.pdf. Accessed April 30, 

2015. 

5. World Health Organization. The Treatment of Diarrhoea: A 

Manual for Physicians and Other Senior Health Workers. 4th ed. 

Geneva, Switzerland: WHO; 2005. http://whqlibdoc.who.int/

publications/2005/9241593180.pdf. Accessed April 30, 2015. 

6. World Health Organization. Dengue: Guidelines for Diagnosis, 

Treatment, Prevention and Control. Geneva, Switzerland: WHO; 2009. 

http://whqlibdoc.who.int/publications/2009/9789241547871_eng.

pdf. Accessed April 30, 2015. 
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Infectious Diseases

7. World Health Organization. Guidance for National Tuberculosis 

Programmes on the Management of Tuberculosis in Children. 2nd 

ed. Geneva, Switzerland: WHO; 2014. http://apps.who.int/iris/

bitstream/10665/112360/1/9789241548748_eng.pdf?ua=1. April 30, 

2015.

8. Pickering LK, ed. The Red Book: 2013 Report of the Committee on 

Infectious Diseases. Elk Grove, IL: American Academy of Pediatrics; 

2009.

9. Connelly MA, ed. Communicable Disease Control in Emergencies: A 

Field Manual. Geneva, Switzerland: World Health Organization; 

2005. http://apps.who.int/iris/bitstream/10665/96340/1/9241546166_

eng.pdf. Accessed April 30, 2015. 

10. Tschudy M, Arcara K, eds. The Harriet Lane Handbook: A Manual for 

Pediatric House Officers. 19th ed. Baltimore, MD: Mosby; 2012.
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Endocrinology

Chapter 30

Endocrinology

Introduction

This chapter provides a basic approach to endocrine issues in an 

austere or combat environment, emphasizing signs, symptoms, 

and an index of suspicion for serious, potentially life-threatening 

situations. Hormone dosing is best determined using accurate 

height and weight to allow exact calculation of body surface area.

Surface area (m2) = Ht (cm) × Wt (kg)

3,600 

When this information is not available, use the estimates obtained 

from a Broselow tape (see inside back cover).

Diabetes Mellitus

• Diabetes diagnostic criteria include:

° fasting blood sugar greater than 126 mg/dL,

° random blood sugar greater than 200 mg/dL in association 

with symptoms of diabetes, or

° blood sugar greater than 200 mg/dL 2 hours after an oral 

glucose tolerance test.

• Symptoms of diabetes mellitus include polyuria, nocturia, 

polydipsia, and polyphagia.

• Weight loss will often occur with diabetes mellitus type 1 

(DM1), but can occur with diabetes mellitus type 2 (DM2).

° Children with polyuria, nocturia, polydipsia, and 

polyphagia who are not overweight should be suspected 

of having DM1 if their blood sugar is elevated.

° Management of DM2 depends on the presentation at the 

time of diagnosis.
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Pediatric Surgery and Medicine for Hostile Environments 

▶ Random blood sugar less than 200 mg/dL without

marked elevations 1 to 2 hours after meals can often be 

managed by diet, exercise, and weight loss without the 

initiation of medications.

▶ Random blood sugar greater than 200 mg/dL will require

medication.

▷ Use caution when initiating antidiabetic medication 

regimens in austere environments with limited 

laboratory or clinical follow-up options.

▷ Consider the risk of hypoglycemia.

▷ For an overweight, newly diagnosed patient with 

DM2 with random blood sugar between 200 and 300 

mg/dL, administer metformin 500 to 1,000 mg once 

or twice a day.

▷ Insulin should be strongly considered in a 

hyperglycemic, nonacute patient with random blood 

sugar greater than 300 mg/dL, although oral therapy 

may be safer (see below).

Diabetic Ketoacidosis

• Diabetic ketoacidosis (DKA) is diagnosed when a patient has:

° D: high glucose.

° K: ketones in the blood.

° A: acidosis.

• Perform a brief history and physical examination to assess for 

shock and degree of volume depletion (Table 30-1).

° Physicians frequently overestimate the degree of fluid

depletion.

° The best data are the patient’s actual weight loss (use 

outpatient records if available).

• Obtain results from the following laboratory tests:

° chemistry panels, including calcium, magnesium, and 

phosphorous, if available;

° arterial blood gas or venous blood gas analysis;

° serum ketones test; 

° urinary analysis;

° C-peptide test; and

° consider looking for an infectious trigger via complete 

blood count with differential, urine culture, and the like.
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Endocrinology

• Obtain intravenous (IV) access and begin correcting deficit 

slowly, unless patient is in shock.

° Give normal saline (NS) 10 to 20 mL/kg over 1 hour.

° The rest of the deficit should be replaced over 48 hours 

to avoid dropping serum osmoles too quickly and 

precipitating cerebral edema.

° Placing two large IVs allows treatment through one and 

sampling through the other.

• Insulin therapy need not be viewed as emergent therapy, but 

should be initiated as soon as possible.

° Use regular insulin (100 units in 100 mL NS) with an insulin 

drip at 0.05 to 0.1 units/kg/h.

° Do not bolus with insulin; it can precipitously drop 

glucose levels and serum osmolarity, exacerbating risk of 

cerebral edema.

° The goal of therapy should be a drop in serum glucose of

50 to 100 mg/dL/h (start on the low end of the range and 

increase over time).

° Plastic tubing binds insulin; run insulin through tubes 

before using.

° Blood sugar checks should be done every hour.

° In mild DKA, especially in the austere environment, if no

IV access is available, intramuscular (IM) insulin can be 

given every 3 hours, rather than using an insulin drip.

Table 30-1. Assessing Dehydration in the Pediatric Patient 

with Diabetes

Parameter Mild Moderate Severe

Estimated volume deficit (%) 3 6 10

Clinical signs

Perfusion Normal Normal or i i

Heart rate Normal h h

Blood pressure Normal Normal or i Normal or i

Labs 

HCO3 Normal 10–20 < 10

pH Normal > 7.20 < 7.20

Glucose 300–400 400–600 > 600

BUN < 20 < 30 > 25

BUN: blood urea nitrogen

HCO3: bicarbonate
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Pediatric Surgery and Medicine for Hostile Environments 

▶ The dose of IM regular insulin is 0.1 to 0.3 units/kg.

▶ Start at the low end and increase over time to avoid 

inadvertently administering excessive amounts of 

insulin.

• Preferred fluid choice is 1/2NS with potassium.

° Use potassium chloride and potassium phosphate 

to administer 40 mEq/L (even though the patient is 

hyperkalemic, total-body potassium is low).

° Add glucose when blood sugar drops into the 250 to 300 

mg/dL range.

° Always anticipate the next bag needed and order it ahead 

of time from the pharmacy. Be prepared to escalate dextrose 

concentration from 5% to 10% or 12.5% dextrose to stabilize 

glucose levels while the insulin works to clear the acidosis.

• Cerebral edema is a major concern; perform neurological 

checks hourly.

° When faced with a deteriorating mental status, consider 

performing a computed tomography scan of the head to 

look for cerebral edema.

° Administer mannitol (dose 0.25 g/kg) for progressive 

neurological deterioration or focal neurological examination.

° There is a high risk for cerebral edema when fluids are

administered at more than 4,000 mL/m2/day.

• Check glucose hourly, venous blood gas or arterial blood gas 

tests and chemistry panels every 4 hours, and urinary analysis 

every void (or more frequently when necessary).

• Do not reduce insulin prematurely if glucose is falling—give 

more glucose! Giving enough glucose (D5 > D10 > D12.5) allows 

room to provide enough insulin to correct the acidosis.

• Transition to subcutaneous (SQ) insulin from insulin drip 

when patient is expressing hunger, the acidosis is mostly gone, 

and there is food immediately available.

° Turn off the drip, administer the SQ insulin, and wait 30 

minutes before feeding.

° Typically, rehydration without glucose will need to be 

continued once the patient is eating.
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Endocrinology

Diabetes Management

• Dietary management is generally the same in DM1 and DM2.

° Dietary treatment of diabetes consists of a well-balanced

diet low in refined and simple sugars.

° The diet should be approximately 55% carbohydrate, 30%

fat, and 15% protein.

° Carbohydrate intake should favor complex carbohydrates.

▶ In general, infants and toddlers (0–3 years old) will need 

30 to 45 g of carbohydrates per meal.

▶ Older children (4–12 years old) need 45 to 60 g of 

carbohydrates per meal.

▶ Teenagers (13–18 years old) need 75 to 90 g of 

carbohydrates per meal.

• Insulin therapy

° Insulin therapy and timing depends on the type of insulin 

available (Table 30-2).

Table 30–2. Types and Action Times of Insulin

Type of insulin Onset Peak (h) Duration (h)

Lispro/aspart 10–15 min 1–2 2–4 

Regular 30–60 min 2–4 6–9 

NPH 1–2 h 3–8 12–15 

Lente 1–2 h 3–14 18–20 

Ultralente 2–4 h 6–14 18–20 

Glargine 1–2 h 2–22 24

NPH: Neutral Protamine Hagedorn

▶ In theater, it is likely that only neutral protamine 

Hagedorn (NPH) and regular insulin are available.

▶ Start with a total daily dose of 0.6 units/kg/day if the 

initial glucose at diagnosis is less than 500 mg/dL.

▷ When initial glucose at diagnosis is greater than 500 

mg/dL and there is no acidosis, use a total daily dose 

of 0.8 units/kg/day.

▷ When initial glucose at diagnosis is greater than 500 

mg/dL and acidosis is present, use a total daily dose 

of 1.0 unit/kg/day.

▷ When initial glucose at diagnosis is unavailable, start 

with 0.8 units/kg/day.
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Pediatric Surgery and Medicine for Hostile Environments 

▶ Morning insulin should constitute two-thirds of the total

daily dose.

▷ This amount should be divided further to two-thirds 

NPH and one-third regular insulin (Exhibit 30-1).

Exhibit 30-1. Case Study: Insulin Dosing Using Neutral 

Protamine Hagedorn and Regular Insulin

A 30-kg patient presents with an initial blood glucose of 558 mg/dL and 

serum bicarbonate of 20 mEq/L.

Administer 0.8 units/kg/day × 30 (24 units/day).

Morning: 

2/3 of the total dose = 16 units total (10 units NPH and 6 units of regular 

insulin before breakfast)

Evening:

The remaining 1/3 total dose = 8 units total (4 units of NPH and 4 units of 

regular insulin before dinner)

NPH: Neutral Protamine Hagedorn

▷ This dose should be given about 20 minutes before 

breakfast.

▶ The evening dose should constitute one-third of the total 

daily dose.

▷ This amount should further be divided into one-half 

NPH and one-half regular insulin.

▶ This dosing plan places a child at risk for low blood

sugar; the child should have small snacks in the 

midmorning, midafternoon, and at bedtime when this 

insulin plan is used.

° Children on insulin should have multiple blood sugar 

checks per day.

° A combination of rapid-acting insulin (lispro or aspart) 

and glargine is preferable to the regular and NPH 

insulin combination, if available, because it more closely 

approximates normal physiology (further pediatric 

endocrinology consultation is recommended).

° In an austere environment, use a goal blood sugar of 150 

mg/dL.
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Endocrinology

Hypoglycemia

• Signs and symptoms

° Hypoglycemia is nonspecific in infancy, but can include 

cyanotic episodes, apnea, respiratory distress, refusal 

to feed, myoclonic jerks, convulsions, somnolence, 

hypothermia, sweating, and more.

° For older children, symptoms include anxiety, weakness, 

hunger, shakiness, sweating, tachycardia, nausea, 

vomiting, headache, visual disturbances, lethargy/

lassitude, restlessness, mental confusion, somnolence/

stupor, convulsions, bizarre neurological signs, decreased 

intellectual ability, personality changes, and bizarre 

behaviors. 

° Other physical findings associated with recurrent 

hypoglycemia include hepatomegaly, short stature, large 

size for gestational age (newborn), and hemihypertrophy 

of an extremity.

• The definition of hypoglycemia is less than 40 mg/dL in the 

first month of life (older infants, children, and teenagers should 

be able to maintain a blood sugar greater than 60 mg/dL).

• The differential diagnosis includes a host of congenital 

metabolic and hormonal disorders, systemic disease, and drug 

intoxications; the presence of urine ketones may be helpful in 

diagnosis.

° If urine ketones are positive, it is likely that a transient 

abnormality exists that can be treated with IV or oral 

glucose therapy.

° The absence of ketones in the face of profound hypoglycemia 

generally represents an excess of insulin secretion or the 

presence of a disorder of fatty acid metabolism.

• Treatment varies by age.

° Neonates: 2 to 4 mL/kg 10% dextrose in water (D10W) IV 

bolus.

° Children: 2 to 4 mL/kg 25% dextrose in water (D25W) IV, 

administered slowly.

▶ Follow each immediately by continuous glucose 

infusion.
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Pediatric Surgery and Medicine for Hostile Environments 

▶ If IV therapy is unavailable, oral or nasogastric therapy 

should be undertaken in a child that is awake and able 

to tolerate it.

° If a child is actively seizing or comatose due to low blood 

sugar, administer 1 mg of glucagon IM. Be aware that 

vomiting is common after glucagon administration; lay 

children on their sides after giving glucagon.

Thyroid

• Hypothyroidism

° Hypothyroidism can be congenital or acquired. 

° Congenital hypothyroidism is almost impossible to 

recognize early on. Signs and symptoms include:

▶ macroglossia,

▶ open posterior fontanelle,

▶ developmental delay,

▶ constipation, and

▶ coarse facial features, including a broad nasal bridge, 

eyelid edema, flat facies, and a large head.

° Treatment for congenital hypothyroidism is oral thyroid 

replacement.

▶ Starting dose is 12 to 15 μg/kg/day for neonates.

▶ Most children with congenital hypothyroidism are on 5 

μg/kg/day of levothyroxine by 1 year of age.

▶ Most infants require 37.5 μg daily (given as 1.5 25-μg 

tablets).

▶ Pills should be crushed, mixed in formula or applesauce, 

and given directly to the patient. DO NOT make elixirs 

for this therapy (stability may be affected).

° Acquired hypothyroidism is recognized by the presence of 

the following signs and symptoms:

▶ constipation,

▶ fatigue,

▶ cold intolerance, and

▶ enlarged thyroid gland.

° Most children with acquired hypothyroidism require an 

initial dose of 2 to 3 μg/kg/day of levothyroxine.

• Hyperthyroidism
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Endocrinology

° Symptoms of hyperthyroidism in infants and children 

include:

▶ irritability,

▶ flushing,

▶ tachycardia,

▶ hypertension,

▶ poor weight gain,

▶ goiter,

▶ exophthalmos, and 

▶ hepatosplenomegaly, jaundice, thrombocytopenia, and 

hypoprothrombinemia.

° Signs are typically subtle and slowly progressive. Initial 

signs of irritability and jitteriness should lead one to suspect 

sepsis or hypoglycemia first.

° Treatment in infants and children is initiated with 

propranolol (1 to 2 mg/kg/day divided three times daily 

[tid]) and propylthiouracil (PTU) 5 to 10 mg/kg/day divided 

tid.

° The female-to-male ratio of acquired hyperthyroidism in

teenagers is 5 to 1.

° Symptoms in teenagers include:

▶ tachycardia,

▶ restlessness,

▶ difficulty sleeping,

▶ widened pulse pressure,

▶ heat intolerance,

▶ increased frequency of loose stools, and

▶ enlarged, nontender thyroid.

° Etiology is generally autoimmune but if a prominent 

thyroid nodule is palpable, that may be the cause.

° Treatment in teenagers can be surgical resection of all or 

part of the thyroid gland, or medical or radioactive iodine 

ablation.

▶ Medical treatment consists of β-blocker therapy with 

atenolol (25 to 50 mg/day) until the marked symptoms 

have resolved, and PTU at 5 to 10 mg/kg/day divided 

tid.
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Pediatric Surgery and Medicine for Hostile Environments 

▶ If medical treatment is initiated, thyroid function tests 

should be obtained prior to therapy and sent to a referral 

laboratory (this should be possible in a deployment 

situation).

▶ After the free thyroxine level has normalized or 

lowered, add levothyroxine at 2 μg/kg/day to maintain 

a euthyroid state.

▶ The thyroid can be adequately suppressed while treating 

the patient with PTU.

Adrenal Disorders

• Adrenal insufficiency is uncommon; however, an index of 

suspicion for adrenal disorders is critical because they can be 

fatal.

• A patient with a known autoimmune condition, such as 

diabetes or thyroid disease, has the potential to develop 

adrenal insufficiency.

• Tuberculosis, human immunodeficiency virus, adrenal 

hemorrhage, and traumatic adrenal resection may also lead 

to adrenal insufficiency.

• Signs and symptoms include:

° unexplained hypotensive shock;

° progressive weakness, fatigue, dehydration, and 

hypotension (these are the most common symptoms);

° anorexia, nausea, vomiting, myalgias, and personality 

changes (possible symptoms); and

° o t h e r s u g g e s t i ve p h y s i c a l f i n d i n g s , s u c h a s 

hyperpigmentation of the skin and mucous membranes 

(especially the creases and the nipples); vitiligo and alopecia 

may also be associated.

° Laboratory evidence suggestive of adrenal insufficiency 

includes hyponatremia, hyperkalemia, and hypoglycemia. 

Unexplained eosinophilia may also be present in the acutely 

ill patient.

• If adrenal insufficiency is suspected, obtain a blood specimen 

in a serum separator tube (red, tiger, yellow). Separate the 

serum and freeze the specimen.

• Treatment includes aggressive IV fluid therapy (20 cc/kg bolus 

of NS followed by reassessment).
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° Pressor agents are sometimes required.

° Hydrocortisone hemisuccinate should be given urgently 

by IV (50 mg/m2).

▶ Infants: 25 mg.

▶ Toddlers and young children (less than 6 years old): 

50 mg.

▶ Older children and teenagers (6 and older): 100 mg.

° Regular dosing (every 6 hours) should be continued at a 

dose of 100 mg/m2/day, divided in equal doses.

° If the adrenals have been removed or primary adrenal 

disorders are suspected, mineralocorticoid therapy 

(fludrocortisone) will be necessary when the hydrocortisone 

dose is dropped below 100 mg/m2/day.

▶ This is safe when the child stabilizes or the significant 

stressor (surgery, illness, etc) has resolved.

▶ Maintenance hydrocortisone dose is 12 to 15 mg/m2/day 

(divided tid).

▶ Fludrocortisone dose is 0.1 mg twice daily for infants, 

and 0.1 mg four times daily in patients 1 year and older.

Calcium and Vitamin D Disorders

• Hypocalcemia

° Symptoms can range from nothing to severe (eg, tetany 

and seizures).

° Long QT interval is apparent on electrocardiogram.

° Symptomatic hypocalcemia generally occurs when calcium

levels in the blood are below 6 mg/dL.

° Managing acute hypocalcemia requires calcium and 

vitamin D.

▶ Administer 10% calcium gluconate at 1 mL/min, not to 

exceed 2 mL/kg.

▶ Give IV but with care; SQ infiltration of calcium can 

cause severe burns.

▶ Vitamin D is given as calcitriol at a dose of 20 to 60 ng/

kg/day.

▶ Once acute symptoms have resolved, oral calcium should 

be given at 50 to 75 mg of elemental calcium per kilogram 

of body weight every 24 hours (oral calcium is much 

safer to give than IV calcium).
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Pediatric Surgery and Medicine for Hostile Environments 

▶ Vitamin D may be needed long term in some cases, such 

as in the presence of hypoparathyroidism.

▶ Hypocalcemia may not respond to therapy if the patient’s 

magnesium level is also low (see Hypomagnesemia, 

below).

• Hypercalcemia

° Severe hypercalcemia (more than 13.5 mg/dL) requires 

treatment.

° Initiate treatment with IV NS to establish optimal fluid

hydration.

▶ Once urine output is substantial (more than 2 cc/kg/h), 

give furosemide at a dose of 1 to 2 mg/kg IV.

▶ If hypercalcemia persists, give hydrocortisone 

hemisuccinate 1 mg/kg IV every 6 hours.

▶ Bisphosphonates can also be used, but are not likely to 

be available in an austere environment.

▶ In an immobilized patient, it may be prudent to start a 

low-calcium diet and avoid vitamin D.

▶ Encourage copious fluid intake.

• Hypomagnesemia

° Hypomagnesemia may cause hypocalcemia.

° Hypocalcemia will be resistant to treatment in the presence

of untreated hypomagnesemia.

° Treat magnesium levels below 1.4 mg/dL.

° Treatment consists of 50% magnesium sulfate 0.1 to 0.2 mL/

kg. Repeat the dose in 12 to 24 hours if the magnesium level 

remains low.

• Rickets

° The most common cause of rickets is vitamin D deficiency.

° Infants and children at risk for vitamin D deficiency 

typically have a history of prolonged breast-feeding and 

live in a northern latitude.

° Signs and symptoms of rickets include:

▶ rachitic rosary,

▶ bowed legs,

▶ bowing forearms,

▶ frontal bossing,

▶ craniotabes,

▶ short stature,
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Endocrinology

▶ suboptimal weight, and

▶ systemic symptoms, including hypotonia, weakness, 

anorexia, and delay in walking.

▶ Vitamin D deficiency can present as seizures when severe 

hypocalcemia is present.

° Radiographic evidence of vitamin D deficiency consists 

of cupping, widening, and irregularity of the distal 

metaphyses; there is also evidence of osteopenia with 

cortical thinning.

° Treatment in an urgent situation includes administering IV

calcium and providing vitamin D treatment.

▶ In an otherwise normal child, ergocalciferol should be 

administered in doses of 1,000 to 2,000 international 

units (IUs) per day. Start at the higher end of the dose 

and wean to 1,000 IU/day after 2 to 4 weeks.

▶ Supplemental vitamin D should be continued until there 

is radiographic evidence of healing. This usually takes 

2 to 3 months, but can take longer in cases of severe 

vitamin deficiency.

▶ If symptoms of vitamin D deficiency persist despite 

adequate replacement, changing vitamin D to 

1,25-hydroxyvitamin D may alleviate the problem.

▷ Calcitriol should be used at a dose of 20 to 60 ng/kg/

day.

▷ Calcitrol has a long half-life and care should be 

taken not to overdose the medication. Monitor for 

hypercalcemia.

° To prevent rickets, breast-fed babies should receive a daily 

multivitamin containing 400 IU of vitamin D. 
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Pediatric Surgery and Medicine for Hostile Environments 
507

Common Neurological Problems

Chapter 31

Common Neurological Problems

Pediatric Neurological Examination

Neurological examinations help identify abnormalities 

in a structured manner. Key elements assessed include 

development (see Developmental Stages in Chapter 36, Nursing 

Assessment), cognition, motor, and sensory processing. 

Identifying neurological defects helps localize the area affected 

(brain, spine, nerve, muscle, multiple areas of nervous system) 

and aids in the subsequent development of a differential 

diagnosis.

Key Aspects of a Pediatric a Neurological Examination 

The mental status aspect of a pediatric neurological exam differs 

from that in adults and is discussed in greater detail later on in 

this chapter. 

• The following are common to both pediatric and adult 

neurological exams:

° age-appropriate awareness of current environment, and

° ability to communicate.

• Cranial nerves are assessed, including:

° Motor nerves.

▶ Muscle bulk 

▷ Increased muscle bulk is evidence of hypertrophy 

(compensated overuse), or pseudohypertrophy 

(Duchenne muscular dystrophy, storage disease).

▷ Decreased muscle bulk is evidence of a central nervous 

system process (stroke, cortical malformation, spinal 

cord injury) or a peripheral nervous system process 

(neuropathy, myopathy).

▶ Muscle tone is the inherent resistance of musculature at 

rest.
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Pediatric Surgery and Medicine for Hostile Environments 

▷ Increased tone suggests central nervous system 

pathology (upper motor neuron finding) involving 

the brain or spinal cord.

▷ Decreased tone is seen in infants and toddlers under 

age 2 with processes involving the brain. It often 

transitions to increased tone as the child ages (for 

example, in the case of spastic quadriplegia from 

perinatal anoxia). Low tone in older children suggests 

peripheral nervous system pathology (lower motor 

neuron finding) involving nerves or muscle.

▶ Muscle strength is one’s ability to move extremities 

against resistance.

▶ Reflexes: increased reflexes suggest central nervous 

system pathology (upper motor neuron finding). 

Decreased reflexes suggest peripheral nervous system 

pathology (lower motor neuron finding; eg, absent 

reflexes in spinal muscular atrophy).

▶ Primitive reflexes come and go over time. For example, 

Babinski reflex is present until age 12 months; Moro 

reflex is present from birth to age 6 months; anterior 

propping is present at 4 to 5 months; parachute reflex is 

present at 6 to 12 months; and lateral propping is present 

at 6 to 7 months.

• The sensory system is the most difficult aspect of the exam 

to assess objectively and it is difficult for a young child to 

cooperate with it.

• Gait should be assessed to determine if it is appropriate for 

the child’s age (most children walk independently by age 18 

months). Observe for ataxia, pain, and abnormal posture in 

limbs.

Altered Mental Status

The following are important to consider in children when 

performing a pediatric neurological examination.

• Was the child age appropriate in development prior to 

evaluation? This includes development in the following areas:

° gross motor functions,

° fine motor functions,
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Common Neurological Problems

° language, and

° social interactions.

• Timing of the change.

° Acute (encephalopathy and encephalitis)

▶ trauma (head injury, occult hemorrhage),

▶ infection (bacterial, viral, parasitic),

▶ rapidly progressive intracranial pressure (ICP; 

hydrocephalus, intracranial hemorrhage),

▶ ingestion (alcohol, medications, toxins around home),

▶ toxic/metabolic (carbon monoxide, heavy metals, 

electrolyte abnormalities, glucose),

▶ autoimmune (acute disseminated encephalomyelitis, 

multiple sclerosis, cerebritis),

▶ psychiatric (mood disorder, primary psychosis), and

▶ epilepsy (focal, generalized).

° Subacute/chronic (regression, static encephalopathy)

▶ congenital/cerebral palsy (hypoxemia at birth),

▶ hydrocephalus,

▶ slow-growing mass lesion (tumor, parasite, abscess),

▶ endocrine (thyroid, glucose),

▶ metabolic disorders (mitochondrial disorders and inborn 

errors of metabolism), and

▶ chromosomal abnormalities (trisomy, fragile X, etc).

Attempt to rapidly diagnose and correct reversible causes, 

especially of acute mental status changes.

Weakness

• The child’s age and timing of the onset of weakness assist with 

determining the most likely etiology of weakness.

° Infants

▶ Chronic: hypoxic ischemic encephalopathy, congenital 

cerebral malformations, and perinatal stroke.

▶ Subacute and progressive: hydrocephalus, spinal 

muscular atrophy, muscle disorder, chromosomal.

▶ Acute: sepsis, meningitis, spine trauma, metabolic 

derangement, botulism, organophosphate exposure, 

and tick paralysis.

° Children
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Pediatric Surgery and Medicine for Hostile Environments 

▶ Chronic: cerebral palsy, cerebral malformations, and 

perinatal stroke.

▶ Subacute: cerebral or spinal mass, muscle disorder, and 

spinal muscular atrophy.

▶ Acute: Guillain-Barré syndrome, spine trauma, acute 

stroke, organophosphate exposure, tick paralysis, focal 

seizure, and polio.

Hypotonia

The causes of hypotonia are myriad and the sources can 

be from the brain (eg, severe prematurity), spinal cord (eg, 

meningomyelocele), anterior horn cell (eg, spinal muscular 

atrophy), neuromuscular junction (eg, botulism), peripheral 

nerve (eg, Guillain-Barré), muscle (eg, Duchenne muscular 

dystrophy), or the ligaments (eg, Marfan syndrome). Seek 

expert consultation or a pediatric neurology text for more 

comprehensive diagnosis, diagnostics, and management advice. 

Headache

• The following red flags associated with headaches warrant 

increased attention and additional work-up (neuroimaging, 

laboratory tests, lumbar puncture):

° patient describes pain as the worst headache of his/her life 

(subarachnoid hemorrhage);

° progressive symptoms (mass lesion, hydrocephalus);

° fever (meningitis, encephalitis, abscess);

° persistent visual change, diplopia (increased ICP);

° focal weakness or sensory change on examination (mass 

lesion, hemorrhage);

° depressed mental status;

° headache always in the same location; and

° asymmetric pupils.

• If red flags are present, consider additional medical 

evaluations, including:

° admission to a medical facility for close clinical monitoring,

° frequent neurologic checks,

° vital signs monitoring, and

° “STAT” head imaging (computed tomography or magnetic 

resonance imaging).
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Common Neurological Problems

° Consider lumbar puncture after neuroimaging and if there 

are no concerns for elevated ICP.

• Headache is a common complaint in all children as they age 

(more reported in adolescents).

• Frequent primary headache types:

° Migraine (75% of all pediatric headaches)

▶ Migraine consists of four phases: prodrome, aura (if 

present), headache, recovery.

▶ Associated symptoms include photophobia, 

phonophobia, nausea, emesis, and desire to sleep.

▶ Common auras include bright flashes, lines, colorful 

spheres, and objects in vision appearing large or small.

▶ Headaches may be unilateral, bifrontal, or bitemporal, 

or may occur in the posterior scalp/neck region.

▶ Duration is minutes up to several days.

▶ Triggers are numerous and include stress, anxiety, foods, 

lack of sleep, dehydration, etc.

▶ Patient may also have family history of frequent 

migraines in immediate family.

° Acute symptomatic medications best early in headache 

include:

▶ Nonsteroidal antiinflammatory drugs (NSAIDs) or 

acetaminophen as first-line treatments.

▷ Ibuprofen (10 mg/kg every 6–8 hours, oral, maximum 

dose of 1,200 mg/day).

▷ Naproxen (5 mg/kg every 10–12 hours oral, maximum 

daily dose 600 mg/day).

▷ Acetaminophen (15 mg/kg every 4–6 hours oral).

▷ Ketorolac (0.5 mg/kg intravenous [IV] or 1 mg/kg 

intramuscular [IM] daily, maximum IV dose 15 mg, 

maximum IM dose 30 mg).

▷ Triptans (older children): 

▪ rizatriptan (5 mg for children under 40 kg; 10 mg 

for children 40 kg and larger as a single oral dose).

▪ sumatriptan (5–20 mg intranasal in those older than 

5 years, as a single dose, given as soon as possible 

after the onset of migraine).

° Tension headache

▶ Typically bifrontal and band-like pain.

▶ Typically no aura. 
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Pediatric Surgery and Medicine for Hostile Environments 

▶ Duration is minutes to days.

▶ Similar triggers as migraines.

▶ Give NSAIDs or acetaminophen as first-line treatments 

(see above).

° Cluster headaches

▶ Rare in children under 10 years old.

▶ Severe unilateral pain located in frontal and orbital 

regions.

▶ Duration is minutes to 3 hours.

▶ Associated with ipsilateral lacrimation, rhinorrhea, 

ophthalmic injection, and occasionally Horner’s 

syndrome.

▶ Acute symptomatic medications include 100% oxygen 

and triptans (see above).

▶ Prophylaxis:

▷ verapamil (4–8 mg/kg/day divided three times daily), 

OR

▷ topiramate (2–3 mg/kg/day divided twice daily. 

Do not abruptly discontinue therapy; taper dosage 

gradually to prevent rebound effects).

° Chronic daily headache

▶ Headache frequency is 15 or more days a month 

for longer than 3 months in the absence of organic 

pathology.

▶ Often associated with medication overuse; child should 

not use acute treatments more than three times per week.

▶ Treatment options:

▷ family education;

▷ reduction in use of acute headache medications;

▷ cyproheptadine (age over 3 years: 2–8 mg divided 

twice daily, maximum dose 0.5 mg/kg/day);

▷ topiramate (age over 5 years: 2–3 mg/kg divided twice 

daily);

▷ nortriptyline (age over 6 years: 0.5–1 mg/kg nightly);

OR

▷ amitriptyline (age over 5 years: 0.25–1 mg/kg nightly).
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Common Neurological Problems

Seizure

• Consider any seizure lasting longer than 5 minutes or more 

than 3 seizures in an hour as status epilepticus (see Chapter 

8, Status Epilepticus).

• Typical clinical classifications include: febrile seizures, 

childhood epilepsy (focal or generalized), and provoked 

seizure (including posttraumatic seizure).

Febrile Seizures

• Febrile seizures occur when the child:

° is normal in growth and development,

° exhibits a convulsion associated with an elevated 

temperature greater than 38°C,

° is 6 months to 6 years of age,

° previously exhibited normal growth and development,

° does not have central nervous system infection or 

inflammation,

° does not have an acute systemic metabolic abnormality that 

may produce convulsions,

° does not have a history of previous afebrile seizures, and

° often has a family history of febrile seizures.

• Simple febrile seizures are the most common type of febrile 

seizure. They:

° last less than 15 minutes,

° have no focal features, and

° occur once in a 24-hour period.

• Complex febrile seizures are seizures that:

° last more than 15 minutes,

° have focal features,

° have postictal paresis, or 

° occur more than once in 24 hours.

° No prophylaxis treatment is recommended.

° There is a slightly elevated risk of epilepsy in complex 

febrile seizures.

° Consider acute benzodiazepine for seizures longer than 10 

minutes (see Chapter 8, Status Epilepticus).
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Pediatric Surgery and Medicine for Hostile Environments 

Childhood Epilepsy

• Defined when any one of the following are present:

° At least two unprovoked (or reflex) seizures occurring more 

than 24 hours apart.

° Diagnosis of an epilepsy syndrome.

• Consider baseline metabolic screening, electroencephalogram, 

and neuroimaging (magnetic resonance imaging is better than 

computed tomography), if available.

• Evaluate for toxic metabolic states, infections, cerebral 

abnormalities (congenital injury, congenital malformations, 

remote perinatal stroke, mass lesions, etc).

Focal Epilepsy

• Focal epilepsy is the most frequent type of seizure after febrile 

seizure.

• Seizures originate from one cerebral hemisphere.

• Frequently associated with impaired consciousness.

• Motor seizures are characterized by:

° focal motor activity,

° anatomic spread or march of activity (Jacksonian),

° versive movement (turning of the eyes, head, and/or trunk), 

and

° vocalization or arrest of speech.

• Sensory seizures are characterized by:

° paresthesias,

° feelings of distortion of an extremity,

° vertigo,

° gustatory sensation,

° olfactory symptoms,

° auditory symptoms, and

° visual phenomena, such as flashing lights.

• Autonomic seizures are characterized by:

° epigastric “rising” sensation (a common aura with medial 

temporal lobe epilepsy),

° sweating,

° piloerection, and

° pupillary changes.

• Auras with focal seizures include:
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Common Neurological Problems

° psychic symptoms,

° dysphasia,

° feelings of familiarity (“deja vu”),

° distortions of time,

° affective changes (particularly fear),

° illusions, and

° formed hallucinations.

° Focal seizures may evolve to bilateral, convulsive seizures 

(secondary generalization).

Generalized Epilepsy

• Generalized epilepsy originates at some point within, and 

rapidly engages, bilaterally distributed networks.

• Consciousness is impaired. 

• Motor manifestations are bilateral.

• Provoked seizures are secondary to another medical process, 

such as:

° head trauma,

° infection (meningitis, encephalitis, sepsis),

° metabolic derangement (glucose, electrolytes), or

° cerebral injury (stroke, intracranial hemorrhage).

• Treatment should focus on correcting the primary cause of 

cerebral injury or dysfunction. Consider immediate use of 

antiseizure medications in the setting of acute severe traumatic 

brain injury (reduce ICP and cerebral metabolic demand; see 

Chapter 8, Status Epilepticus, for treatment recommendations).

Antiepileptic Medications (Chronic Therapy)

The following medications are in order of preferred usage based 

on expert opinion. Consider neurology consultation prior to 

embarking on a chronic antiepileptic regimen.

Broad Spectrum (useful for focal and generalized seizures)

• Levetiracetam

° Very good initial choice from safety and drug-to-drug 

interaction perspective.

° Useful in newborns to adults.

° Treats myoclonic seizures.
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Pediatric Surgery and Medicine for Hostile Environments 

° IV loading dose: 20 mg/kg.

° Oral dosing: 20 to 60 mg/kg/day divided twice daily. Start 

with 10 mg/kg divided twice daily and increase by 10 mg/

kg weekly.

▶ Precautions: renal clearance; limit in cases of kidney 

failure.

▶ May cause neuropsychiatric changes, agitation, and 

depression.

▶ Few drug-to-drug interactions.

• Valproate

° Not recommended for use in patients under age 2 because 

of a high risk of severe hepatotoxicity.

° Treats myoclonic seizures well.

° IV loading dose: 20 mg/kg.

° Oral dosing: 20 to 60 mg/kg divided twice daily. Start with 

10 mg/kg divided twice daily and increase by 10 mg/kg 

weekly.

° Precautions: hepatotoxicity, life-threatening pancreatitis, 

thrombocytopenia, hyperammonemic encephalopathy, 

congenital malformations.

° Liver metabolized, with some drug-to-drug interactions.

• Topiramate

° Useful in newborns to adults.

° There is no IV formulation.

° Oral dosing: 5 to 10 mg/kg divided twice daily. Start with 

3 mg/kg divided twice daily. Increase by 3 mg/kg weekly.

° Precautions: cognitive impairment, appetite suppression, 

secondary acute angle closure glaucoma, acute myopia, 

metabolic acidosis, oligohydrosis, and nephrolithiasis.

• Phenobarbital (barbiturate)

° Useful in newborns to adults.

° IV loading dose: 15 to 20 mg/kg.

° Oral: 5 mg/kg/day divided twice daily, maximum dose of 

400 mg/day. Start 1 to 3 mg/kg divided once or twice daily. 

Increase by 1 mg/kg weekly. 

° Precautions: respiratory depression, depressed mental 

status, bradycardia. 

° Liver metabolized, with some drug-to-drug interactions.
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Common Neurological Problems

• Clonazepam (benzodiazepine)

° Useful from newborns to adults.

° There is no IV formulation.

° Oral dosing: 0.05 to 0.2 mg/kg/day divided two to three 

times daily, maximum dose of 20 mg/day. Initial dosing 

is 0.01 to 0.03 mg/kg/day given in 2 to 3 divided doses. 

Increase the dosage by no more than 0.25 to 0.5 mg 

daily, every third day, until seizures are controlled or 

maintenance dose of 0.1 to 0.2 mg/kg divided into 3 equal 

doses has been reached.

° Precautions: respiratory depression, depressed mental 

status.

° Liver metabolized with some drug-to-drug interactions.

Focal Seizure Medications (will worsen generalized epilepsy)

• Carbamazepine (shake liquid well before use)

° Useful in patients aged 6 years to adult.

° There is no IV formulation.

° Oral dosing: 20 to 40 mg/kg divided twice daily. Start 10 

to 20 mg/kg divided twice daily. Increase by 5 to 10 mg/kg 

weekly.

° Precautions: depressed mental status, hyponatremia, 

angioedema, hypersensitivity reaction, and hepatotoxicity.

° Liver metabolized, with some drug-to-drug interactions.

• Phenytoin (shake liquid well before use)

° Useful in newborns to adults.

° IV loading dose: 15 to 20 mg/kg.

° Oral dosing: 5 to 10 mg/kg divided twice daily. Start 5 mg/

kg divided twice daily. Increase by 1 mg/kg weekly.

° Precautions: cardiac arrhythmias and arrest (infuse IV 

slowly at 1 mg/minute and dilute in normal saline), 

hypersensitivity reaction, depressed mental status, 

hepatotoxicity, hematologic toxicity, gingival hyperplasia, 

and coarsened facial features.

° Phenytoin serum level determinations may be necessary 

for optimal dosage adjustments.

° Liver metabolized, with some drug-to-drug interactions.
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Pediatric Surgery and Medicine for Hostile Environments 

Table 31-1. TBI Severity Classification

Mild Moderate* Severe*

Loss of consciousness None or > 30 minutes to > 24 hours

< 30 minutes < 24 hours

Altered consciousness < 24 hours > 24 hours > 24 hours

Posttraumatic amnesia < 1 day > 1 day > 7 days

 < 7 days

Glasgow Coma Scale 13–15 9–12 < 9

*Consider urgent medical evaluation at a tertiary care facility for moderate 

and severe traumatic brain injury.

TBI: traumatic brain injury

Concussion

Mild traumatic brain injury (TBI), also known as concussion, is 

a very common childhood injury and typically does not require 

hospitalization (Table 31-1).

• Immediately remove the patient from “high-risk” activities to 

avoid second impact syndrome (catastrophic cerebral edema 

and herniation).

• Expect full recovery (symptoms peak at 72–96 hours).

• Common causes of concussion include falls, assaults, play, 

sports, and motor vehicle accidents.

• Symptoms after concussion include:

° headaches (consider further evaluation if red flags are 

present),

° poor sleep,

° irritability,

° poor concentration, and 

° depressed mood.

• Gradually return to normal activities once symptoms have 

resolved.

• Recovery is often slowed when the patient sustains multiple 

concussions in 1 year.
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Common Neurological Problems

• Consider neuroimaging if the following red flags develop: 

headache, new focal deficits, worsening cognition, and 

atypical recovery.

Posttraumatic Seizures 

• Posttraumatic seizures require treatment in the acute setting, 

especially in the presence of increased ICP.

° Phenobarbital is the preferred antiepileptic agent in patients 

less than 2 years old.

° Treat older children with phenytoin sodium or fosphenytoin 

(see Chapter 13, Neurosurgery).

• Seizures within the first week of trauma need to be treated 

acutely; however, there is a low risk of long-term epilepsy.

• Patients who develop seizures after the first week following 

trauma are more likely to have posttraumatic epilepsy.

Further Reading

1. Tschudy MM, Arcara KM, eds. The Harriet Lane Handbook. 19th ed. 

New York, NY: Mosby; 2012.

2. Pina-Garza JE. Fenichel’s Clinical Pediatric Neurology. 7th ed. New 

York, NY: Elsevier Saunders; 2013.

3. Swaiman KF, Ashwal S, Ferriero DM, Schor NF. Swaiman’s Pediatric 

Neurology, Principles and Practice. 5th ed. New York, NY: Elsevier; 

2012.

4. Glauser TA, Loddenkemper T. Management of childhood epilepsy. 

Continuum (Minneap Minn). 2013;19(3):656–681.

5. Babineau SE, Green MW. Headaches in children. Continuum 

(Minneap Minn). 2012;18(4):853–868.

6. Defense and Veterans Brain Injury Center. A Parent’s Guide to 

Returning Your Child to School After Concussion. DVBIC: Silver 

Spring, MD; 2014. https://dvbic.dcoe.mil/sites/default/files/2014_

ParentsGuide_09-03-14.pdf. Accessed March 26, 2015.

7. Ling, GS, Marshall SA, Moore DF. Diagnosis and management of 

traumatic brain injury. Continuum (Minneap Minn). 2010;16(6):27–40.
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Pediatric Surgery and Medicine for Hostile Environments 
521

Hematology and Oncology

Chapter 32

Hematology and Oncology

When blood disorders are being considered in a differential 

diagnosis, a detailed history, careful physical examination, and 

review of a blood smear can often yield an accurate diagnosis, 

even in the absence of advanced testing.

Anemia

• Anemia is a quantitative deficiency of hemoglobin (Hgb) 

or red blood cells less than a fifth percentile for age, with 

potential decreases in oxygen-carrying capacity. 

• It can be due to decreased production, increased destruction, 

or increased losses.

• It is important to identify anemia as a sign or etiology of 

disease state. 

• Understanding age-related normative values is imperative. 

Norms are readily available in resources such as The Harriet 

Lane Handbook (see Further Reading) or as shown in Table 32-1.

When to Suspect Anemia (Chief Complaints)

• Common symptoms of anemia include: 

° fatigue (classic symptom), 

° shortness of breath,

° dizziness,

° poor weight gain and failure to thrive, 

° complaints of chronic diarrhea, and

° developmental delays.

• Anemia is more common in regions lacking in fortified foods 

(iron, B12, folate). 

History

• Considerations include age, nutritional status, family history, 

medication history, and potential toxin exposure.
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Pediatric Surgery and Medicine for Hostile Environments 

• In the newborn period (birth through 1 month), consider:

° inheritable disorders of red blood cell production, such as 

hemoglobinopathies (eg, sickle cell) and thalassemias;

° increased destruction, including enzymopathies, 

membranopathies, and neonatal alloimmunization;

° prematurity (should also raise concerns of decreased 

nutritional stores); and

° concomitant anomalies (may trigger concerns of a genetic 

disorder or prenatal infection). 

• In older children, consider decreased production resulting 

from:

Table 32-1. Normal Red Blood Cell Values

HgB (g/dL) RBC Count MCHC

Age Mean (–2SD*) (×1012/L) MCV (fL) (g/%RBC)

0 days 16.5 (13.5) 3.9–5.5 108 (98) 33 (30)

1–3 days 18.5 (14.5) 4.0–6.6 108 (95) 33 (29)

2 wk 16.6 (13.4) 3.6–6.2 105 (88) 31.4 (28.1)

1 mo 13.9 (10.7) 3.0–5.4 101 (91) 31.8 (28.1)

6–8 wk 11.2 (9.4) 2.7–4.9 95 (84) 31.8 (28.3)

3–6 mo 12.6 (11.1) 3.1–4.5 76 (68) 35 (32.7)

6–24 mo 12.0 (10.5) 3.7–5.3 78 (70) 33 (30)

2–6 y 12.5 (11.5) 3.9–5.3 81 (75) 34 (31)

6–12 y 13.5 (11.5) 4.0–5.2 86 (77) 34 (31)

12–18 y 

female 14 (12) 4.1–5.1 90 (78) 34 (31)

male 14.5 (13) 4.5–5.3 88 (78) 34 (31)

18–49 y

female 14 (12) 4.1–5.1 90 (80) 34 (31)

male 15.5 (13.5) 4.5–5.3 90 (80) 34 (31)

*2SD below mean. 

HgB: hemoglobin

MCV: mean corpuscular volume

MCHC: mean corpuscular hemoglobin concentration

RBC: red blood cell

SD: standard deviation 

Data source: Nathan DG, Oski FA. Nathan and Oski’s Hematology of Infancy and 

Childhood. 6th ed. Philadelphia, PA: WB Saunders; 2003: 1841, App 11.
523

Hematology and Oncology

° nutritional deficiencies due to dietary insufficiency or 

intestinal malabsorption,

° poor utilization of nutrients in chronic inflammatory states, 

° chronic occult blood loss, 

° bone marrow failure syndromes,

° acquired aplastic anemias,

° medication-induced anemias, and

° organ dysfunction, such as chronic renal insufficiency, 

hypersplenism, portal hypertension (as seen in hepatic 

failure), and thyroid dysfunction. 

Physical Examination

• Visually inspect the patient’s palms, nail beds, conjunctiva, 

lips, and below the tongue for evidence of pallor. Pallor is a 

late sign of anemia and often reflects very low red blood cell 

counts.

• Scleral icterus or cola-colored urine will suggest increased 

destruction of red blood cells. 

• Dysmorphic physical features may suggest a genetic condition 

or inheritable bone marrow failure syndrome. 

• Check for tachycardia in a euvolemic state (see Chapter 1, 

Basic Approach to Pediatric Trauma, Table 1-1, for age-related 

normative values). 

• In cases of severe anemia, a bounding precordium or rales in 

the lungs can indicate potential cardiac failure. 

• Isolated splenomegaly suggests increased destruction 

or peripheral sequestration of blood, or occasionally, 

extramedullary hematopoiesis due to bone marrow failure.

• Murphy’s sign reflecting the presence of cholelithiasis suggests 

increased destruction and turnover of blood cells, resulting in 

heme-pigmented stones and indirectly suggesting anemia. 

• Isolated hepatomegaly associated with anemia can suggest a 

viral etiology. 

• Hepatosplenomegaly associated with anemia can also suggest 

viral etiology or could represent malignancy. 

• Easy bruising or bleeding should be noted; when it occurs 

with symptoms of anemia, consider a bone marrow process 

affecting multiple cell lines (leukemia), although viral infection 

is still possible. 
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Pediatric Surgery and Medicine for Hostile Environments 

• Observe the skin for dry or thinning hair, which suggests 

vitamin or hormone deficiencies such as hypothyroidism that 

may affect red blood cell production. 

• Occult blood in the stool suggests chronic intestinal blood 

loss. 

• Frontal bossing and maxillary hyperplasia can be signs of 

thalassemias.

Laboratory Evaluation

• Begin with a complete blood count (CBC) with reticulocyte 

count (RC) and peripheral blood smear evaluation. Normal 

peripheral red blood cell values generated by automated 

laboratory analyzers will vary by age. 

• Although Hgb values are used to identify anemia, the 

additional information provided can help identify a process 

of inadequate production or increased destruction. 

• Quick tools (applicable to children older than 1 year):

° Microcytosis: mean corpuscular volume (MCV) is less than 

70 + (age in years, up to age 10). 

° Macrocytosis: MCV greater than 100.

° Hypochromia: greater than one-third diameter central 

pallor under microscopy, or low mean corpuscular Hgb 

concentration. 

° Hyperchromia: less than one-third diameter central 

pallor under microscopy, or high mean corpuscular Hgb 

concentration.

• Other parameters 

° RC: typically 1% to 3%.

▶ Anemia with high RC indicates increased loss or 

destruction.

▶ Anemia with low RC indicates decreased production.

° Red blood cell distribution width (RDW): increased value 

suggests various sizes and shapes (decreased uniformity). 

Diagnosis and Treatment: Microcytic Anemias 

Iron Deficiency

• Additional symptoms of iron deficiency include pica and lack 

of concentration.
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Hematology and Oncology

• Laboratory findings

° Hypochromic, microcytic anemia.

° Low RC. 

° High RDW.

° Iron studies show low serum iron with high total iron 

binding capacity and low ferritin.

• Treatment depends on the level of symptoms.

° Asymptomatic: 4 to 6 mg elemental iron per kilogram 

divided twice or three times daily. Increased reticulocytosis 

will be seen within 3 to 7 days. 

° If the patient is symptomatic, transfusion may be indicated. 

If intravenous (IV) iron is available, it may be considered 

for patients who do not tolerate oral iron, do not absorb 

oral iron, or in whom compliance may be a concern. A test 

dose given 1 hour before the first full infusion can screen for 

allergic reactions. Several formulations are available, with 

low molecular weight, iron dextran, and iron sucrose being 

the least likely to cause an allergic reaction or anaphylaxis. 

Total iron deficit (mg) = body weight (kg) × (target Hgb – 

actual Hgb) (g/dL) × 2.4 + 500 mg (for patients over 35 kg). 

Chronic Lead Poisoning

• Additional symptoms of chronic lead poisoning include 

abdominal pain, headaches, neurologic effects, constipation, 

failure to attain or regression of developmental milestones, 

growth arrest, and kidney disease.

• Physical examination will show gingival lead lines.

• Laboratory findings

° Hypochromic, microcytic anemia.

° Basophilic stippling in the RBC seen under microscopy.

° Low RC. 

° Elevated lead level.

• Treatment 

° Remove exposure.

° Levels above 45 μg/dL require chelation with 

dimercaptosuccinic acid or succimer; oral dimercaptosuccinic 

acid can be given at 30 mg/kg/day for 5 days, followed by 

10 to 20 mg/kg/day for 14 days to prevent rebound in blood 

lead levels.
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Pediatric Surgery and Medicine for Hostile Environments 

Thalassemia 

• Thalassemia is an inherited disorder of Hgb synthesis with 

disordered production and hemolytic anemia.

• Can be α-thalassemia or β-thalassemia and is classified 

as minor, intermedia, or major based on symptoms and 

inheritance patterns.

• Regional patterns can often be determined in those with 

familial descent from the Mediterranean, North Africa, Middle 

East, India, Central Asia, and Southeast Asia.

• Symptoms 

° Failure to thrive, developmental delays, fatigue.

° Present within first 2 years of life for thalassemia major, may 

be more indolent in intermedia; generally asymptomatic in 

thalassemia minor or trait.

• Physical examination will show scleral icterus, splenomegaly, 

and bony dysplasia (maxillary hyperplasia, vertebral 

expansion). 

• Laboratory findings

° Hypochromic, microcytic anemia.

° Target cells.

° Normal RDW.

° High RC.

° Quick tool: Mentzer index = MCV/RBC count 

▶ A result less than 12 is consistent with thalassemia.

▶ A result greater than 13.5 is consistent with iron 

deficiency. 

▶ Although Hgb electrophoresis is not likely to be available 

▷ An elevated Hgb A2 would suggest beta thalassemia 

(trait or thalassemia major).

▷ Alpha thalassemia intermediate (Hgb H disease) 

would have Hgb H. 

▷ Alpha thalassemia trait would have normal 

electrophoresis.

• Treatment depends on severity.

° Thalassemia minor: no treatment (genetic counseling for 

future offspring). 

° Thalassemia intermedia: supplement with folic acid (1 mg 

orally daily) and provide supportive care for crises.
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Hematology and Oncology

° Thalassemia major is diagnosed with Hgb, MCV, and 

Hgb electrophoresis. Give chronic blood transfusions and 

iron chelation; splenectomy is occasionally needed. Note: 

Iron deficiency and thalassemia may be concomitant, but 

thalassemias tend to have increased iron absorption; do not 

treat with iron unless the patient is deficient.

Chronic Inflammation

• Chronic inflammation prevents normal utilization of iron for 

Hgb synthesis.

• Signs and symptoms are consistent with the underlying 

disease.

• Laboratory findings 

° Hypochromic, microcytic, or normocytic anemia.

° Low RC. 

° RDW is generally increased.

° Iron studies show low serum iron and total iron binding 

capacity, as well as high ferritin. 

• Treat the underlying disease. 

Diagnosis and Treatment: Macrocytic Anemias 

Vitamin B12 Deficiency

• Etiology: nutritional deficiency, poor intestinal absorption, 

parasites, or bacterial overgrowth.

• Symptoms include fatigue, pallor, and peripheral neuropathies. 

In infants, symptoms include tremors, microcephaly, 

developmental regression, and failure to thrive.

• Laboratory findings 

° Low RC.

° Elevated RDW.

° Neutropenia and thrombocytopenia may be present.

° Microscopy may show hypersegmented neutrophils (6 or 

more lobes).

° Serum B12 levels may be low.

▶ Vitamin B12 deficiency is more common and occurs at 

younger ages in patients of northern European decent. 

It is rare in patients of Asian and African descent.
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Pediatric Surgery and Medicine for Hostile Environments 

▶ Additional laboratory abnormalities suggesting B12 

deficiency include elevated lactate dehydrogenase, 

bilirubin, iron with increased transferrin saturation, and 

serum cholesterol; immunoglobulins may be decreased.

▶ Bowel resections removing the ileum can result in B12 

deficiency.

• Treatment

° Consider other potential nutritional deficiencies.

° For cases of inadequate intake, supplement with vitamin 

B12. Provide parenteral supplementation (intramuscular or 

subcutaneous; 1 mg weekly for 8 weeks and then monthly, 

or oral 1 mg daily). Reversal of neurologic symptoms can 

be seen in 48 hours.

Folic Acid Deficiency

• Etiology: nutritional deficit (drinking primarily goat’s 

milk), poor intestinal absorption (celiac disease), increased 

body requirements (rapid growth or cell turnover ), 

metabolic disorders (inborn errors of metabolism), or folate 

antagonistic drugs (eg, phenytoin, methotrexate, triamterene, 

trimethoprim) can result in folic acid deficiency.

• Symptoms include typical anemia symptoms without the 

associated neurologic symptoms seen in B12 deficiency. 

• Laboratory findings are similar to those for vitamin B12 

deficiency. 

° Low RC.

° Neutropenia and thrombocytopenia may be present.

° RDW will be elevated.

° Microscopy may show hypersegmented neutrophils (6 or 

more lobes).

° Serum folate will be low (< 3 ng/mL) early with deprivation 

followed by low RBC folate (< 150 ng/mL) which may lag 

for several weeks. RBC folate is more representative of total 

folate stores.

• To distinguish folic acid deficiency from B12 deficiency, treat 

with 100 to 500 μg folate daily. Reticulocytosis will be seen 

in 2 to 4 days. Treatment of B12 deficiency with folate may 

improve anemia but will not improve neurologic sequelae. If 

in doubt, treat both.
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Hematology and Oncology

• Once B12 deficiency is ruled out, treat with folic acid (1 mg 

oral daily) supplementation. 

Bone Marrow Stress or Failure

• Aplastic anemia occurs when bone marrow’s ability for 

hematopoiesis is reduced or absent. It can be the result of 

acquired or congenital factors.

• Bone marrow infiltration is when bone marrow spaces are 

occupied by tumor, leukemia, fibrosis, or storage disease.

• Dyserythropoiesis and myelodysplastic syndromes result 

from ineffective erythropoiesis that presents with a decrease 

in one cell line and progresses to pancytopenia.

• Laboratory findings 

° Low RC. 

° Other cell lines are low or abnormal.

° Microscopy may show teardrops, macrocytosis, or leukemic 

blasts. 

° Normal RDW.

° Bone marrow examination for definitive diagnosis.

• Treatment is supportive and consists of transfusions and 

antibiotics until definitive care is available. 

Liver Disease

• Signs and symptoms are consistent with liver disease.

• Laboratory findings

° Microscopy will show burr cells or target cells.

° Prolonged prothrombin time (PT) or activated partial 

thromboplastin time (aPTT) may be seen.

• Treatment consists of supportive care for coagulopathies and 

liver disease management.

Hypothyroidism

• Signs and symptoms are consistent with hypothyroidism, 

including weight gain, fatigue, cold intolerance, hair loss, 

constipation, depression, and weakness.

• Laboratory findings: spiculated, large red blood cells are 

evident on microscopy. Thyroid hormone levels will be low.

• Treatment consists of levothyroxine hormone replacement 

along with treatment of any underlying thyroid disorder. 
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Pediatric Surgery and Medicine for Hostile Environments 

Normocytic Anemias 

Hemolytic Anemias 

• The normal red blood cell lives for 120 days in circulation. 

• Premature red blood cell destruction can result in anemia. 

• Destruction can be intravascular or extravascular, inherited 

or acquired.

• Management is based on the specific etiology of hemolytic 

anemia. History and laboratory findings can help distinguish 

between the etiologies of hemolytic anemia.

• Laboratory findings

° Normocytic, normochromic, or hyperchromic anemia.

° Morphology of red blood cells can provide clues to the 

etiology (schistocytes, target cells, bite cells). 

° High RC.

° High indirect bilirubin and lactate dehydrogenase.

° Decreased haptoglobin.

° Urinalysis will show hemoglobinuria. 

° Direct antibody testing would be positive in autoimmune 

hemolytic anemia.

° Osmotic fragility testing would be abnormal in hereditary 

spherocytosis and other red cell membrane disorders.

° Glucose-6-phosphate dehydrogenase (G6PD) activity 

would be low in G6PD deficiency. Levels may be normal 

during an acute hemolytic event and should be checked 

while a patient is not in active hemolysis.

• Physical examination will show scleral icterus, splenomegaly, 

and dark-colored urine. 

• Differential 

° Enzymopathies (other than G6PD; see below).

° Membranopathies, such as spherocytosis or elliptocytosis.

° Autoimmune hemolytic anemias, such as

▶ immune-mediated hemolysis, and

▶ drug-induced hemolysis.

° Microangiopathy, such as 

▶ hemolytic uremic syndrome,

▶ disseminated intravascular coagulopathy, and

▶ Kasabach-Merritt syndrome (large hemangiomas).
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Hematology and Oncology

Glucose-6-Phosphate Dehydrogenase Deficiency

• G6PD functions as a reducing enzyme, is found in all cells, 

and has a normal half-life of 60 days. Most people with G6PD 

deficiency do not have symptoms.

• Red blood cells with reduced levels of G6PD have a shorter 

half-life and are susceptible to hemolysis when exposed to 

oxidative stress. Microscopy shows Heinz bodies.

• Inheritance is X-linked; males are much more likely to have 

symptomatic deficiency than females. 

• Most patients with G6PD deficiency have descended 

from Africa (20% of all those from African descent), the 

Mediterranean (4%–30%), and Southeast Asia.

• Symptoms can be episodic. The African variant is often less 

severe than many Mediterranean and Asian subtypes.

• Diagnosis: assess G6PD level, which may be normal in the 

acute phase because all deficient red blood cells will have 

lysed.

• Treatment includes avoiding agents known to cause hemolysis 

(primaquine for malaria, sulfa drugs, etc; see www.g6pd.org 

for a complete list), supportive care for crises, and adequate 

hydration. Transfusions may be required.

Acute Blood Loss

• Control hemorrhage and manage acute trauma.

• Check for occult blood if the source of blood loss is not overt.

Transient Erythroblastopenia of Childhood

• Typical age of onset is about 2 to 3 years of age.

• Symptoms include pallor and tachycardia from profound 

anemia, but otherwise the patient appears well. 

• Laboratory examination shows low RC. MCV is normal, but 

the patient may be macrocytic in early recovery.

• Treatment consists of supportive care. 

Chronic Renal Disease

• Multifactorial anemia: chronic inflammation, nutritional 

deficiency, uremia, and decreased erythropoietin.
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Pediatric Surgery and Medicine for Hostile Environments 

• Symptoms are consistent with renal insufficiency (dependent 

edema). 

• Laboratory examination shows low RC and erythropoietin 

levels.

• Treatment consists of addressing the underlying renal disease. 

Erythropoietin or iron may be indicated in an advanced-care 

setting. 

Sickle Cell Disease

• Inherited defects in beta (b) genes involved in Hgb production 

result in sickling of cells, vasoocclusion, inflammation, and 

multiorgan effects.

• Sickle cell disease shows a regional preference. It occurs 

frequently in people living in certain parts of Africa, India, 

and the Middle East; in the United States, it occurs in 0.2% of 

African Americans. 

• Symptoms vary based on phenotype. Early recognition, 

education, and management are key to preventing further 

complications. Acute chest syndrome, stroke, and sepsis are 

deadly. 

• Sickle cell disease is often found in the compound heterozygote 

state with other hemoglobinopathies.

° More severe phenotypes/more frequent sequelae include 

homozygous Hgb SS disease, Hgb S/beta-zero thalassemia.

° Less severe phenotypes/less frequent sequelae include 

heterozygous Hgb S/Hgb C disease, Hgb S/beta+ 

thalassemia.

• Symptoms vary based on phenotype and stressors.

° Symptoms can include pain (vasoocclusive) crises: 

▶ Bony (most common locations are the lumbosacral spine, 

hip, femur, knee, shoulder, and elbow).

▶ Dactylitis (swelling of distal extremities with pain) in 

infants.

▶ Priapism.

▶ Abdominal pain.

° Rule out splenic sequestration (presents with weakness, 

splenomegaly, left-sided abdominal pain, and progressive 

shock; associated with a 30% mortality rate).
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Hematology and Oncology

° Rule out gallstones, which are common during the second 

decade of life.

° Acute chest syndrome (multiple explanations are possible; 

this is common in older children).

▶ Presents as fever with respiratory symptoms and a new 

infiltrate on radiography consistent with pneumonia.

▶ Can be due to pulmonary fat embolism or an associated 

infection.

▶ Pulmonary infarction is also a part of acute chest 

syndrome.

▶ Often hypoventilation is attributable to narcotic 

administration or chest pain on breathing caused by 

infarction of rib or sternum.

° Ischemic stroke/transient ischemic attack.

° Developmental delays.

° Poor growth.

° Aplastic crisis (most often caused by parvovirus B19).

° Multiorgan dysfunction, evidenced by retinopathy, cardiac 

dysfunction and pulmonary hypertension, and immune 

dysfunction (functional asplenia).

° There is a risk of sepsis from encapsulated organisms 

(pneumococcal and meningococcal sepsis).

• Laboratory examination

° RC is elevated (aplastic crisis is a concern if RC is decreased 

in the acute setting).

° White blood cell count may be elevated.

° Sickled cells or target cells (if concomitant thalassemia) are 

visible on peripheral blood smear.

° Lactate dehydrogenase and indirect bilirubin are elevated.

° Perform Sickledex (Strek, Inc, Omaha, Nebraska) or sickle 

prep solubility test.

° Use Hgb electrophoresis for definitive diagnosis.

• Treatment in the deployed setting is limited to early 

recognition and management.

° Ensure adequate hydration (free access to fluids, avoid 

overhydration).

° Provide penicillin 125 mg oral twice daily for prophylaxis 

from pneumococcal infections until patient is 3 years 

old, then increase to 250 mg oral twice daily (lifelong 

prophylaxis is ideal). 
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Pediatric Surgery and Medicine for Hostile Environments 

° Ensure adequate nutritional support (multivitamin with 

folic acid supplementation).

° Encourage a comprehensive immunization program, 

including pneumococcal conjugate vaccine and 

meningococcal series.

° Hydroxyurea, if available, can often decrease long-term risk 

of complications (requires advanced care and monitoring).

° Pain should be managed aggressively. 

▶ Give nonsteroidal antiinflammatory drugs to decrease 

inflammation and pain. 

▶ Opioids and ketamine can be useful for pain management; 

consider patient-controlled analgesia, if available.

▶ Abdominal or chest pain that is not well controlled can 

result in splinting and hypoventilation, which can lead 

to life-threatening sickling in the lungs (acute chest 

syndrome).

° Maintain oxygenation.

° Use bronchodilators and incentive spirometry for 

respiratory symptoms and pulmonary toilet.

° Administer antibiotics and aggressively evaluate any 

temperature greater than 38°C, giving broad-spectrum 

antibiotics (ceftriaxone) for fevers. Add azithromycin 

or fluoroquinolone for atypical coverage in the case of 

respiratory symptoms.

° Transfusions, including partial and complete exchange 

transfusions, may be necessary for emergency situations 

(eg, acute chest syndrome). 

Thrombocytopenia

• Thrombocytopenia is a quantitative decrease in platelet count 

less than 150,000/mm3 that may be secondary to decreased 

production, increased peripheral destruction, sequestration, 

or medication- or toxin-mediated myelosuppression.

• Thrombocytopenia results in bleeding, most commonly 

in mucous membranes, including epistaxis, oral bleeding, 

menorrhagia and increased bleeding with childbirth, and in 

the skin (including petechiae and bruising).

° Increased bleeding may be seen in trauma or medical 

procedures for patients with platelet counts less than 

100,000/mm3.
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Hematology and Oncology

° Spontaneous bleeding typically does not occur until platelet 

counts drop below 30,000/mm3, and risks for spontaneous 

hemorrhage increase as numbers decrease.

• When to suspect thrombocytopenia (chief complaints):

° Easy or spontaneous bruising and/or petechiae.

° Recurrent or prolonged epistaxis.

° Excessive bleeding with dental surgery or tonsillectomy.

° Severe menorrhagia or excessive bleeding after childbirth.

• History

° Considerations include age, recent illnesses, medication 

history, and potential toxin exposure.

° Etiologies to consider in the newborn period:

▶ Inheritable disorders of platelet production, including: 

▷ congenital amegakaryocytic thrombocytopenia, 

▷ thrombocytopenia-absent radius syndrome, 

▷ Fanconi anemia, 

▷ Bernard-Soulier syndrome (associated with large 

platelets),

▷ May-Hegglin anomaly (giant platelets and pale-blue 

leukocyte inclusions),

▷ grey platelet syndrome,

▷ Alport syndrome,

▷ Wiskott-Aldrich syndrome (small platelets, severe 

eczema), and

▷ Gaucher disease.

▶ Increased destruction, such as:

▷ neonatal alloimmune thrombocytopenia and 

▷ viral or bacterial sepsis.

▶ Platelet sequestration:

▷ hypersplenism or

▷ K a s a b a c h - M e r r i t t s y n d r o m e d u e t o a 

hemangioendothelioma.

° In the older child or teen, consider:

▶ decreased production, including:

▷ undiagnosed inheritable disorder of platelet 

production,

▷ myleodysplastic syndrome or leukemia,

▷ human immunodeficiency virus,

▷ Lyme disease, and
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Pediatric Surgery and Medicine for Hostile Environments 

▷ other viral or infection suppression.

▶ Increased destruction, including:

▷ immune thrombocytopenic purpura (ITP),

▷ thrombotic thrombocytopenic purpura,

▷ viral or bacterial sepsis, 

▷ disseminated intravascular coagulation (DIC),

▷ dengue fever,

▷ systemic lupus erythematosus,

▷ paroxysmal nocturnal hemoglobinuria,

▷ hemolytic uremic syndrome, and

▷ snakebites (particularly from pit vipers).

▶ Medication- or toxin-mediated myelosuppression caused 

by (consult a pharmacist for a more comprehensive drug 

list):

▷ valproic acid,

▷ chemotherapeutic agents,

▷ isotretinoin,

▷ montelukast sodium,

▷ heparin, and

▷ some cephalosporins.

° Physical examination

▶ Visually inspect the skin for evidence of bruising, 

purpura, or petechiae.

▶ Visually inspect the mouth and nose for evidence of 

bleeding.

▶ Dysmorphic physical features may suggest a genetic 

condition or inheritable disorder of platelet production. 

▶ Look for hemangiomas. If a child has multiple superficial 

hemangiomas, further imaging studies may locate 

larger internal hemangioendotheliomas responsible for 

Kasabach-Merritt Syndrome (platelet sequestration).

▶ Splenomegaly can also suggest splenic sequestration. 

▶ Signs of anemia should be noted. When seen with 

symptoms of thrombocytopenia, consider a bone 

marrow process affecting multiple cell lines (leukemia), 

although viral infection is again still possible. 

▶ For significantly ill children (those with sepsis, shock, or 

mental status changes) consider DIC, hemolytic uremic 

syndrome (HUS), or thrombotic thrombocytopenic 

purpura (TTP).
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Hematology and Oncology

° Laboratory evaluation: begin with a CBC and peripheral 

blood smear evaluation. A platelet count greater than 

150,000/mm3 is normal for all ages.

Diagnosis and Treatment

Immune (Idiopathic) Thrombocytopenic Purpura

• ITP is a common cause of thrombocytopenia in children, 

resulting when autoantibodies attack platelets. It may be acute 

or chronic and most commonly occurs between the ages of 2 

and 8 years. 

• ITP presents with bruising, petechiae, and mucous membrane 

involvement, including gum bleeding and epistaxis in a child 

who generally appears healthy. Rarely (in 10% of cases) 

splenomegaly will be present. 

• Diagnosis

° Patient will have a decreased platelet count, generally less 

than 20,000/mm3 with normal Hgb and normal white blood 

cell counts.

° Other coagulation studies (PT/aPTT) are normal.

° Bone marrow studies show increased megakaryocytes; a 

bone marrow biopsyshould be considered prior to steroid 

treatment in atypical cases or if additional cytopenias are 

present.

° The presence of ITP for more than 12 to 18 months is 

considered chronic (chronic ITP occurs in 20% of patients 

with acute ITP).

• Treatment of acute ITP

° Observe patient if platelet counts are greater than 20,000/

mm3 and there is no significant bleeding.

° If platelet counts are less than 10,000/mm3

 or less than 

20,000/mm3 with bleeding:

▶ Give prednisone 1 to 2 mg/kg/day, up to 60 mg/daily, 

tapered in 5- to 7-day intervals for 21 to 28 days.

▶ Methylprednisolone 30 mg/kg/day, divided twice daily 

for 3 days, can be used for more severe cases.

▶ Give anti-D immunoglobulin 50 to 75 mg/kg IV.

▶ Administer IV immunoglobulin 0.8-1 g/kg if a more 

rapid increase in the platelet count is needed. 
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Pediatric Surgery and Medicine for Hostile Environments 

▶ Premedicate with acetaminophen and diphenhydramine.

▶ Infuse slowly over 4 hours, with epinephrine on hand 

in case an infusion reaction occurs.

° Platelet transfusion should only be used for emergency, 

including surgery and intracranial hemorrhage, since 

transfused platelets will have a short life span.

° Splenectomy is indicated for severe, life-threatening 

bleeding unresponsive to medical management (if possible, 

vaccination with meningococcal, pneumococcal, and 

Haemophilus influenzae type B vaccines should be given 

prior to splenectomy).

• Treatment of chronic ITP

° Evaluate patients for evidence of other autoimmune diseases, 

such as systemic lupus erythematosus, hereditary bone 

marrow failure syndrome, or human immunodeficiency 

virus.

° Treatment for symptomatic patients is the same as that for 

acute ITP.

Hemolytic Uremic Syndrome/Thrombotic Thrombocytopenic 

Purpura

• Both conditions are forms of microangiopathic anemia 

associated with thrombosis. Thrombus formation consumes 

platelets and hemolyzes red blood cells as they pass through 

small blood vessels. 

• HUS is often seen in association with infections, including 

Shigella dysenteriae or Escherichia coli O157:H7.

• TTP can be seen following viral or bacterial infections, during 

pregnancy, or with certain drugs.

• Presentation

° HUS: gastrointestinal infection, often including bloody 

diarrhea, oliguria, and hypertension.

° TTP: bleeding with neurologic symptoms and later fever.

• Differentiation

° Though both have thrombocytopenia and hemolytic 

anemia, HUS is typically less severe than TTP.

° Platelet counts are greater than 100,000/mm3

 in more than 

50% of patients.
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Hematology and Oncology

° Age of onset is 6 months to 5 years in HUS, and generally 

adult-onset in TTP.

• Treatment

° For HUS, treatment should be focused on the renal disease 

with fluid restriction and hypertension management. 

Packed red blood cell transfusions may be needed. Platelet 

transfusions are not indicated, as life-threatening bleeding 

is rare and platelet transfusion may worsen thrombosis.

° Use plasmapheresis for TTP.

Disseminated Intravascular Coagulation

• DIC is an acquired syndrome of intravascular activation of 

the coagulation cascade that most commonly occurs following 

sepsis.

• Presentation

° Bleeding, petechiae, or mucosal bleeding (may be minimal 

oozing or severe bleeding).

° Laboratory abnormalities include prolonged PT and aPTT, 

decreased fibrinogen, and increased fibrin split products, 

including D-dimer, along with thrombocytopenia on CBC.

• Treatment

° Treat the underlying cause and provide supportive care.

° Transfuse platelets to maintain counts greater than 50,000/

mm3.

° Administer fresh frozen plasma 10 to 15 mL/kg to maintain 

PT less than two times the upper limit of normal.

° Administer cryoprecipitate to maintain fibrinogen greater 

than 100 mg/dL.

Inherited Coagulopathies

Hemophilia

Hemophilia A and B are x-linked deficiencies in factor VIII or 

factor IX, respectively. A rarer autosomal recessive deficiency in 

factor XI is known as Hemophilia C. These factors work together 

to drive the coagulation cascade from the intrinsic pathway to 

the common pathway.

• Presentation

° Hemophilia A and B are clinically identical to each other 

and almost exclusively occur in males.
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Pediatric Surgery and Medicine for Hostile Environments 

° Initial manifestation can be prolonged and excessive 

bleeding after circumcision; therefore most patients are 

identified before 18 months of life.

° Joint bleeding (hemarthrosis) is the hallmark of hemophilia, 

with weight-bearing joints of the legs being most frequently 

affected.

• Evaluation

° PT will be normal but aPTT will be prolonged.

° Factor assays will show decreased activity in the deficient 

factor.

° Mixing study will correct if the patient has not developed 

inhibitors.

• Treatment

° Factor replacement (Table 32-2).

° Patients with mild or moderate factor VIII deficiency can 

be treated with desmopressin acetate 0.3 mg/kg IV over 15 

to 30 minutes, or intranasal desmopressin acetate 1.5 mg/

mL, 1 puff for children under 50 kg and 2 puffs for children 

greater than 50 kg.

° Desmopressin acetate nasal spray for hemophilia is 15-

fold more concentrated than the spray used for diabetes 

insipidus.

° Beware of hyponatremia; avoid excess free water.

Table 32-2. Factor VIII and IX Levels Following 

Replacement*†

Type of Bleed Desired Level (%)

Joint or simple hematoma 20–40

Simple dental extraction 50

Major soft tissue bleed 80–100

Head injury (prophylaxis) 100+

Major surgery (dental, orthopedic, other) 100+

*

For factor VIII, each unit/kg will increase level by 2% (eg, to increase from 

< 10% to 100%, use 50 units/kg).

†

For factor IX, each unit/kg will increase level by 1% (eg, to increase from 

< 10% to 100%, use 100 units/kg).
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Hematology and Oncology

° If specific factors are unavailable or if the hemophilia is not 

known, then fresh frozen plasma 40 mL/kg can be used to 

control bleeding. Volume overload can be a complication, 

so for patients with hemophilia A, cryoprecipitate (50–100 

units factor VIII/10 mL) can be used.

° Administer cryoprecipitate to maintain fibrinogen greater 

than 100 mg/dL.

Von Willebrand’s Disease

Von Willebrand’s Disease is the most common inherited bleeding 

disorder. It occurs in 1% to 2% of the population, though only a 

small number of affected individuals have clinically significant 

bleeding. It is an autosomal-dominant disorder, so often a strong 

family history of bleeding can be elicited. 

• Presentation

° History of bleeding and bruising similar to thrombocytopenia 

with mucocutaneous bleeding, epistaxis, menorrhagia, and 

bruising. 

° Oozing and post-operative bleeding in dental procedures 

and after tonsillectomy or adenoidectomy.

• Evaluation

° Von Willebrand panel. Include von Willebrand activity and 

antigen, factor VIII level, and multimers. All are needed to 

differentiate between the six subtypes of von Willebrand’s 

disease (I, IIa, IIb, IIm, IIn, and III).

• Treatment

° For minor bleeding or prior to minor procedures, patients 

can be treated with desmopressin acetate 0.3 mg/kg IV over 

15 to 30 minutes, or intranasal desmopressin acetate 1.5 mg/

mL, 1 puff (150 mg) for children less than 50 kg and 1 puff 

in each nostril (330 mg) for those weighing over 50 kg.

° To treat significant bleeding or for prophylaxis for major 

surgery, plasma-purified von Willebrand’s factor or 

cryoprecipitate (50–100 units von Willebrand’s factor/10 

mL) should be used.
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Pediatric Surgery and Medicine for Hostile Environments 

Oncology 

• The most common malignancies in childhood include 

leukemia, brain tumors, lymphoma, neuroblastoma, 

Wilm’s tumor of the kidney, bone tumors (such as Ewings 

sarcoma and osteosarcoma), and soft tissue sarcomas, like 

rhabdomyosarcoma.

• Children with cancer are particularly susceptible to infection, 

which is a significant cause for both morbidity and mortality 

in pediatric oncology patients.

• Etiology for this is multifactorial and includes a suppressed 

or abnormal immune system, poor nutritional status, mucous 

membrane damage (stomatitis and ulcers), and indwelling 

central venous catheters.

• In children with fever and neutropenia (an absolute neutrophil 

count less than 500 mm3), broad-spectrum IV antibiotics 

with activity against both gram-negative and gram-positive 

organisms should be initiated within 1 hour of fever onset.

• Carefully examine the patient for a source of infection, paying 

particular attention to the mucous membranes, perineum, and 

skin surrounding the central venous catheter.

• The patient should be admitted until afebrile with no focus 

of infection and negative blood cultures for 48 to 72 hours, 

and have evidence of neutrophil recovery, with absolute 

neutrophil count greater than 200 mm3 on at least two 

occasions separated by 24 hours and rising.

° If a specific infection is identified, a full course of treatment 

should be undertaken.

° If fevers persist for more than 3 to 5 days, or if a patient has 

a new fever after 3 to 5 days on broad-spectrum antibiotic 

therapy, antifungal therapy should be initiated and fungal 

infection should be evaluated, including taking fungal 

blood cultures, imaging, and examinations, excluding 

fungal disease in the eyes, sinuses, lungs, heart, liver, 

spleen, and skin.

Further Reading

1. The Harriet Lane Handbook: A Manual for Pediatric House Officers. 20th 

ed. Engorn B, Flerlage J, eds. Philadelphia, PA:Saunders/Elsevier; 

2015.
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Pediatric Nephrology

Chapter 33

Pediatric Nephrology 

Introduction

Acute kidney injury, electrolyte disturbances, nephrotic 

syndrome, and kidney stones are commonly encountered 

in austere environments or during humanitarian assistance 

operations. When there is any concern about effective renal 

function, determining the estimated glomerular filtration rate 

is paramount. This calculation is necessary when determining 

drug and antibiotic dosing as well as knowing when to 

avoid medications with renal toxicities, such as nonsteroidal 

antiinflammatory drugs (NSAIDs) and aminoglycosides. 

There may be rare circumstances in which “field peritoneal 

dialysis” or renal biopsy may be contemplated, but they should 

be performed in conjunction with host-nation providers on a 

case-by-case basis after consultation with a pediatric nephrologist 

at a stateside medical treatment facility.

Hydration, volume repletion, and common electrolyte 

disturbances are addressed in Chapter 25, Basic Fluid and 

Electrolytes. 

Assessing Kidney Function in Children

• The estimated glomerular filtration rate (eGFR) in mL/

min/1.73 m2 is calculated using the Schwartz formula.

° Two data points are needed for the eGFR calculation: the 

patient’s height (cm) and stable serum creatinine value.

° Schwartz formula: 

eGFR = (height in cm) (k)

(serum dreatinine mg/dL)

Where constant = k = 0.33 for premature infants,

= 0.45 for infants 1 to 52 weeks old
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Pediatric Surgery and Medicine for Hostile Environments 

= 0.55 for all children 1 to 13 years old 

and adolescent females 

= 0.7 for adolescent males 13 to 18 years 

old

° If an absolute increase in serum creatinine greater than 0.5 

mg/dL is observed, treat eGFR as zero or less than 20 mL/

min/1.73m2.

° When kidney function is compromised, dose all medications 

based on eGFR. If eGFR is less than 40 mL/min/1.73m2, 

especially in chronic kidney disease, associated conditions 

may include:

▶ Anemia due to erythropoietin deficiency as well as the 

iron deficiency caused by chronic disease. Treat with 

iron supplementation and erythropoietin (if available).

▶ Secondary hyperparathyroidism, as identified by 

high serum intact parathyroid hormone, phosphate, 

and alkaline phosphatase values, but low calcium 

values. Treat with calcium supplementation at meals 

to bind phosphate and raise calcium. If available, use 

1,25-dihydroxyvitamin D to suppress intact parathyroid 

hormone.

▶ Acidosis. Treat with sodium citrate (2–4 mEq/kg/

day divided into three doses) and calcium carbonate 

supplementation (45–65 mg/kg/dose of elemental 

calcium divided three times per day with each meal) to 

neutralize H+ ion and promote growth.

▶ Hyperkalemia due to severe acidosis and decreased GFR. 

Treat with osmolar K+-binding resin, such as sodium 

polystyrene sulfonate (1 g/kg/dose) every 6 hours as 

needed per os or per rectum to enhance potassium 

excretion. If urine output is present, consider a diuretic 

at high dose.

Acute Kidney Injury

• Acute kidney injury is evident when eGFR is less than 50 mL/

min/1.73 m2, or when creatinine rises by 0.5 mg/dL in children 

or 1.0 mg/dL in adolescents.

• The most common cause in the field or combat environment 
545

Pediatric Nephrology

is inadequate renal perfusion secondary to inadequate 

intravascular volume.

° Use clinical examination to assess for inadequate 

intravascular fluid status.

▶ Findings will include dry mucous membranes, sunken 

fontanelle, weight loss, etc.

▶ Assess for shock by measuring heart rate, blood pressure 

(BP), and capillary refill time.

▶ Check urine sodium if possible; urine sodium less than 

20 mmol/L regardless of serum sodium indicates prerenal azotemia.

▶ Assess for high urine osmolarity or urine-specific 

gravity.

▶ Assess oncotic pressure with serum albumin as a cause 

of low renal perfusion.

• Other causes of acute kidney injury in field environment 

include:

° Obstructive uropathy: neurogenic bladder, posterior 

urethral valves, single kidney with renal stones, etc. 

▶ Look for lower extremity atrophy, sacral dimple, and 

hair tuft for spina bifida occulta, or for other signs of 

associated congenital anomalies.

▶ Perform a kidney ultrasound to assess.

▶ Place Foley catheter into bladder to address urinary flow.

▶ Monitor serum creatinine after bladder decompression.

° Acute glomerulonephritis (GN), evidenced by: 

▶ Hypertension 

▷ The correct BP cuff should measure two-thirds of the 

distance from olecranon to acromion; the bladder 

portion of the cuff should completely enwrap the arm.

▷ Pediatric hypertension formula: 

< 12 months of age: > 100/70 mmHg

Children 1–10 years old:

– Systolic BP = age × (2.0) + 100 (95th percentile)

– Diastolic BP = age × (1.5) + 70 (95th percentile) 

> 10 years of age: use adult blood pressure values
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Pediatric Surgery and Medicine for Hostile Environments 

▶ Proteinuria with acute hematuria (gross or microscopic). 

Red blood cell casts and dysmorphic red blood cells are 

present on microscopic urine evaluation (if available).

▶ Edema.

° Acute tubular necrosis. This presents the same as acute 

GN except granular casts are seen on microscopic urine 

evaluation.

• Treat acute kidney injury as follows:

° Bolus initially with normal saline (NS) 20 mL/kg, blood 

products, or albumin 25% 0.5 to 1 g/kg slowly over 1 to 

2 hours to establish intravascular volume and restore BP 

(Caution: Some patients may already be euvolemic or 

hypervolemic).

° Place Foley catheter and record urine output.

° Use one-third maintenance fluids (1/2NS without potassium) 

and replace the urine output hourly on a 1-to-1 basis with 

1/2NS.

° Control or maintain blood pressure with vasodilators or 

vasopressors based on the patient’s BP. 

▶ For hypotension, use vasopressors.

▶ For hypertension, consider diuretics or calcium channel 

blockers (Caveat: Do not use calcium channel blockers 

in infants less than 12 months of age because of the risk 

of severe cardiac compromise).

▶ Titrate medications based on response.

▷ If the patient becomes oliguric or anuric, consider 

furosemide, 3 to 5 mg/kg, to establish urine output 

to deal with volume overload.

▷ Stabilize electrolytes, especially potassium (see 

Chapter 25 for hyperkalemia management).

▷ Contact a nephrology consultant via the theater 

consult service, if possible.

Nephrotic Syndrome

• Diagnostic criteria

° Hypoalbuminemia (< 2.5 gm/dL).

° Proteinuria is when spot urine protein/creatinine ratio is 

greater than 2.0 OR urine dipstick or urinalysis shows 2+ 

protein or more.
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Pediatric Nephrology

° Hypercholesterolemia (total cholesterol greater than 200 

mg/dL or low-density lipoprotein cholesterol greater than 

130 mg/dL).

° Edema presenting with tibia and eyelid swelling (usually 

first signs), weight gain, and ascites.

° Notably absent: hypertension, elevated serum creatinine 

or decreased GFR, and active urine sediment (eg, no red 

blood cell casts, etc).

• Therapy

° Treat edema if the following are present:

▶ severe hyponatremia (< 125 mEq/L), 

▶ severe pleural effusion with respiratory distress, or

▶ severe anasarca with skin breakdown or severe swelling 

in the scrotum or labial areas.

° Administer “albumin-furosemide-albumin sandwich.”

▶ Albumin 25% 1 g/kg over 4 hours. Watch for declining 

respiratory status on cardiorespiratory monitor, if 

possible.

▶ Follow with furosemide 1 mg/kg IV, then followed by 

the same dose of albumin again over 4 hours. 

▶ This treats edema by increasing oncotic pressure and 

renal perfusion and uses diuretic therapy to excrete free 

water.

° Most cases of nephrotic syndrome will respond to 

prednisone at 2 mg/kg daily, to a maximum dose of 80 mg/

day. 

° Nephrotic syndrome places the patient at risk for venous 

thromboembolic events. Encourage ambulation if possible 

and consider prophylaxis for deep vein thrombosis, 

especially if the patient is bedridden or if there is prolonged 

need for a central line. 

° Contact a nephrology specialist via the theater consult 

service if possible.

Renal Stones

• Renal stones are rare in children but austere environments 

create a risk for kidney stones due to climate and lack of 

potable water.
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Pediatric Surgery and Medicine for Hostile Environments 

• Calcium oxalate stones are the most common type found in 

children. 

• Clinical presentation is similar to adults and includes:

° gross hematuria (pink or red in color);

° inguinal or groin pain originating from the flank or 

abdomen;

° obstructing stones that often cause infection behind the 

stone, evidenced by fever and flank pain; and

° dysuria or a burning sensation if the patient passes gravel 

or stone.

• Evaluation for kidney stones consists of:

° urinalysis (look for hematuria), and 

° renal ultrasound or computed tomography scan (if 

available).

° If possible, check spot urine calcium-to-creatinine random 

level. A urine calcium-to-creatinine ratio greater than 0.2 is 

considered abnormal.

• Treatment

° Hydrate with an extra 0.5 L/day of fluid in younger children 

(< 20 kg), at least 2 L/day in older children. 

° Maintain good urine output (five voids per day).

° Consider citrate for increasing urine pH to solubilize stoneforming crystals.

° Provide analgesia as needed.

° Seek urology consultation, if available, for refractory pain 

or ureteral obstruction.
549

Dermatology

Chapter 34

Dermatology

Introduction

Most pediatric dermatological conditions are not acute and 

may be managed through telemedicine specialty consultation 

if dermatological expertise is needed. This chapter includes 

guidelines for telemedicine and focuses on situations requiring 

expeditious treatment in which potential delays in consultation 

may be deleterious to the patient.

Teledermatology Consultation

Requesting a teledermatology consultation is relatively easy for 

members of the US military. The following components should 

be submitted via e-mail to the US Army consultation service 

(derm.consult.army@mail.mil; be sure to remove the patient’s 

personal information): 

• Multiple focused photographs of all lesions on the patient.

° Photographs are best taken in well-lit settings (natural 

sunlight is optimal), without use of the camera’s flash.

° Use the camera’s “macro” setting, usually indicated by a 

picture of a flower, for close-up photographs of individual 

skin lesions.

• Basic dermatological history of a lesion or condition, including:

° onset;

° evolution;

° duration;

° location;

° symptoms, such as itch or tenderness;

° alleviating and exacerbating factors;

° current skincare regimen, including hygiene and topical 

preparations; and

° associated systemic symptoms.
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Pediatric Surgery and Medicine for Hostile Environments 

• All treatments tried to date.

• Past medical history, including:

° medications and allergies,

° previous skin disease or cancer, and

° systemic disease.

• Evidence of atopic background (eg, eczema, asthma, allergies).

• Family and social history, including:

° skin diseases in other family members,

° similar skin symptoms in close contacts, and

° pertinent environmental exposures, such as climate, pets, 

chemicals, harsh soaps, abrasive brushes, or radiation.

• Results of Gram stain, potassium hydroxide preparation, or 

Tzanck smear, which may immediately elucidate bacterial, 

fungal, or viral infections, respectively (if available). 

• Other laboratory test results that have been obtained (eg, 

complete blood count, cultures, or tissue specimens).

Begin a physical examination, checking vitals (especially fever) 

and general appearance. For a thorough skin examination, the 

patient should be fully disrobed and inspected from head to 

toe (eg, a common mistake is failing to examine the feet when a 

patient presents with hand dermatitis). To aid communication 

with the dermatologist, use the following descriptive terms: 

• Primary skin lesions

° Papule: an elevated, solid lesion up to 0.5 cm in diameter.

° Plaque: a circumscribed, elevated, superficial, solid lesion 

greater than 0.5 cm in diameter.

° Macule: a circumscribed, flat discoloration up to 0.5 cm in 

diameter.

° Patch: a circumscribed, flat discoloration greater than 0.5 

cm in diameter.

° Nodule: a circumscribed, elevated, solid lesion greater than 

0.5 cm in diameter; a larger, deeper papule.

° Pustule: a circumscribed collection of pus (cloudy, free 

fluid, and leukocytes).

° Vesicle: a circumscribed collection of free, clear fluid up to 

0.5 cm in diameter.

° Bulla: a circumscribed collection of free fluid greater than 

0.5 cm in diameter; which may be flaccid (the blister does 

not appear full) or tense (the blister appears tight and full).
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Dermatology

° Wheal (hive): a firm, edematous, transient plaque, which 

lasts hours at most.

• Secondary changes, including:

° Crust (scab): collection of dried serum and cellular debris.

° Scale: excess dead epidermal cells, thickened stratum 

corneum.

° Erosion: a partial focal loss of epidermis.

° Ulcer: a full-thickness, focal loss of epidermis and dermis 

(deeper than erosion, heals with scarring).

° Excoriation: an erosion caused by scratching, often linear.

° Atrophy: depression in the skin resulting from thinning of 

the epidermis or dermis.

° Lichenification: thickened epidermis induced by scratching 

(skin lines are accentuated).

• Special skin lesions include:

° Telangiectasia: dilated superficial blood vessels (blanchable; 

empty completely with compression).

° Petechiae: circumscribed deposit of blood less than 0.5 cm 

in diameter (not blanchable).

° Purpura: circumscribed deposit of blood greater than 0.5 

cm in diameter (not blanchable).

° Erythema: an area of uniform redness that blanches with 

pressure.

• Other important descriptors include:

° Color (eg, erythematous, violaceous, hemorrhagic, dusky, 

skin-colored, blanchable/nonblanchable, beefy red, yellow, 

etc).

° Size (eg, 4 mm, 2 cm, etc).

° Shape (eg, ill-defined oval, well-defined linear streak).

° Specific location (eg, generalized over arms and legs but 

spares the trunk, face, and palms or soles).

° A complete description also includes some comments on 

the mucous membranes (mouth, eyes, genitals, etc) and 

skin appendages (hair, nails).

• A response should be sent from a dermatologist within 24 

hours (often in as few as 6–8 h).
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Pediatric Surgery and Medicine for Hostile Environments 

Febrile Child With Rash

Many inflammatory diseases and viral exanthems may give 

this type of clinical picture. The following diagnoses include 

the majority of diseases that need to be recognized and treated 

emergently.

• Rickettsial diseases

° Rocky Mountain spotted fever, Mediterranean spotted 

fever, typhus, and others. 

° Typically present with skin eruption, fever, headache, 

malaise, and prostration.

° Transmitted by ticks, fleas, or body lice.

▶ Original tick bite may be a clinical clue and often morphs

from an inflamed papule to necrotic eschar (tache noir).

▶ The skin eruption tends to become petechial as it

progresses.

° Diagnosis is based on which diseases may be endemic, 

the clinical presentation, and indirect fluorescent antibody 

testing, which may be confirmed by Western blot.

° It is imperative, especially for the spotted fever group 

of rickettsial diseases, to treat presumptively with oral 

doxycycline, as the intravenous (IV) formulation is unlikely 

to be available in theater (2.2 mg/kg/dose bid IV or oral, 

maximum dose 100 mg bid; Figure 34-1).

• Meningococcemia

° Typically presents acutely, with fever, chills, hypotension, 

and meningitic symptoms (eg, neck stiffness, photophobia).

° Half to two-thirds of patients develop a petechial or 

ecchymotic eruption, primarily on the trunk and lower 

extremities, as well as petechiae on the eyelids and acral 

surfaces (Figure 34-2).

° The petechial eruption tends to progress to hemorrhagic 

bullae or frank necrosis.

° Diagnosis is made on clinical suspicion because treatment 

must be rapid.

▶ Blood cultures growing the gram-negative diplococci of 

Neisseria meningitidis confirm the diagnosis.

▶ Treat these patients emergently with aqueous penicillin 

G (100,000–400,000 units/kg/day divided every 4–6 h, 
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Dermatology

maximum dose of 24 million units/day) or ceftriaxone 

(100 mg/kg/day divided every 12 h IV, maximum dose 

2 g/day) for 7 days. If the diagnosis is suspected, do not 

wait for cultures to confirm.

▶ Close contacts should receive prophylactic rifampin 

(children) or ciprofloxacin (adults).

• Measles (rubeola)

° A prodrome of high fever, malaise, conjunctivitis, cough, 

and coryza (head cold symptoms) is followed by a 

maculopapular eruption (ie, generalized erythematous 

macules and papules), which begins on the head and 

progresses down the body over 2 to 3 days (Figure 34-3).

° Koplik spots (white papules on an erythematous 

background on the buccal mucosa) are pathognomonic and 

appear during the prodrome, lasting 3 days (Figure 34-4). 

Figure 34-1. Rocky Mountain spotted fever. Child’s right hand and wrist displaying the characteristic spotted rash of Rocky Mountain spotted fever. Rocky 

Mountain spotted fever is the most severe and most frequently reported rickettsial illness in the United States. The disease is caused by Rickettsia rickettsii, 

a species of bacteria that is spread to humans by ixodid (hard) ticks. 

Reproduced from Centers for Disease Control and Prevention, Public Health 

Image Library. Image 1962. http://phil.cdc.gov/phil. Accessed August 24, 2015.
554

Pediatric Surgery and Medicine for Hostile Environments 

Figure 34-2. (a) 10-month-old female with high fever and rapidly spreading 

petechial-purpuric rash and septic shock. Blood culture grew Neisseria meningitidis. She did not survive despite antibiotics and early aggressive treatment of 

her shock. (b) 14-year-old boy with acute onset of fever and rapidly developing petechial rash starting on lower extremities and buttocks and generalizing. 

Blood culture grew Neisseria meningitidis. He was treated with ceftriaxone in 

the intensive care unit for severe sepsis and survived, only requiring skin grafts 

over areas of extensive ecchymoses.

Photographs courtesy of Martin Weisse, Colonel, Assistant Director of Pediatrics, Defense Health Agency National Capital Region Medical Directorate. 

From the library of JW Bass.

a

b
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Dermatology

° See Chapter 29, Infectious Diseases, for full discussion of 

measles.

• Scarlet fever

° Caused by toxins of group A streptococcal infection.

° Primarily affects children under 10 years old and was often 

fatal before the era of antibiotics.

° Presents with sore throat (Streptococcus pharyngitis or 

tonsillitis), malaise, headache, nausea, abdominal pain, and 

high fever; an erythematous, blanchable, sandpaper-like 

rash follows within 12 to 48 hours.

° The eruption looks like “a sunburn with goose pimples,” 

and begins on the neck, groin, and axillae before spreading 

to the rest of the body (Figure 34-5).

Figure 34-3. Measles. This child with measles is showing the characteristic 

red blotchy rash on his buttocks and back during the third day of the rash. 

Measles is an acute, highly communicable viral disease with prodromal fever, 

conjunctivitis, coryza, cough, and Koplik spots on the buccal mucosa. A red 

blotchy rash appears around day 3 of the illness, first on the face, then becoming generalized.

Reproduced from Centers for Disease Control and Prevention, Public Health 

Image Library. Image 4497. http://phil.cdc.gov. Accessed August 26, 2015. 
556

Pediatric Surgery and Medicine for Hostile Environments 

° Pastia sign, petechial linear streaks within flexural creases, 

may also be seen.

° Palms, soles, and conjunctivae are typically unaffected.

° In addition to the pharyngitis, the child may have circumoral 

pallor, cervical lymphadenopathy, palatal petechiae, and 

white strawberry tongue, which later morphs into red 

strawberry tongue.

° Diagnosis is clinical, though a throat culture may be useful.

° Treatment with penicillin or amoxicillin should be initiated 

to prevent the development of rheumatic fever.

° Desquamation typically occurs 7 to 10 days after the 

eruption and should not be cause for concern.

° Complications include otitis, peritonsillar abscess, 

pneumonia, myocarditis, meningitis, and arthritis, as 

well as the immune sequelae of glomerulonephritis and 

Figure 34-4. Measles with Koplik spots. This patient presented on the third 

pre-eruptive day with “Koplik spots” indicative of the onset of measles. Koplik 

spots occur 1 to 2 days prior to eruption of the rash and last 1 to 2 days after the 

cutaneous rash erupts. They appear as punctate blue-white spots on a bright 

red background of the oral buccal (cheek) mucosa. Their presence is considered to be pathognomonic for measles. 

Photograph courtesy of Scott Norton, MD, MPH, MSc, Division Chief, Dermatology; Children’s National Health System, Washington, DC.
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Dermatology

rheumatic fever. Consider measles, toxic shock syndrome, 

drug hypersensitivity, staphylococcal scalded skin, and 

Kawasaki disease in the differential.

• Kawasaki disease (mucocutaneous lymph node syndrome)

° Kawasaki disease is typically seen in children older than 

5 years. It is diagnosed by the presence of fever for more 

than 5 days plus four of the following diagnostic criteria:

▶ Polymorphous skin eruption (ie, a rash that may take 

many shapes). An erythematous, desquamating perianal 

rash is often an early sign. As the illness progresses over 

10 to 20 days, fingers and toes may desquamate, starting 

around the nails.

▶ Stomatitis (injected pharynx, strawberry tongue, 

fissuring cheilitis).

▶ Edema of the hands and feet.

Figure 34-5. This patient revealed a scarlet fever rash on the volar surface of 

the forearm due to group A Streptococcus bacteria. The scarlet fever rash first 

appears as tiny red bumps on the chest and abdomen, then may spread all over 

the body. It looks like a sunburn, feels like a rough piece of sandpaper, and lasts 

about 2 to 5 days.

Reproduced from Centers for Disease Control and Prevention, Public Health 

Image Library. Image 5163. http://phil.cdc.gov. Accessed August 26, 2015. 
558

Pediatric Surgery and Medicine for Hostile Environments 

▶ Conjunctival injection (nonpurulent).

▶ Cervical lymphadenopathy.

° Treatment

▶ Although intravenous immunoglobulin (IVIG) is the 

treatment of choice, it is unlikely that it will be available 

in theater. When it is used, infuse 2 g/kg over 12 hours 

and monitor. 

▶ Evacuation to a higher level of care is appropriate.

▶ Aspirin is concomitant therapy and may also be 

considered in the absence of IVIG therapy. Initial 

treatment is dosing at 80 to 100 mg/kg/day divided into 

four doses. When the patient is afebrile for 48 hours, 

change to 3 to 5 mg/kg/day for 6 to 8 weeks.

• Toxic shock syndrome can be caused by either Streptococcus 

or Staphylococcus.

° Streptococcal toxic shock syndrome presents with fever, 

shock, multiorgan system failure, and usually soft-tissue 

infection, such as necrotizing fasciitis.

▶ Streptococcal toxins have direct effects on the major 

organs, leading to shock and, ultimately, a mortality 

rate of 30%.

▶ Do not wait for cultures; treat emergently with fluids 

and pressors as needed if available. 

▶ Also give clindamycin (40 mg/kg/day divided every 6–8 

h) and surgically debride any soft-tissue infection source 

if possible.

° Staphylococcal toxic shock syndrome, caused by an 

exotoxin of Staphylococcus aureus, is typically associated 

with a staphylococcal wound or catheter infections, or with 

surgical or nasal packing.

▶ Patients present with sudden onset of high fever, 

myalgias, vomiting, diarrhea, headache, and pharyngitis; 

progression to shock can be rapid and fatal.

▶ Patients typically develop a diffuse scarlatiniform 

exanthem, erythema, and edema of the palms and soles, 

strawberry tongue, hyperemia of the conjunctiva, and a 

nonpitting generalized edema.

▶ Treat with supportive care and penicillinase-resistant 

antibiotics; remove any nidus for infection, such as nasal 

packing, tampons, and catheters.
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Dermatology

▶ When considering toxic shock syndrome, also include 

Kawasaki disease, scarlet fever, staphylococcal scalded 

skin syndrome, toxic epidermal necrolysis, systemic 

lupus, rickettsial spotted fevers, and leptospirosis in the 

differential diagnosis.

▶ Desquamation of the palms and soles typically follows 

toxic shock syndrome by 1 to 3 weeks. 

• Lyme disease is mainly caused by Borrelia burgdorferi and is 

transmitted by Ixodes species ticks. 

° It occurs in the United States and Europe, and sporadic 

cases have been reported in Asia and Northern Africa.

° Early localized disease is characterized by local infection 

at the site of the tick bite, usually manifested as the “bull’s 

eye” rash of erythema migrans (Figure 34-6), about 10 days 

after the bite. Only 80% of patients develop the rash, and 

it is less common in European cases.

° Fever, malaise, body aches, and flu-like symptoms may 

occur. 

° See Chapter 29, Infectious Diseases, for more information on 

the various presentations, diagnostic criteria, and treatment 

of Lyme disease.

° Treatment for most people with early localized infection is 

oral administration of doxycycline, which is contraindicated 

in children younger than 8 years old. Alternatives include 

amoxicillin, cefuroxime axetil, and azithromycin.

Bullae, Erosions, and Desquamation in Neonates and Young 

Children

The differential diagnosis for bullae in the neonate is vast and 

may include a variety of incurable genetic disorders that must be 

managed with intensive supportive care. For this reason, in the 

deployed setting, it is best to determine if the bullae are related 

to something acute or treatable, such as bullous staphylococcal 

impetigo or acute burn injury.

• Bullous staphylococcal impetigo

° Bullous staphylococcal impetigo can be life-threatening in 

neonates and often occurs between the fourth and tenth 

days of life.
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Pediatric Surgery and Medicine for Hostile Environments 

Figure 34-6. Lyme disease (erythema migrans). This depicts the pathognomonic erythematous rash in the pattern of a “bull’s-eye,” which manifested at 

the site of a tick bite on this Maryland patient’s posterior right upper arm. A 

key component of early diagnosis is recognition of the characteristic Lyme disease rash, erythema migrans. This rash often manifests itself in a “bull’s-eye” 

appearance, and is observed in about 80% of Lyme disease patients. 

Reproduced from Centers for Disease Control and Prevention, Public Health 

Image Library/James Gathany. Image 9875. http://phil.cdc.gov. Accessed August 26, 2015. 
561

Dermatology

Figure 34-7. Staph scalded skin syndrome. This toddler presented with a 

1-day history of fever, painful skin, and spreading red rash over her entire 

body. There was no specific focus of infection. Note the denuded blisters and 

peeling skin over the entire back. Nasal culture grew Staphylococcus aureus

(methicillin-sensitive S aureus). She rapidly improved with nafcillin therapy. 

Photograph courtesy of Scott Norton, MD, MPH, MSc, Division Chief, Dermatology; Children’s National Health System, Washington, DC.
562

Pediatric Surgery and Medicine for Hostile Environments 

° Bullae may appear on any part of the body, often starting 

on the face or hands. Intertriginous areas are commonly 

involved.

° Weakness, fever, and diarrhea may follow; sepsis may occur 

without antistaphylococcal antibiotics.

• Staphylococcal scalded skin syndrome (Figure 34-7)

° Staphylococcal scalded skin syndrome preferentially affects 

neonates and young children.

° It begins with abrupt fever, skin tenderness, and erythema 

involving the neck, groin, and axillae.

° Over the next few hours to days, erythema progresses 

to cover more surface area, before ultimately evolving 

into a very superficial, generalized desquamation (more 

superficial and less severe than in toxic epidermal 

necrolysis).

▶ Large sheets of epidermis separate.

▶ Nikolsky sign is positive (the upper layer of the skin 

detaches with application of lateral fingertip pressure 

to intact skin adjacent to a lesion).

▶ The affected skin extends far beyond areas of actual 

infection (usually the pharynx, nose, ear, conjunctiva, 

skin, or septicemia).

° Cultures are best taken from the mucous membranes, 

although they may be negative.

° Rapid diagnosis can be made by examining frozen sections 

of a skin biopsy from a blister, though in theater the 

diagnosis is clinical.

° Treatment includes IV fluids and cefazolin (50–100 mg/kg/ 

day IV divided every 8 h, maximum dose 6 g/day; adjust 

for methicillin-resistant S aureus as necessary, according to 

cultures).

• Neonatal herpes simplex virus (HSV) can also be lifethreatening.

° Neonatal HSV presents with vesicles in the newborn (Figure 

34-8).

° The majority of transmission occurs during delivery, and 

almost all patients present at 4 to 21 days of life.

° It may be localized to the skin and/or eye, involve the central 

nervous system, or be disseminated (encephalitis, hepatitis, 

pneumonia, coagulopathy).
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Dermatology

Figure 34-8. Note the grouped vesicles on one hand. A Tzanck smear was 

positive and a viral culture confirmed the diagnosis of herpes simplex virus 

infection. 

Photograph courtesy of Brian P Green, Major, Medical Corps, US Army; Walter Reed National Military Medical Center, Bethesda, MD.
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Pediatric Surgery and Medicine for Hostile Environments 

▶ Encephalitis or disseminated HSV can be fatal in up to 

half of affected neonates.

▶ More than half of survivors sustain neurological 

disability.

° Classic HSV presentation involves painful clusters of 

vesicles on an erythematous base; however, in over a third 

of cases, vesicles may not be seen.

▶ Clusters of erosions tend to remain where vesicles were 

located. When these clusters coalesce, they leave behind 

an erosion or shallow ulcer with scalloped borders.

° Confirmation with a Tzanck smear or more specific 

immunofluorescence testing is ideal, but it is often 

unavailable in theater.

° If neonatal HSV is suspected, begin IV acyclovir (60 mg/kg/

day IV divided every 8 h for 21 days) immediately; ensure 

adequate hydration to avoid renal injury.

• Bullous drug reactions can vary dramatically in severity 

and many dermatologists consider drug-induced erythema 

multiforme, drug-induced Stevens-Johnson syndrome (SJS), 

and toxic epidermal necrolysis (TEN) to represent variations 

of the same disease process but on a spectrum of severity 

(Figures 34-9 and 34-10).

° The definitions of SJS and TEN are somewhat arbitrary and 

overlap exists; usually SJS affects less than 10% body surface 

area and TEN affects greater than 30% body surface area.

° The more widespread and severe the epidermolysis, the 

worse the prognosis and the more likely the process is 

drug-induced.

° The separation of skin layers in TEN is deeper than that in 

staphylococcal scalded skin syndrome (see above), with 

resultant denudation comparable to widespread burns. 

Accordingly, patients with TEN require supportive care 

in an intensive care unit or burn center.

° Patients with SJS have a better prognosis than those with 

TEN, but whether the mucocutaneous denudation is due 

to TEN or SJS, offending drugs should be discontinued 

immediately and the patient should be transferred to an 

intensive care unit for careful fluid management, wound 

care, nutritional support, and sepsis precautions.
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Dermatology

Figure 34-9. This image depicts the right arm of a 6-month-old boy who, after 

having received a primary smallpox vaccination, developed toxic epidermal 

necrolysis. Many people develop skin rashes after vaccination, almost all of 

which are benign. Rarely, a more serious eruption, like toxic epidermal necrolysis or its milder counterpart, Stevens-Johnson syndrome, may occur, requiring more aggressive therapy that may include steroids. If possible, a dermatology consultation should be obtained before initiating steroid therapy.

Reproduced from Centers for Disease Control and Prevention, Public Health 

Image Library/Arthur E Kaye. Image 3284. http://phil.cdc.gov/phil. Accessed 

August 26, 2015.
566

Pediatric Surgery and Medicine for Hostile Environments 

Figure 34-10. (a) Erythema multiforme major, also referred to as StevensJohnson syndrome, is a toxic or allergic rash in response to some vaccines or 

medications (it can also be idiopathic). It can take various forms, be mildly 

pruritic, and range from moderate to severe. When the lesions fade, a faint 

purple-pink hue can remain, helping differentiate it from urticaria (hives), 

which will leave no trace. 

Reproduced from Centers for Disease Control and Prevention, Public Health 

Image Library/Allen W Mathies, MD, John Leedom, MD/California Emergency Preparedness Office, Immunization Branch. Image 4653 (a) and 4650 

(b). http://phil.cdc.gov/phil. Accessed August 26, 2015.

a
567

Dermatology

▶ Early ophthalmologic intervention is needed to avoid 

ocular scarring and blindness.

▶ The use of systemic corticosteroids and IVIG for either 

disease is controversial. The best treatment in theater is 

evacuation to a higher level of care.

° Erythema multiforme (minor) typically occurs in the spring 

or fall, and is often associated with HSV or, less commonly, 

Mycoplasma pneumoniae.

▶ The lesions can have many different morphologies 

(hence “multiforme”), but are often targetoid in nature 

and can be acral in location (Figure 34-10a).

▶ Most cases are self-limited and do not require treatment.

▶ Daily suppressive anti-HSV therapy may be considered 

if the erythema multiforme recurs frequently (eg, 

acyclovir).

° Severe contact dermatitis can also present with widespread 

erythema and bullae.

▶ Even when severe and widespread, contact dermatitis 

typically displays a patterned distribution.

▶ It is very pruritic.

b

(b) Same patient. Note mucosal involvement. 
568

Pediatric Surgery and Medicine for Hostile Environments 

▶ In severe cases, patients may require a 3- to 4-week taper 

of oral corticosteroids.

▶ Encourage good skin hygiene (at least twice daily gentle 

cleansing, if possible, followed by bland emollient, such 

as petrolatum).

° Antistaphylococcal antibiotics may also be necessary in 

cases of secondary infection (suggested by tenderness, 

expanding honey-colored crusts, and a positive bacterial 

culture).

• Atopic dermatitis (eczema)

° Eczema is a common inflammatory skin disease in 

childhood characterized by intense pruritus and cutaneous 

inflammation.

° In addition to affecting quality of life, atopic dermatitis 

can lead to disruption of the skin barrier and increase 

susceptibility to infection.

° It can be associated with asthma and seasonal allergies (the 

atopic triad).

° Exacerbating factors may include irritants (soap, overwashing, drying chemicals) and allergens (skin contact is far 

more detrimental than contact with foods or aeroallergens).

▶ Presentation in infants and toddlers: erythematous 

papules and plaques often with overlying excoriation, 

crusting, and serous exudates; distribution is usually 

over the scalp, forehead, cheeks, trunk, and extensor 

surfaces of the extremities.

▶ Presentation in children and adults: dry, intensely 

pruritic papules and patches on flexor surfaces of the 

arms, neck, and legs. The dorsum of the hands and feet 

are often involved.

° Secondary changes are often seen, such as lichenification 

and postinflammatory hypopigmentation and 

hyperpigmentation. 

° The differential diagnosis includes seborrheic dermatitis, 

psoriasis, pityriasis rosea, candidiasis, and keratosis pilaris.

° Treatment:

▶ Avoid known allergens and irritants.

▶ Soak and smear: hydrate the skin by soaking in 

lukewarm water for 20 minutes; follow immediately 
569

Dermatology

(while the skin is still damp) by sealing in the moisture 

with emollient (ointment, cream, or thick lotion). 

Moisturize frequently with less greasy lotions between 

soak-and-smear treatments.

▶ Use only mild soaps when necessary.

▶ Apply topical corticosteroids to localized plaques; taper 

off the steroids as the plaques clear.

▶ Avoid topical steroids on the face and on open wounds.

▶ Use oral corticosteroids only in very severe cases (there is 

the potential for a rebound effect upon discontinuation).

▶ Use topical or oral antibiotics directed against S aureus

for superinfection.

• Smallpox (variola major) has theoretically been eradicated 

since 1977, but is mentioned here due to its potential as 

a bioterrorism threat (smallpox was fatal in up to 40% of 

untreated patients).

° Smallpox is characterized by fever, severe headache and 

backache, and enanthem followed by exanthem.

° Lesions progress simultaneously from erythematous 

macules to papules to vesicles, and finally pustules, which 

crust and collapse.

▶ This progression takes approximately 2 weeks.

▶ The lesions first appear on the palms and soles, then 

spread to the face and extremities (Figure 34-11).

° By contrast, varicella (chickenpox) presents with lesions 

in varying stages of development (macules, papules, 

vesicles, crusts) and tends to involve the trunk and face 

preferentially.

▶ Varicella lesions evolve from vesicle to crust within 24 

hours.

▶ Varicella can be identified at the bedside with a Tzanck 

smear, but a smear for direct fluorescent antibody 

staining and a viral culture confirm the diagnosis.

° Smallpox can be definitively diagnosed by viral culture, 

polymerase chain reaction, or electron microscopy; 

however, based on clinical suspicion, patients thought to 

have smallpox should be isolated, receive supportive care, 

and be attended only by properly vaccinated healthcare 

workers.
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Pediatric Surgery and Medicine for Hostile Environments 

Figure 34-11. Smallpox. Depicted in this 1974 photograph is a Bengali boy 

who was an inhabitant of a Bangladesh village. As evidence from this image, 

he had sustained the ravages of smallpox, with the classic maculopapular rash 

evident on his torso and arm.

Reproduced from Centers for Disease Control and Prevention, Public Health 

Image Library/Jean Roy. Image 10661. http://phil.cdc.gov. Accessed August 26, 

2015. 
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Dermatology

° Smallpox is spread by the respiratory route and patients 

are infectious from the onset of enanthem until about 10 

days after the eruption begins (lesions are crusted).

° Patients with varicella should also receive supportive care; 

20 mg/kg tid acyclovir over 5 days may speed recovery if 

initiated within 24 hours of the appearance of the eruption.

▶ Acyclovir should always be given to children over 

13 years old and to any child with a history of atopic 

dermatitis.

▶ Aspirin should never be given to varicella patients 

because of the risk of Reye’s syndrome (fulminant 

hepatitis and encephalopathy).

• Purpura in children

° Henoch-Schönlein purpura (anaphylactoid purpura or 

allergic vasculitis; Figure 34-12) is the most common 

leukocytoclastic vasculitis in children ages 4 to 8 years old 

(predominantly males).

▶ The trigger is often viral infection or streptococcal 

pharyngitis, as well as food, drugs, and lymphoma.

▶ The rash is characterized by palpable purpura on the 

arms, legs, and buttocks.

▶ Patients can also have mild fever, abdominal colic, 

bloody stools, and arthralgias.

▶ Renal involvement with microscopic or gross hematuria 

is seen in half of patients, and a small percentage of 

patients go on to develop renal failure.

▶ Fatal pulmonary hemorrhage complicates rare cases.

▶ Diagnosis is clinical.

▶ Purpura typically lasts 6 to 16 weeks.

▶ Treatment is supportive, though oral corticosteroids can 

be given for abdominal pain.

▷ IVIG can be used in extreme cases.

▷ Nonsteroidal antiinflammatory drugs should be 

avoided (they may exacerbate renal or gastrointestinal 

problems).

° Purpura fulminans is a rapid, dramatic, and often fatal 

reaction seen in children (Figure 34-13).

▶ It may be categorized as neonatal, idiopathic, or acute 

infectious (eg, N meningitides, Staphylococcus, and 

Streptococcus).
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Pediatric Surgery and Medicine for Hostile Environments 

▶ The appearance of widespread ecchymoses on the 

extremities, followed by frank acral necrosis, is 

characteristic.

▶ Disseminated intravascular coagulation (DIC) typically 

follows an infectious process, such as scarlet fever, 

meningitis, pneumonia, or superinfected varicella.

▶ Treatment is supportive and best managed in the intensive 

care unit.

▶ Many patients die from this complication and others require 

amputations.

Figure 34-12. Henoch-Schönlein purpura. This previously healthy boy developed palpable purpuric lesions on his extremities, face, and buttocks 2 weeks 

after an upper respiratory infection. He subsequently experienced swelling of 

his ankles and wrists, colicky abdominal pain, and hematuria. His skin eruption and associated symptoms recurred for 3 weeks before resolving without 

complications.

Photograph courtesy of Scott Norton, MD, MPH, MSc, Division Chief, Dermatology; Children’s National Health System, Washington, DC.
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Dermatology

• Necrosis in children

° Necrotizing fasciitis, or “flesh-eating bacteria,” is most 

commonly caused by b-hemolytic streptococci, though 

other organisms, both aerobic and anaerobic, can be 

causative.

° Bacteria typically enter through a surgical or puncture 

wound, but necrotizing fasciitis may also occur de novo.

° Within 24 to 48 hours, as the bacteria spread along fascial 

planes and destroy tissue, the involved skin progresses 

from red, painful edema to dusky blue, anesthetic skin, 

with or without serosanguineous blisters.

° An early clue of necrosis is tenderness outside the area of 

cellulitis.

° By the fourth or fifth day, the purple areas become 

gangrenous.

° Patients present in severe pain and are often hypotensive 

with leukocytosis.

Figure 34-13. Purpura fulminans due to a fatal case of meningococcemia in 

6-month-old child. 

Photograph courtesy of Martin Weisse, Colonel, Medical Corps, US Army, Assistant Director of Pediatrics, Defense Health Agency National Capital Region 

Medical Directorate. From the library of JW Bass.
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Pediatric Surgery and Medicine for Hostile Environments 

° Mortality is around 20%.

° Prompt surgical intervention is necessary to conserve tissue 

and preserve the life of the patient.

° Neonatal necrotizing fasciitis most commonly affects the 

abdominal wall and incurs a higher mortality rate than 

fasciitis in adults.

• DIC

° DIC presents with widespread intravascular coagulation 

and, in two-thirds of patients, skin eruption of petechiae 

and ecchymoses, with or without hemorrhagic bullae.

° Purpura fulminans may supervene.

° DIC can be due to a number of disorders, including sepsis, 

arthropod venom, obstetric complications, and acidosis.

° Supportive care and replacement of appropriate coagulation 

factors (including vitamin K) and treatment with IV heparin 

are necessary for patients with DIC.

• Anthrax

° Anthrax may pose a bioterrorism threat, but it typically 

occurs from the handling of animal hides or from contact 

with infected animals (alive or dead).

° Patients present with a rapidly necrosing, painless eschar 

with suppurative regional adenitis (Figure 34-14).

° Anthrax may be cutaneous (most common), inhalational, 

or gastrointestinal.

° Cutaneous anthrax begins as an inflamed papule at the 

inoculation site.

▶ The papule progresses to a bulla with surrounding

edema.

▶ The bulla ruptures to leave behind a dark brown or black 

eschar, surrounded by vesicles over a red, hot, swollen 

base.

° Although regional lymph nodes may be tender, the anthrax 

lesion itself is painless.

° In about 20% of untreated cases, patients may develop high 

fever, collapse, and eventually die over days to weeks.

° Diagnosis is made by identifying the gram-positive bacillus 

in smears or culture. 

° Treat early with ciprofloxacin or doxycycline for 60 days.

▶ If the child is less than 2 years old, treat intravenously, 

if possible.
575

Dermatology

▶ Asymptomatic exposed individuals should be given 6 

weeks of prophylactic doxycycline or ciprofloxacin.

Further Reading

1. VisualDx. LearnDerm webpage. Rochester, NY: VisualDX. 

www.learnderm.org. Accessed February 13, 2015. Tutorial takes 

approximately 11/2 hours and encompasses the essentials of the skin 

examination, including describing morphology and recognizing 

patterns of distribution and configuration.

2. VisualDx website. Rochester, NY: VisualDX. www.visualdx.com. 

Accessed February 13, 2015. From any US military computer, click 

on the login tab (US military has purchased access). Comprehensive 

source of skin lesion photos. May enter diagnosis or key words to 

search to get a visual differential.

Figure 34-14. Anthrax. Anthrax lesion on the skin of the forearm caused by 

the bacterium Bacillus anthracis. Here the disease has manifested itself as a 

cutaneous ulceration, which has begun to turn black, hence the origin of the 

name “anthrax,” after the Greek name for coal.

Reproduced from Centers for Disease Control and Prevention, Public Health 

Image Library/James H Steele. Image 2033. http://phil.cdc.gov. Accessed 

August 26, 2015. 
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Pediatric Surgery and Medicine for Hostile Environments 
577

Malnutrition and Emergency Nutrition for Sick or Injured Infants and Children

Chapter 35

Malnutrition and Emergency 

Nutrition for Sick or Injured Infants 

and Children

Introduction

Clinicians in austere environments must be prepared to 

nutritionally support critically ill or injured children, seriously 

ill children with underlying malnutrition (who have a higher 

associated morbidity and mortality than those who are 

appropriately nourished), and occasionally larger populations 

of children with chronic protein-energy malnutrition. This latter 

group may be numerous in a complex humanitarian emergency. 

In these situations, US military providers are most likely to play 

a support role, while nongovernmental and other relief agencies 

take the lead. Understanding key features and management 

principles for these situations is crucial to maximizing patient 

outcomes.

Assessment Methods for Height, Weight, and Nutrition Status

• Estimating height and weight:

° In the absence of severe malnutrition, the Broselow 

Pediatric Emergency Tape (see back inside cover of this 

book) has been shown to provide an accurate and rapid 

estimation of ideal child weight in emergencies. 

° Detailed nutritional assessments and trending of clinical 

progress should use either weight for height percentiles or 

weight for height z score.

° Age- and length-based norms for weight are published by 

the World Health Organization (WHO). A rapid synopsis 

for use in emergencies is presented in Table 35-1. 
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Pediatric Surgery and Medicine for Hostile Environments 

° Mid-upper arm circumference (MUAC) is a screening tool 

used to measure acute malnutrition in children ages 6 to 

60 months, without edema, using the circumference of the 

child’s mid-upper arm (Table 35-2).

Table 35-1. Average Weights and Heights for Age and Gender*

Males Females

Length/Height Weight Length/Height Weight

Age (cm) (kg) (cm) (kg)

2–6 months 62 6 62 6

7–12 months 72 9 71 8

1–3 years 87 12 86 12

4–8 years 116 20 115 20

9–13 years 143 36 145 37

14–18 years 173 61 163 54

19–30 years 177 70 163 57

*World Health Organization norms.

Table 35-2. Mid-Upper Arm Circumference Screening for 

Malnutrition

MUAC Measurement Degree of Malnutrition

< 115 mm Severe acute malnutrition

≥ 115 and < 125 mm Moderate acute malnutrition

≥ 125 mm Not acutely malnourished 

MUAC: mid-upper arm circumference

Calorie and Protein Needs

• Overall nutritional goals for sick or injured infants and 

children are to provide sufficient calories and protein to spare 

mobilization of body reserves (prevent catabolism), promote 

wound healing, and protect from infection.

• Calorie needs are generally lower in the initial phase of trauma 

or critical illness because of: 

° lack of activity, 

° decreased metabolic rate, and 
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Malnutrition and Emergency Nutrition for Sick or Injured Infants and Children

° the body becoming catabolic, which inhibits use of calories 

for growth.

• Calorie needs will increase as the infant or child becomes more 

stable. Exogenous calories and protein can be used to promote 

anabolism. 

• The metabolic stress of serious illness and injury results in 

increased protein breakdown, which can cause a negative 

protein balance if at least 1.5 gm/kg of dietary protein is not 

provided. 

• Protein needs are even higher in sick infants and children 

with open wounds, burns, or losses (eg, diarrhea or ostomy 

output).

• Calorie and protein needs are best calculated using the child’s 

actual weight. 

• It is important to avoid underfeeding, which can compromise 

healing, as well as overfeeding.

° Overfeeding can cause metabolic and respiratory 

stress, leading to hyperglycemia, diarrhea, tachypnea, 

hypercarbia, and failure to wean off mechanical ventilation.

° Calculations for estimating energy needs are not exact. 

Overfeeding should be considered whenever a patient on 

nutritional support exhibits any of the above signs and 

symptoms.

• A patient’s total energy expenditure can be calculated using 

the following equation and Tables 35-3 and 35-4 as a reference:

total energy expenditure = resting energy expenditure × 

activity factor × stress factor 

° For example: A 4-year-old male (15.9 kg), sedated and 

intubated with a closed head injury.

resting energy expenditure = (22.7 × 15.9) + 495 = 856 kcal/day

total energy expenditure = 856 × 1.0(activity factor) × 1.3(stress 

factor) = 1,113 kcal/day

Malnutrition

According to United Nations Children’s Fund WHO-World 

Bank joint child malnutrition estimates (see Further Reading at 

the end of this chapter), 26% of all children under 5 years of age 
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Pediatric Surgery and Medicine for Hostile Environments 

are stunted, 16% are underweight, and 8% demonstrate wasting 

(90% are from Africa or Asia). “Protein-energy malnutrition” is 

an overarching term used to describe a deficiency of multiple 

nutrients.

Table 35-3. World Health Organization Equations for 

Estimating Resting Energy Expenditures*

Resting Energy Expenditure (kcal/day)

Age (years) Males Females

0–3 (60.9 × weight in kg) – 54 (61.0 × weight in kg) – 51

3–10 (22.7 × weight in kg) + 495 (22.5 × weight in kg) + 499

10–18 (17.5 × weight in kg) + 651 (12.2 × weight in kg) + 746

*Use in combination with an activity and stress factor to determine total 

energy expenditure.

Data source: World Health Organization. Energy and Protein Requirements: 

Report of a Joint FAO/WHO/UNU Consultation. Geneva, Switzerland: WHO; 

1985. Technical Report 724.

Table 35-4. Effects of Activity and Stress Factors on Energy 

Requirements for Children

Type of Activity Factor Multiply REE By

Nonambulatory (intubated, sedated) 1.0

Bed rest 1.1

Ambulatory 1.2–1.3

Type of Stress Factor Multiply REE By

Starvation 0.7–0.9

Surgery 1.1–1.5

Sepsis 1.2–1.6

Closed head injury 1.3

Trauma 1.1–1.8

Growth failure 1.5–2.0

Burn 1.5–2.5

Cardiac failure 1.2–1.3

REE: resting energy expenditure
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Malnutrition and Emergency Nutrition for Sick or Injured Infants and Children

• Severe acute malnutrition (SAM) can present as follows:

° Marasmus: severe deprivation of calories and protein 

characterized by severe wasting. 

° Kwashiorkor: the result of inadequate protein intake; 

characterized by bilateral dependent edema, flaking skin 

lesions, changes in hair color, abdominal bloating, and 

hepatomegaly. 

° Marasmic–kwashiorkor: a mixed form resulting in both 

wasting and bilateral pitting edema. 

• Managing SAM 

° Therapeutic feeding programs are intensively managed 

dietary regimens with medical intervention (see references 

in the Further Reading section for detailed guidance) used 

to treat malnourished populations.

° Military care providers practicing in remote or austere 

conditions are very likely to encounter individual patients 

with SAM. 

° The approach to these patients is distinct from nutritional 

support for critically ill or injured children.

° Indications for therapeutic feeding programs:

▶ MUAC less than 115 mm (for those ages 6–60 months; 

cutoffs for older age groups have not been established).

▶ Weight for height z score less than 3 standard deviations 

below median (see WHO Child Growth Standards 

and the Identification of Severe Acute Malnutrition in 

Infants and Children in Further Reading at the end of 

this chapter).

▶ Bilateral edema (kwashiorkor), regardless of weight, 

height, and MUAC measurement.

° Individuals with SAM who have an appetite and no medical 

conditions requiring inpatient monitoring can be managed 

in an outpatient setting.

° Ready-to-use therapeutic foods such as Plumpy’Nut

(Nutriset, Normandy, France), MANA (Mana Nutrition, 

Matthews, NC), and BP-100 (GC Rieber, Bergen, Norway) 

are most commonly used and administered based on 

weight.
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Pediatric Surgery and Medicine for Hostile Environments 

° Children who fail to respond to ready-to-use therapeutic 

foods or who develop medical complications should be 

referred for inpatient care. 

° Humanitarian Daily Rations may also be provided in this 

setting, but are not a substitute for mass ration distribution 

and other relief actions. Each humanitarian daily ration 

offers complete daily nutrition with wide acceptance for 

diverse religious and dietary restrictions (National Stock 

Number: 8970013750516, The Wornick Company, McAllen, 

Texas). Detailed nutritional and logistic information about 

Humanitarian Daily Rations, as well as procurement 

information, is available through the Defense Logistics 

Agency (https://www.troopsupport.dla.mil/subs/rations/

programs/hdr/hdrabt.asp).

• Refeeding syndrome

° Severely malnourished patients experience loss of lean 

muscle mass, water, and minerals, with total-body 

depletion of phosphorus (although serum levels may 

remain normal).

° Refeeding syndrome occurs when a malnourished patient 

is rapidly re-fed.

° Carbohydrates trigger the release of insulin.

° Intracellular glucose and phosphorous uptake and protein 

synthesis are enhanced.

° Phosphorus-dependent metabolic functions decline, 

resulting in cardiac and neuromuscular dysfunction and 

acute ventilatory failure. 

° Potassium and magnesium stores may also become 

depleted, leading to further clinical complications. 

° Treatment

▶ Refeeding syndrome can further be avoided when 

providing total parental nutrition (TPN) or tube feeding 

by starting delivery below the goal caloric intake and 

slowly increasing over several days while maintaining 

an appropriate ratio of calorie delivery from protein, 

carbohydrates, and fats.

▶ During the initial phases of refeeding (first 3 days), 

electrolytes, including phosphorus, should be monitored 

frequently, ideally every 12 hours (if resources are 

available), and replaced as indicated. 
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Malnutrition and Emergency Nutrition for Sick or Injured Infants and Children

▶ Consider empiric phosphorus supplementation.

▶ Anticipate constipation given reduced peristalsis.

° If laboratory data is not available, observe the patient 

closely for physical signs of metabolic disturbances to guide 

therapy.

▶ Hyperglycemia: polyuria, polydipsia, weakness, fatigue, 

and blurred vision.

▶ Hypoglycemia: decreased consciousness, sweating, 

anxiety, shakiness, palpitations, weakness, hunger, 

faintness, headaches, tremor, and tachycardia.

▶ Hypophosphatemia: weakness, respiratory failure, 

cardiac myopathy, seizures, and delirium.

▶ Hypokalemia: cardiac arrhythmia, muscle weakness, 

nocturia, elevated blood pressure or hypotension, atonia, 

paraesthesia, and hyporeflexia.

▶ Hypomagnesemia: seizure, muscle cramps, tetany, 

tremor, weakness, vertigo, dysphagia, and confusion.

Breast-Feeding

• Breast milk (orally or enterally) is always preferable to 

commercial formulas.

• Use of formula may undermine breast milk production and 

suggest to mothers that breast milk is inferior. 

• Powdered formulas are frequently reconstituted with 

contaminated water. 

• Breast milk should be given exclusively for the first 6 months 

of life and can routinely be given to children up to age 2 years 

or beyond.

• Managing SAM in children under 6 months of age should 

focus on establishing or reestablishing exclusive breastfeeding by the mother or other caregiver. 

• If clean equipment is available to obtain pumped breast milk, 

additional calories and protein can be added to expressed milk 

if the volume is inadequate or the child’s medical condition 

requires fluid restriction. 

° One scoop (8–9 g) of infant formula powder (20 cal/oz) 

added to 8 ounces of pumped breast milk (20 cal/oz) yields 

24 calories per ounce. 
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Pediatric Surgery and Medicine for Hostile Environments 

° Carbohydrates from a clean source, such as granulated 

sugar (16 cal/tsp), can also be added to breast milk to 

increase caloric density. For example, 2 teaspoons of sugar 

added to 8 ounces of breast milk yields 24 cal/oz.

Tube Feeding

• When available, age-appropriate tube feedings should try to 

meet the goals outlined in Table 35-5. 

• Standard adult formulas are acceptable in children over 1 year 

old and can be used if they are the only type available. 

° Protein content will be 1.5- to 2-fold that of pediatric 

products. 

° Intake above 4 grams of protein per kilogram per day 

should be avoided so as not to overwhelm renal urea 

excretion. 

° The higher osmolarity of adult formulas may also impact 

feeding tolerance and can be associated with increased 

stooling.

° When using higher protein concentrations, ensuring 

adequate fluid intake is essential. 

• High-protein formula may still not meet total caloric 

requirements. If additional calories are needed, they can be 

given using vegetable oil (100 kcal per 15 mL) and sugar (48 

calories per 15 mL) or intravenous (IV) dextrose.

• The overall goal rate for enteral feedings will depend on the 

patient’s caloric and fluid needs (Table 35-6). If the patient is 

on IV fluids, the volume should be adjusted accordingly.

Total Parenteral Nutrition

• Compared to pediatric formulations, premixed adult TPN 

solutions are higher in protein and some electrolytes, such as 

potassium (Table 35-7). 

• When using premixed adult TPN, calculate the maximum 

volume of solution to avoid excessive volume intake, then adjust 

with additional dextrose 50% to meet estimated calorie needs. 

• If no central access is available, give as partial parenteral 

nutrition; however, the osmolarity should be less than 900 

osmoles per liter, and dextrose concentration should be no 

higher than 12.5%.
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Malnutrition and Emergency Nutrition for Sick or Injured Infants and Children

Table 35-5. Nutritional Needs (Enteral and Oral) in Infants 

and Children

 Distribution of kcals

Age Calories Protein

(yr) (per kg) (g/kg) Fat Protein Carbohydrate

0–1 80–120 2.5–3.5 35%–45% 8%–15% 45%–65%

1–10 60–90 2.0–2.5 30%–35% 10%–25% 45%–65%

11–18 30–75 1.5–2.0 25%–30% 12%–25% 45%–65%

Table 35-6. Guidelines for Initiating and Advancing 

Continuous Enteral Feeding

Age (yr) Initial Infusion Incremental Advances

0–1 1–2 mL/kg/h 10–20 mL/kg/day

1–6 1 mL/kg/h 10 mL/kg every 2–8 h

> 7 10–25 mL/h 20–25 mL every 2–8 h

*Hourly infusion increases incrementally until goal calories are achieved.

Table 35-7. Parenteral Electrolyte Needs

Infants and

Toddlers Children Adolescents

Sodium 2–4 mEq/kg 2–4 mEq/kg 60–150 mEq

Potassium 2–4 mEq/kg 2–4 mEq/kg 70–180 mEq

Chloride 2–4 mEq/kg 2–4 mEq/kg 60–150 mEq

Magnesium 0.25–1 mEq/kg 0.25–1 mEq/kg 8–32 mEq

(125 mg/mEq)

Calcium 0.45–4 mEq/kg 0.45–3.15 mEq/kg 10–40 mEq

(20 mg/mEq)

Phosphorus 0.5–2 mmol/kg 0.5–2 mmol/kg 9–30 mmol/kg

(31 mg/mmol)
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Pediatric Surgery and Medicine for Hostile Environments 

• Maintain a balanced distribution of calories from protein, 

carbohydrate, and fat (see Table 35-4, use the lower range of 

recommended protein) to maintain nutrient efficiency and to 

minimize hepatic damage from TPN.

Specific Nutrient Needs in Certain Conditions

• Burns, open wounds, gunshot wounds, and fragment injuries 

will require higher calorie intake, higher protein intake, 

and supplementation with vitamin C and zinc, if available 

(otherwise use a standard multivitamin-mineral supplement).

• Ventilated, sedated, or paralyzed patients need lower calorie 

intake; however, they have standard protein needs (see Table 

35-5). 

• For sepsis, give midrange calories and protein.

• If the patient is febrile, give increased calories and protein.

• Intake needs for patients with amputation should be based 

on actual weight measurements, when available. Otherwise, 

estimate needs based on adjusted ideal body weight.

Micronutrients

The following micronutrients significantly impact morbidity and 

mortality in food-insecure populations worldwide. Specific and 

proven interventions are feasible for US military medical systems 

to implement on small scales and support on a larger scale.

Vitamin A

• Signs and symptoms of vitamin A deficiency include 

xerophthalmia, night blindness, corneal and conjunctival 

xerosis, Bitot’s spots (greyish foamy patches on the 

conjunctiva), corneal ulcers, and keratomalacia. 

• Treatment and prevention 

° Early recognition and treatment can prevent irreversible 

loss of sight and other ophthalmologic complications and 

reduce measles-related mortality. All children diagnosed 

with measles should receive vitamin A supplementation 

at the time of diagnosis, 24 hours later, and again in 4 to 6 

weeks. 
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Malnutrition and Emergency Nutrition for Sick or Injured Infants and Children

° In nutritionally at-risk populations, empiric, oral, twice 

yearly vitamin A supplementation is recommended 

(Table 35-8; see Periodic, Large Oral Doses of Vitamin A for 

the Prevention of Vitamin A Deficiency and Xerophthalmia: A 

Summary of Experiences, in Further Reading at the end of 

this chapter). This is an especially important adjunct for 

controlling or preventing outbreaks of measles.

Table 35-8. Vitamin A Dosing for Deficiency Prevention 

Age Vitamin A Dose Frequency

< 6 months 50,000 IU Single dose

6–12 months (or under 8 kg) 100,000 IU Every 4–6 months

1–5 years (or over 8 kg) 200,000 IU Every 4–6 months

Iron 

• Signs and symptoms of deficiency include fatigue, weight loss, 

thin or spoon-shaped nails, and pallor of skin, conjunctiva, 

nail beds, and palms. 

• Complete blood count, if available, frequently shows a 

microcytic anemia.

• Treatment and prevention consists of the following:

° Improve access to iron-rich or fortified foods based on local 

availability. 

° The WHO recommends periodic, empiric, mass drug 

administration targeting soil-transmitted helminth 

infections (albendazole, typically every 6 months) and 

schistosomiasis (praziquantel) to improve nutritional 

status, prevent anemia, and reduce overall morbidity 

(see Prevention and control of schistosomiasis and soiltransmitted helminthiasis, in Further Reading at the end of 

this chapter). Sleeping under insecticide-treated nets may 

also reduce anemia due to malaria.

° Provide iron supplements. Education and follow-up care are 

key to increasing compliance and preventing toxicity from 

accidental overdose; however, these are difficult to provide 
588

Pediatric Surgery and Medicine for Hostile Environments 

in a deployed setting and are compounded by language 

barriers. Avoid providing iron supplements during the 

initial phase of treatment for SAM, as it increases the rate of 

complications. Iron supplementation may increase morbidity 

from malaria in settings with poor access to therapy.

Zinc 

• Zinc deficiency is widespread in developing countries. Most 

cases are asymptomatic, though deficiency impacts immune 

function and wound healing.

• Treatment and prevention are as follows.

° For cases of diarrhea, zinc supplementation lasting 10 to 14 

days reduces severity, duration, and recurrence of diarrhea.

° Zinc acetate should be given as a supplement and not part 

of a multivitamin.

° Dosing (in elemental form; 10–14-day course): 

▶ Infants younger than 6 months old: 10 mg/day.

▶ Children older than 6 months: 20 mg/day. 

° Zinc supplements may now be available in the Central 

Command formulary as zinc sulfate 220 mg tablets, and 

as IV multitrace 4 for use with TPN Multitrace-4 Pediatric 

(trace elements injection 4, USP; American Regent, Inc, 

Shirley, NY). Note: The US Food and Drug Administration 

indication for Multitrace-4 is as a supplement to IV 

solutions given for TPN. Each milliliter provides: 

▶ zinc: 1 mg, 

▶ copper: 0.1 mg, 

▶ manganese: 25 μg, and 

▶ chromium: 1 μg. 

° Zinc supplements are also commercially available under 

the trade name Orazinc 110 (Mericon Industries, Inc, Peoria, 

IL). Each tablet provides 25 mg of elemental zinc. If using 

Orazinc 110, recommended dosages comparable to WHO 

guidelines are as follows: 

▶ Infants between 2 to 6 months: half a tablet or 12.5 mg 

elemental zinc once daily for 14 days.

▶ Children older than 6 months to 5 years old: one tablet 

or 25 mg elemental zinc, once daily for 14 days. 

• See Table 35-9 for specific signs of other nutritional deficiencies. 
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Malnutrition and Emergency Nutrition for Sick or Injured Infants and Children

Table 35-9. Signs of Specific Nutrient Deficiencies

Nutrient Deficiency Symptoms

Protein Kwashiorkor, weakness, lethargy, edema, ascites, 

fatty liver, dermatitis, depigmented hair, alopecia, 

decubitus ulcers, moon face, muscle wasting, 

growth failure, hypotension, cheilosis, stomatitis, 

delayed wound healing 

Protein/Energy Marasmus; dry, dull hair; drawn-in cheeks; carious 

teeth; ascites; diarrhea; weakness; irritability; 

increased appetite; muscle wasting; growth failure; 

other vitamin deficiencies 

Fat/EFAs Xerosis; flaking; scaly skin; dermatitis; follicular 

hyperkeratosis; dry, dull hair

Vitamin A Eggshell nails, night blindness, dermatitis, taste 

changes, xerosis, keratomalacia

Vitamin C Decubitus ulcers, perifolliculitis, petechiae, bleeding 

gums, swollen gums, stomatitis, bone pain, dry or 

rough pigmented skin, poor wound healing, anemia

Vitamin D Rickets, bowed legs, prone to fractures, restlessness, 

frequent crying, sweating, muscular atony, 

weakness, scoliosis, back pain, bone pain, spinal 

changes

Calcium Weight loss, muscle weakness, bone pain, skeletal 

deformities

Vitamin B12 Megaloblastic anemia, scarlet tongue, fatigue, weight 

loss, jaundice, oral mucosa ulcerations, dementia, 

sensory loss, yellow skin pallor, hypertrophy, gait 

sensory ataxia

Iron Fatigue, weight loss, glossitis, stomatitis, tachycardia, 

tachypnea, thin or spoon-shaped nails

Zinc Delayed wound healing, alopecia, night blindness, 

taste changes, decubitus ulcers, delayed wound 

healing, dermatitis, erythema, xerosis

Iodine Goiter, outer third of eyebrow missing

Thiamine Edema, weakness, irritability, burning feet, pruritus, 

nausea, vomiting, anorexia, muscle wasting, muscle 

tenderness and cramps, beriberi, photophobia, 

confusion 

(Table 35-9 continues)
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Pediatric Surgery and Medicine for Hostile Environments 

Further Reading

1. World Health Organization. Child Growth Standards and the 

Identification of Severe Acute Malnutrition in Infants and Children. 

Geneva, Switzerland: WHO; 2009. http://www.who.int/nutrition/

publications/severemalnutrition/9789241598163/en/. Accessed 

March 9, 2015.

2. World Health Organization. Updates on the Management of Severe 

Acute Malnutrition in Infants and Children. Geneva, Switzerland: 

WHO; 2013. http://www.who.int/nutrition/publications/guidelines/

updates_management_SAM_infantandchildren/en. Accessed 

March 9, 2015.

3. Médecins Sans Frontières. Clinical Guidelines: Diagnosis and Treatment 

Manual for Curative Programmes in Hospitals and Dispensaries, 

Guidance for Prescribing. Paris, France: MSF; 2013. Available at: http://

refbooks.msf.org/msf_docs/en/clinical_guide/cg_en.pdf. Accessed 

March 9, 2015.

4. United Nations Children’s Fund. Nutrition in Emergencies online 

course. New York, NY: UNICEF. http://www.unicef.org/nutrition/

training/. Accessed April 14, 2015.

5. United Nations Children’s Fund, World Health Organization, The 

World Bank. UNICEF WHO-World Bank Joint Child Malnutrition 

Estimates. New York, NY: UNICEF; Geneva, Switzerland: WHO; 

Washington, DC: The World Bank; 2012. http://www.who.int/

nutgrowthdb/jme_unicef_who_wb.pdf. Accessed April 14, 2015.

Niacin Pellagra, dermatitis, diarrhea, dementia, red/

scarlet tongue, erythema, depression, irritability, 

stomatitis, glossitis, cheilosis, hyperpigmentation

Folic acid Megaloblastic anemia, skin pallor, stomatitis, 

scarlet tongue, glossitis, sensory loss, oral mucosa 

ulcerations

Riboflavin Flaking, scaly dermatitis, conjunctivitis, magenta 

tongue, stomatitis, glossitis, cheilosis, hypertrophy

EFA: essential fatty acid

(Table 35-9 continued)
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Malnutrition and Emergency Nutrition for Sick or Injured Infants and Children

6. US Department of Defense, Defense Logistics Agency. Troop 

Support website. Fort Belvoir, VA: DLA. https://www.troopsupport.

dla.mil/subs/rations/programs/hdr/hdrabt.asp. Accessed April 14, 

2015.

7. West KP, Sommer A. Periodic, Large Oral Doses of Vitamin A for the 

Prevention of Vitamin A Deficiency and Xerophthalmia: A Summary of 

Experiences. Washington, DC: Nutrition Foundation; 1984.

8. World Health Organization Expert Committee. Prevention and 

control of schistosomiasis and soil-transmitted helminthiasis. World 

Health Organ Tech Rep Ser. 2002;912:i–vi, 1–57, back cover.
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Chapter 36

Nursing Assessment

Pediatric Growth and Development

Child development is organized into developmental stages, and 

communication with children should be appropriate to their 

stage of development. Interpreters should be used to explain 

care and treatment to parents or caregivers and children. If an 

interpreter is not available, a picture board may be used as a 

communication tool. Keep in mind that published US pediatric 

growth curves may be less useful in developing countries. 

Developmental Stages

• Infancy: birth to 12 months of age

° First month of life (neonatal period) is differentiated from 

subsequent months due to major physiologic adjustments.

° This is a time of rapid motor, cognitive, and social 

development.

° Children in infancy are dependent on caregivers.

° These children respond to pain by crying and withdrawing.

° Milestones approximation

▶ 2 months: head control.

▶ 4 months: arms and chest control.

▶ 6 months: sitting.

▶ 8 months: crawling.

▶ 10 months: standing supported/cruising.

▶ 12 months: walking, few words, self-feeding.

° Children in this stage can make eye contact, orient 

preferentially to faces, and track brightly colored objects.

° These children have an open anterior fontanelle until 

around 16 months.

° Nursing considerations

▶ Assess activity, movement of extremities, eye contact, 

and tracking to voice or objects.
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▶ Irritability along with high-pitched, shrill, or weak cry 

is a concerning finding.

▶ Weakness, flaccidity, or an unresponsive infant is 

indicative of clinical deterioration.

• Early childhood: 1 to 6 years of age

° Toddler: 1 to 3 years of age

▶ Developmental characteristics include:

▷ upright, to walking, to language development, to 

activity and discovery;

▷ toilet training begins (bowel then bladder, daytime 

then nighttime);

▷ ability to eat table foods;

▷ fear of abandonment and separation anxiety; and

▷ denial or saying “no” (common toddler behavior).

▶ Toddlers are very ritualistic; disruption in their routine 

leads to a feeling of loss of control.

▶ Nursing considerations

▷ To minimize separation anxiety and fear, keep a 

parent or caregiver with the child or hold the child 

during assessment or interventions.

▷ Lack of anxiety during separation from a parent or 

caregiver may indicate clinical deterioration.

▷ Children at this age are resistant to being touched, 

separated from their caregivers, having their clothing 

removed, and donning masks (eg, oxygen).

▷ Children at this age may believe that injury and illness 

are forms of punishment.

° Preschool: 3 to 6 years of age

▶ These children typically:

▷ are toilet trained;

▷ are entering into school;

▷ talk in full sentences, think concretely;

▷ exhibit more subtle responses to stress (eg, loss of 

appetite or sleep) than toddlers;

▷ have active imaginations that may lead to exaggeration 

and fear, or to fantasies that may take over; and 

▷ are curious about equipment and tasks.

▶ Nursing considerations: Children this age

▷ may worry over body integrity (eg, wonder if a body 

part under a cast is actually missing);
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Nursing Assessment

▷ have increased awareness and fear related to pain, 

death, blood, or permanent injury;

▷ think concretely and interpret what they hear literally; 

and 

▷ believe that injury and illness are their own fault and 

view them as punishment.

• Middle childhood: 6 to 11 or 12 years of age

° Key characteristics of this period

▶ A critical period of self-concept.

▶ Characterized by development of peer relationships.

▶ Children are concerned about privacy and are selfconscious when undergoing physical examinations.

▶ Children may be anxious about death.

▶ Illness or injury affects the child’s sense of self-worth or 

achievement.

▶ Children are capable of cooperating with procedures 

and answer questions about health.

• Later childhood: 12 to 19 years of age

° Prepubertal: 10 to 13 years

° Adolescence: 13 to approximately 18 years

▶ This is a period of rapid biological and personality 

maturation, with the onset of puberty and development 

of secondary sexual characteristics.

▶ Adolescents fear loss of control and enforced dependence.

▶ Children this age believe that nothing bad can happen 

to them.

° Nursing considerations for middle and later childhood:

▶ Vital signs are similar to those of adults.

▶ Children this age are concerned with privacy and 

modesty.

Communicating With Children

• Explain procedures to children and their parents; plan on 

having to repeat explanations.

• Talk in a quiet, gentle tone.

• Be reassuring to children and parents.

• Provide a security object.

• Keep your hands visible.

• Use appropriate terminology.
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Pediatric Surgery and Medicine for Hostile Environments 

• Assign the child a task if possible (eg, “keep your eyes on the 

purple cow in your bed”).

• Explain monitoring noises.

• Use the child’s name.

Admission Tips and Preparation

• Establish weight in kilograms with a scale or estimate weight 

using the Broselow tape (see the inside back cover).

• Develop a binder or computer file with emergency medication 

calculations of the most commonly used medications, and 

divide doses into 5-kg increments.

• A precalculated emergency medication sheet should be posted 

at each child’s bedside.

Online weight-based emergency medication calculators are 

available (see http://www.globalrph.com/acls-pediatric.htm, or 

refer to the Broselow tape for emergency medication dosing).

Obtaining Vital Signs 

• Refer to Chapter 1, Basic Approach to Pediatric Trauma, Table 

1-1 for normal vital sign ranges by age.

• A satisfactory pulse rate can be obtained radially in children 

over 2 years of age. Use the brachial or apical pulse method 

for children less than 2 years of age. 

• If time and situation permit, listen to pulse for at least 1 minute 

to detect potential irregularities.

• The preferred site for noninvasive blood pressure (BP) 

measurement is the right upper arm. Other sites for BP 

measurement include the left arm, thighs, and calf.

• Temperature can be obtained by axillary method from birth 

to over 5 years of age. Axillary temperature measurement 

frequently underestimates core temperature.

• If a definitive (core) reading is needed, obtain a rectal 

temperature in infants to 5 years. Care should be taken when 

obtaining rectal temperatures in neonates. Avoid taking 

rectal temperatures in neutropenic patients. Oral temperature 

measurement can be used in older children.

• Fever is a temperature greater than 38°C; hypothermia is a 

temperature less than 36°C.
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Nursing Assessment

Respiratory/Airway

• Refer to the comprehensive equipment table in Appendix C 

for appropriate equipment sizes for airway adjuncts, such as 

masks for bag-valve mask ventilation, oral pharyngeal airway, 

nasopharyngeal airway and endotracheal tubes (ETTs), and 

suction catheters.

• Intubation supplies needed include:

° A monitor to evaluate heart rate, BP, and respiratory rate 

(cycle BP every 5 minutes during procedure).

° A spare ETT and stylets (appropriate size and one size 

smaller).

° Functional intravenous (IV) access. 

° Emergency medications. 

° Functioning Yankauer catheter and suction.

° Bag-valve mask ventilation with appropriately sized mask, 

attached to flowing oxygen.

° End tidal carbon dioxide detector.

° Ventilator.

• Nursing tips for care of the intubated patient

° Pediatric ETTs are often flimsy in children and can occlude. 

Consider using a stiffer tube as a stent outside the primary 

tube.

° Pediatric ETTs need to be suctioned at least every 2 to 3 

hours.

° Always have an extra tube at the bedside for emergencies. 

° Prevent ventilator-associated conditions (eg, pneumonia).

▶ Elevate the head of the bed to 30 degrees, unless 

contraindicated. 

▶ Assess and document the position of the ETT every 4 

hours and during transport, and with any change in the 

patient’s position.

▶ Use waterproof (cloth) tape to secure tubes (because of 

oral secretions). DO NOT use paper tape.

Cardiovascular/Intravenous Access

• Refer to Chapter 1, Basic Approach to Pediatric Trauma, Table 

1-1 for age-specific BP and pulse measurements.
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• Assess capillary refill time for adequate perfusion. Normal 

capillary refill time in children should be 2 seconds or less.

• Supplies for IV access

° Alcohol prep pads, tourniquet, pore tape, Tegaderm (3M 

Co, St Paul, MN).

° IV catheters; sizes 24 and 22 are the most commonly used 

in children. 

° Butterfly needles can be used in emergency situations; 

however, they must be adequately secured with pore tape 

with constant provider monitoring of the site.

° Intraosseous (IO) placement should be considered 

immediately in critically ill children in need of urgent 

access. See Chapter 3, Vascular Access, for guidance beyond 

routine peripheral IV access.

• Nursing tips

° Forms of restraint for IV placement include swaddling 

(infants), and mummy restraint with a sheet for small 

children.

° Have at least 2 or 3 people help hold a toddler down for 

blood work or IV placement.

° Make sure the involved extremity is well restrained before 

starting.

° IO access requires careful securing and monitoring of the 

insertion site and constant evaluation by provider.

° Stabilize the IV extremity with an armboard.

° Armboards may be constructed by using two tongue blades 

or by cutting down larger armboards used for adults. Pad 

the board with 4×4 gauze and monitor the extremity for 

potential skin breakdown at pressure points.

° Normal saline is the fluid of choice for resuscitation. Typical 

bolus amount is 10 to 20 mL/kg.

▶ Push fluids in using syringes during resuscitation; 

infusion pumps take too long. 

▶ For fluid boluses in infants, use a 20 to 60 mL syringe 

with a 3-way stopcock to a normal saline bag. This 

method can be used to deliver rapid boluses.

° For maintenance fluids, to avoid unintentional delivery of 

excess fluid, program a load of only 2 hours of volume to 

be infused into the pump.
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Nursing Assessment

° Frequently reassess IV site. 

° Document all fluid given, including flushes, in the intake 

section of the nursing flow sheet.

° Although not recommended, blood draws may be obtained 

from IV sites. Aspirating from 24-gauge IVs placed in 

smaller veins may result in the loss of the IV.

° Blood may also be collected via heel stick.

° Pediatric tubes are recommended for laboratory samples 

to minimize blood loss.

° A hand-held analyzer, such as an iStat (Abbott Laboratories, 

Abbott Park, IL), is recommended to handle small blood 

volumes. 

° Ensure the blood amount taken is documented in the 

“output” section of the nursing flow sheet.

Neurological

• Monitor for altered mental status using the Glascow Coma 

Scale score (with infant modifications, if appropriate). See 

Chapter 1, Basic Approach to Pediatric Trauma, Table 1-3 for 

the Glasgow Coma Scale, including infant modifications.

• Record Glasgow Coma Scale score regularly and notify 

physician if there is deterioration.

• Early signs and symptoms of increased intracranial pressure 

(ICP)

° Infant: change in mental status, lethargy, poor feeding, 

bulging fontanelle.

° Child: change in mental status, severe acute headache, 

seizure activity.

• Nursing care of increased ICP in infant and child

° Keep the head of the bed elevated 30 to 45 degrees.

° Maintain the head and neck in the midline position.

° Maintain normothermia.

• ICP monitoring: See Figures 36-1–36-3. Also see Chapter 

13, Neurosurgery, for more information on the utility 

of ventriculostomy catheters for both management and 

monitoring of ICP.
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Pediatric Surgery and Medicine for Hostile Environments 

Fig 36-1. Transducer stopcock set “open to drain.”

Off to transducer = Open to drain

Pain 

• Pain is often undertreated in children.

• Response to painful stimuli is individually based on prior 

experiences and cultural beliefs.
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Nursing Assessment

• Children 7 years of age and above typically use the 0-to-10 pain 

scale. Other scales include the FLACC (Face, Legs, Activity, 

Cry, Consolability) scale (see Merkel, et al, in Further Reading) 

and the Wong-Baker FACES scale (see Baker C, Wong D, in 

Further Reading).

Fig 36-2. Transducer stopcock set “off to drain” to transduce accurate intracranial pressure.

Physician ordered pop-off 

set to cmH2O

Example: Pop-off 

set at 10 cmH2O
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Pediatric Surgery and Medicine for Hostile Environments 

• A simple pain management approach is an “around-the-clock” 

baseline analgesic (eg, acetaminophen or ibuprofen) with 

supplemental, as-needed narcotics.

Fig 36-3. Level to tragus of the ear to transduce accurate intracranial pressure.

Level tranducer to the tragus

of the ear and turn OFF to drain

to record accurate ICP
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Nursing Assessment

Gastrointestinal and Genitourinary

• Evaluate the child’s nutritional status and have culturally 

specific foods on hand to promote nutrition.

• Have electrolyte-containing oral solutions on hand, such as 

Pedialyte (Abbott Laboratories, Abbott Park, IL).

• Have nipples, 60-mL graduated feeders, and pacifiers in stock.

• Order specialized nipples, such as a pigeon nipple, if there is 

high incidence of cleft palate in the area of operation.

Tubes and Drains

• Refer to the comprehensive pediatric equipment sizing table 

in Appendix C of this book for approximate sizes according 

to weight.

• Size 5 and 8 Fr feeding tubes can also be used as Foley catheters 

in infants less than 6 months old.

° Connect tubing to a urimeter by attaching it to a syringe 

without a plunger. 

° An inline burette can also be used as a urine collection 

device.

• Foley catheters can get clogged; therefore, irrigation may be 

necessary if a sudden drop in urine output is noticed. 

• To measure small amounts of output, consider hooking to an 

upright Lukens trap with suction.

• Nasogastric (NG) tube placement: measure the tube from the 

child’s nose to earlobe to xiphoid process. Secure the tube to 

the side of the child’s face with Tegaderm or Medipore (3M 

Co, St Paul, MN) tape. Confirm placement with radiograph.

• Tube feeding may be necessary for nutritional rehabilitation. 

It can be useful in the acute setting of a child with dehydration. 

It is also useful for enteral drip fluid and electrolyte 

replacement when IV placement is impossible.

° Usually the feeding tube is placed nasogastrically, but 

transpyloric feeds can be used in children if severe vomiting 

continues with an NG tube.

° To encourage transpyloric passage, allow slack on the tube 

and add metoclopramide (0.1–0.2 mg/kg PO/IV).

° Appropriate tube size depends on the patient’s age; 

see comprehensive pediatric equipment sizing table in 

Appendix C for guidance.
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° The tube should be soft and changed periodically 

(approximately every 4 to 6 wk) if used long term.

° Feeding with a continuous drip is helpful in vomiting 

patients because more calories can be delivered with less 

vomiting. 

° In the case of a transpyloric tube, continuous feeding is 

imperative; bolus feeds can only be given via the NG route.

° The appropriate fluids through an NG tube are formulas 

or electrolyte solution, not pureed foods. 

Pediatric Medication Administration Tips

• Take a confident, positive approach; be kind but assertive.

• Allow the child some control by offering appropriate choices 

(eg, allow the child to choose which arm to use for an injection 

or the flavor of an oral drug chaser; never give the child a 

choice when none exists).

• Be truthful about the pain and discomfort associated with the 

procedure. 

• Compare the expected sensation with something the child has 

likely experienced before (eg, a pinch or a pinprick).

• When explaining how long a procedure will take, remember 

that children generally do not fully understand the concept 

of time until approximately 7 to 8 years of age; use terms the 

child can understand (eg, “by the time you count to 3, it will 

be over”).

• Children tend to take language literally; avoid using imprecise 

and potentially frightening jargon. 

• Because needles and syringes can produce anxiety, keep them 

out of the child’s view until you’re ready to administer the 

medication.

• Oral administration

° Check the child’s gag reflex and ability to maintain airway 

in the presence of fluids; assess for nausea and vomiting.

° A liquid dosage form ensures a more accurate dose for 

children; use liquid dosage whenever it is available 

(exceptions include phenytoin, carbamazepine, and 

isoniazid). 

° If only tablets are available, crush and mix them with 

compatible syrup or food. Do not crush extended release 
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or sustained release tablets. Crushing may reduce the 

effectiveness of some drugs. Check with a pharmacist 

or consult a drug manual before crushing and mixing 

medications.

° For liquid-soluble medications, a small syringe may be 

used. Remove the plunger from the syringe and place the 

tablet inside. Replace the plunger and use it to crush the 

pill. Then 1 or 2 mL of water, saline, or other liquid may 

be used to dissolve the medication.

° To administer oral drugs to infants:

▶ Raise the infant’s head to prevent aspiration.

▶ Gently press down on the infant’s chin with your thumb 

to open the infant’s mouth.

▶ Administer the dose.

▷ Syringe: place the tip of the syringe in the pocket 

between the patient’s cheek and gum. This prevents 

the child from using the tongue to spit out the 

medication. Administer slowly and steadily to 

prevent aspiration.

▷ Nipple: place medication in a rubber nipple and allow 

the infant to suck the contents. 

▷ Never mix medications into a baby’s bottle (if the child 

does not finish the entire bottle, the correct dosage 

will not be ingested; also, some formulas interfere 

with the absorption of some drugs).

▷ For safety, never refer to a drug as “candy” or a 

“treat,” even if it has a pleasant taste.

• NG route: check for residuals if giving enteral feedings that 

interfere with drug absorption.

• Rectal route

° Be aware of the special significance of this part of the body 

to children.

° Toddlers in toilet training will resist the rectal route.

° Older children perceive this as an invasion of privacy and 

may react with embarrassment, anger, or hostility.

° To reduce a child’s anxiety, explain the procedure and 

reassure the child that it will not hurt.

° After administering the suppository, hold the child’s 

buttocks together for a few minutes to prevent expulsion.
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° Concurrent critical illness may impair absorption.

• IV infusion

° To reduce pain at the injection site, offer to use topical 

anesthetic preparations (eg, lidocaine/prilocaine) with 

occlusive dressing 30 to 60 minutes prior to the IV access 

attempt. 

° Although there is a greater incidence of infiltration and 

phlebitis in children, the IV route is the most effective to 

deliver medications during critical illness.

° Use smaller flushes of 2 to 3 mL after each medication. 

Adult “standard” flush volume is too much for infants and 

children. 

° Check the compatibility of the solution. Ensure IV 

medications, flushes, and parenteral nutritional fluids 

infused in the same IV line are physically and chemically 

compatible.

° In infants (especially neonates), hyperosmolar drugs must 

be diluted to prevent radical fluid shifts that may cause 

intracerebral hemorrhage.

• Intramuscular (IM) injection

° Do not use lidocaine as a diluent for drugs needing 

reconstitution; doing so places the patient at risk for local 

anesthetic toxicity.

° Reconstitute medication in the highest concentration 

possible to avoid having to administer two separate 

injections to give the entire dose.

° The optimum site for IM injection depends on the child’s 

age:

▶ Less than 3 years old: vastus lateralus (lateral thigh) 

muscle.

▶ Older than 3 years: gluteus muscle or ventrogluteal area.

▶ Appropriate needle size depends on the child’s age and 

muscle mass.

▷ In young infants, a 5/8-inch needle is usually used. 

▷ Children or thin, debilitated adolescents may require 

a 1-inch or smaller (5/8-in.) needle.

▷ For most children and adolescents, use a 1-inch or 

1.5-inch needle, respectively.
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Nursing Assessment

▷ Needle gauge is determined by the viscosity of the drug 

formulation. A 19-gauge needle is used for viscous 

drugs (eg, penicillin G procaine). A 21-gauge needle 

is used for aqueous formulations (eg, penicillin G).

▷ To avoid unnecessary tissue damage, use the shortest 

length and highest gauge needle possible.

▷ The optimum amount of drug to administer via an 

IM site varies with the child’s age, size, and health.

▷ Usual maximum volume for IM administration:

Neonate: 0.5 mL

Child: 1–2 mL

Adult: 2–3 mL 

▷ Rotate sites.

• IO route: recall that any medication that may be given IV may 

also be given IO.

• Subcutaneous (SQ) injection

° Infants and children have less SQ fat than adults.

° The SQ injection procedure is similar to IM injection, but 

uses shorter needles and volume should be limited to 1.5 

mL or less.

▶ Use a 25-gauge to 27.5-gauge needle.

▶ For infants and small children 3 years old and younger, 

use a 3/8-inch or 1/2-inch needle.

▶ For larger children, use a 5/8-inch needle. Obese children 

and adolescents may require a 1-inch needle.

• Inhalants

° Correct administration depends on the child’s cooperation.

° If a nebulizer is to be used to deliver medication, the child 

needs to wear the mask at all times during drug delivery. 

Nebulized medicines with a blow-by technique lose 90% 

of drug delivery. 

° Inhalants can be used in children as young as 3 months 

old if an appropriate spacer (valved holding chamber with 

mask) is available.

° Clean the spacer with warm water and mild soap every 

week to minimize bacterial contamination; do not rinse soap 

from the inside of the holding chamber; the soap film acts 

as a surfactant and reduces static charge so that medication 

particles do not adhere to the sides of the chamber.
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Pediatric Surgery and Medicine for Hostile Environments 

° Prime the spacer with several actuations of the metereddose inhaler prior to use.

° Use a different spacer for each child (do not share spacers).

° Common spacer instructions (spacer instructions may vary; 

read package insert for specific instructions):

▶ Shake canister well before (5 seconds) each puff.

▶ Properly assemble canister-spacer.

▶ Inhale and exhale slowly (if possible).

▶ Place spacer mouthpiece between lips (or mask that 

covers the child’s nose and mouth completely). 

▶ Press canister down one time.

▶ Inhale slowly (if a whistle sound is heard, patient is 

inhaling too fast).

▶ Take spacer out of mouth and close mouth.

▶ Hold breath for 10 seconds, then exhale slowly.

▶ If unable to hold breath for 10 seconds, exhale and inhale 

into spacer up to 10 times.

Further Reading

1. Merkel SI, Voepel-Lewis T, Shayevitz JR, Malviya S. The FLACC: a 

behavioral scale for scoring postoperative pain in young children. 

Pediatr Nurse. 1997;23(3):293–297.

2. Baker C, Wong D. Q.U.E.S.T.: a process of pain assessment in 

children. Orthop Nurs. 1987;6(1):11–21.

3. Hockenberry MJ, Wilson David, eds. Wong’s Essentials of Pediatric 

Nursing. 8th ed. Maryland Heights, MO: Mosby Inc; 2009.
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Behavioral Healthcare of Children in Austere Environments

Chapter 37

Behavioral Healthcare of Children in 

Austere Environments

Introduction

Psychological trauma is frequently overlooked as caregivers tend 

to focus on treating a physical injury or illness. The emotional 

and cognitive sequelae must be treated as well as the physical 

complications of injury, and both can be quite severe. Healthcare 

providers should consider and vigorously address psychological 

sequelae as soon as a patient arrives for treatment, and they must 

integrate behavioral healthcare into the patient’s plan of care. 

This chapter will highlight several useful principles for the care of 

injured (and psychologically traumatized) children in a deployed 

medical-surgical setting and provide ways for a busy provider 

taking care of injured children to intervene psychiatrically to 

improve both compliance and outcomes. 

General Principles

Principle 1: All “Psychiatric” Issues Are Organic Until Proven 

Otherwise

• Clinicians are obligated to perform a full medical evaluation, 

including physical examination and laboratory and diagnostic 

studies, before making a psychiatric diagnosis. 

• In the face of new onset psychiatric symptoms, always 

rule out traumatic injuries, intracranial pathology, sepsis, 

metabolic syndromes, toxic exposures, and delirium (waxing 

and waning consciousness) before resorting to a psychiatric 

diagnosis. 
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Pediatric Surgery and Medicine for Hostile Environments 

Principle 2: Behavioral Health Concerns Need to Be Addressed 

With the Same Care as Other Medical Concerns

• A bio-psycho-social history, including specific (targetable) 

symptoms, should be documented. In complex situations, the 

histories provided may be limited, unreliable, or impacted by 

the lack of a safe environment. It is important to get a sense of 

the remote past and the context (what happened around the 

onset of symptoms) as well as more immediate events. Focus 

on the specifics of current symptoms—the more specific the 

better—including:

° time course, including specific event and symptom 

evolution; 

° severity (what makes symptoms worse or better?); and 

° other bio-psycho-social narrative components: 

▶ Biological: Is there a family history of psychiatric 

problems?

▶ Temperamental: What kind of temperament does the 

child have? Anxious? Securely attached?

▶ Developmental: Has the child met normal milestones? 

Does the child make eye contact? Is speech normal? Does 

the child exhibit any unusual behaviors?

▶ Event-based: Has the child lost attachment figures? Has 

the child relocated? Has the child sustained abuse? Did 

the child witness traumatic events (eg, people being 

injured, explosions)?

• Historians may be unreliable because they:

° may be traumatized (not able to manage the experiences); 

° may not have been present but are willing to conjecture; 

° don’t want to provide the history (for reasons that may not 

be obvious to the provider); 

° may purposefully falsify the story, either consciously or 

unconsciously; or

° may be confronting unsettling realities and their own 

unsavory choices. 

• In certain environments, stating reality can be highly 

dangerous. The risks of ongoing physical danger to both the 

patient and the historian should always be considered when 

analyzing the history obtained and planning for the future. 
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Behavioral Healthcare of Children in Austere Environments

Principle 3: Work in the Cultural Context in Which You Find 

Yourself

• Clinicians should prepare themselves by learning the local 

traditions and then budgeting time and effort to perform them.

° Medical “scrubs” and white coats may be off-putting and 

anxiety provoking.

° Western understanding of professionalism may not be 

understood or accepted, an individual’s “character” may 

be of greater importance. 

° If time allows, providers should establish a “therapeutic 

relationship” with their patients.

▶ Spend time and energy establishing a personal 

relationship with patients, parents, and elders. 

▶ Know and acknowledge local customs, respect attitudes, 

and make efforts to reach out in warm and generous 

ways. 

• Patients do not necessarily share the same worldview as their 

caregivers and may even disagree with the most basic goals 

for treatment. 

• Assume that foreign patients and their families may not 

entirely trust clinicians and do not understand medical 

treatments or procedures.

• To understand the local culture, a list of customs should be 

reviewed and considered, including:

° Is it a male-dominated culture? How are women to be 

treated, both publicly and privately?

° Who should be addressed first in a group?

° How should one introduce oneself? 

° What’s the best way to conduct a physical examination so 

as not to offend?

° What are the prevailing religious beliefs and how do they 

relate to medical care?

° What are the local experiences with the healthcare facility 

and providers?

• In many cultures, sharing food or a beverage, such as tea or 

coffee, engenders trust.

° Allow the senior person to eat or drink first. 

° This custom may be essential to working together. 

° Don’t talk about the medical “work” until the repast is over. 
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Pediatric Surgery and Medicine for Hostile Environments 

Principle 4: Communication Is Key

• Clinicians should use reliable methods of communication, 

including drawings, to exchange information with the patient 

and responsible adults. 

• Translation is surprisingly unreliable. 

° Clinicians expect a translator to provide a simple linguistic 

translation; however, translators generally make what 

they deem appropriate cultural interventions. As a result, 

clinicians are frequently dumbfounded at the reactions to 

recommended interventions. 

° Ensure translators are an active part of the working team. 

Knowing and influencing the translator’s attitudes can have 

dramatic impact on treatment. 

• Interventions involving drawing, writing, and pictures (eg, 

using white boards and models) can be invaluable tools; 

however, keep in mind that graphic displays or pictures may 

be offensive in some cultures.

° Many cultures are dominated by superstitions and strongly 

held beliefs (eg, belief in evil spirits, the role of “elixirs,” 

illness or injury as punishment for sins or “hexes”), and 

these can quickly creep into medical discussions. Enlisting 

a local holy or medical person may prove useful. 

° The process of educating patients includes understanding 

and appreciating local beliefs as well as communicating 

the clinician’s goals for treatment.

• Remember that patients and their families may be illiterate.

Principle 5: There Are Often Several “Patients” to Be Treated

• Ensure patients and caregivers understand the point and 

nature of treatment procedures.

• Ensure patients and responsible adults have a cognitive 

understanding of the medical problems and the treatment in 

the context of the cognitive, developmental, and educational 

level of the audience. 

• Pediatric patients have limited cognitive abilities and, 

depending on their developmental age, use more or less 

“magical” thinking, and primitive associations. 
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Behavioral Healthcare of Children in Austere Environments

° Lay out simple explanations. Focus on making sense of 

events and what needs to be done, and create a meaningful 

narrative to explain the healing process. 

° Provide enough detail for the patient and adults to 

understand the basics, and no more. 

° If children feel safe and have a relationship with the 

provider, they may ask further questions to titrate their 

own anxiety. If they don’t ask, they may not want to know 

more. 

° Children often have frightening fantasies about things they 

don’t fully understand. Be cognizant of evolving phobias 

and anxiety.

° Positive reassurance, accompanied by simple mechanical 

explanations using metaphors from the local environment 

(eg, how streams work for explaining fluids, or how plants 

or animals grow), is best. 

° Providing “toys” and visuals can help clarify otherwise 

confusing explanations and may also provide amusing 

distractions (eg, glove “balloons” or plastic syringe “water 

toys”) and create a warmer and “safer” environment.

• The other “patients” to be considered are the parents or 

responsible adults, who are less likely to be open, transparent, 

or trusting and are often more fearful than the child. 

° Talk to parents or responsible adults without the child 

present to explore their fears before administering a 

treatment. 

° Even when time is of the essence, exploring the adult’s 

(sometimes irrational) understanding of the injury, 

treatment, and outcome fears will prove extremely 

beneficial for treatment compliance and outcome. 

° Designating an alternative provider to liaise with the parent 

may save time, but it potentially splits the authority and 

can appear disrespectful. 

Principle 6: Provide a Safe Environment

• Psychological safety is a key goal. Physical comfort and a 

psychologically nourishing environment facilitate compliance 

and speedy medical recovery. 
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• Anxiety is the most frequent behavioral health problem and 

the final common pathway for all conditions. 

° Anxiety is the psychological equivalent of pain and always 

needs to be considered and treated. 

° Anxiety and stress result from physical hardship and 

injury, changes in conditions, novel experiences, and an 

environment that results in sleep deprivation, disturbing 

recollections, and future worries. Stress is ubiquitous and 

can be toxic. 

° Treatment should focus on reducing stress and anxiety, 

which includes managing physical pain (see Chapter 2, 

Anesthesia).

° Ensure patients are physically comfortable and that the 

environment is stable and predictable. 

° Cultural supports (pictures, religious items, etc) and close 

friends and family in attendance are highly valuable. 

° Employing families to minister to patients is generally 

culturally consistent, helps the family and patient connect 

with the medical team, ensures some continuity of care after 

discharge, and ensures that the patient receives warmth 

and human contact. 

Principle 7: Encourage Verbalization

• Much therapeutic benefit comes from the process of talking, 

which can limit the danger of irrational fears. Distinguishing 

between fears and wishes, thoughts and words, and actions 

and reality can be quite useful. 

• Children frequently have a hard time differentiating and 

verbalizing the nature of their distress. They can protect 

themselves in primitive ways. For example, as they try to 

manage their internal experiences, they “act out” their distress 

through physical symptoms (somatic complaints) or unruly 

behaviors (refusal, agitation, etc). 

• The goal of treatment is to allow patients to communicate 

their internal thoughts and learn to deal with their distress 

in appropriate, acceptable, and healthy ways. 

° Encourage verbalization and play. 

° Ensuring loved ones are available, along with toys and 

props, allows healthy expression of anxiety.
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° Once a certain level of trust is established, young or “shy” 

children may be unexpectedly willing to share thoughts, 

feelings, and fears. 

° Be aware that both the parent and the child can be 

retraumatized by recollections or expressed concerns.

° It is up to the clinician to slow the child down, help 

titrate the intensity, and keep the patient from becoming 

overwhelmed.

• Adolescents will often maintain a distance or even become 

hostile to a clinician or unfamiliar caretaker. This hostility 

psychologically defends the vulnerable adolescent from 

intense feelings or dangers. Adolescents can (understandably) 

lash out in very destructive ways.

Principle 8: Discharge Planning Should Always Be a Part of the 

Initial Treatment Plan

• While providing safety, clinicians must also balance the 

warmth and care of the treatment environment with clear 

expectations for the family about the end of treatment. 

• Managing the end of treatment and what will happen after 

discharge can be challenging. Medical follow-up may be 

difficult to arrange, and how a patient and his/her family will 

obtain even the most basic needs may be unclear. If the child 

is an orphan, the family’s home is threatened, or the family 

members are outcasts, the end of treatment at a Western 

treatment facility will only be the beginning of their travails. 

° Outside conditions often act as a disincentive to the goal 

of a speedy recovery. 

° Patients and their families can become needy and 

pathologically dependent on the medical environment to 

protect themselves from a hostile and dangerous outside 

environment. 

° Enslavement, prostitution, and forced military draft are 

common in austere environments and threaten catastrophic 

changes for patients who are pending discharge. 

• As discharge approaches, expect clinical setbacks and 

appreciate they may be manifestations of the patient’s (and 

the family’s) anxiety about the future. 
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• At the beginning of the treatment process, create a clear 

expectation for the end of treatment (and of the finite nature 

of the care). Ensure those responsible have a clear expectation 

of what should happen after treatment is over. 

Treatment

Phases

• Generally, there are three phases to treatment of new onset 

symptoms, particularly posttraumatic conditions: 

° Acute: In the immediate aftermath of a precipitating event 

(and within the first few hours), the focus of treatment is to 

provide safety and security and to decrease hyperarousal 

and shock.

° Medium term: The first few days after an event, when 

the situation is still “raw” and cognitively “in play,” 

stabilization and symptom relief are indicated. Clinicians 

should focus simply on:

▶ managing hyperarousal symptoms, helping patients feel 

safe and secure in a comfortable environment;

▶ providing reassurance, minimizing reminders of the 

event, and normalizing symptoms; and

▶ ensuring patients (and family) are able to sleep, eat, and 

regain normal daily routines. 

° Long term: Beyond the acute aftermath, the goals of 

treatment are to establish a stable environment and manage 

symptoms, providing behavioral health treatments (eg, 

cognitive behavioral, exposure, etc) and medications. 

▶ Careful consideration should be given entering into a 

long-term therapeutic relationship with local foreign 

patients.

▶ Many medications will not be available in the local health 

system.

▶ The impending departure of care providers may provoke 

anxiety and feelings of abandonment in patients or their 

families. 
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Therapeutic Modalities 

• A calm, safe environment is a powerful tool. A low-stimulus 

environment that provides physical comfort; a clean, 

temperate shelter; food; a predictable schedule; rest; and the 

safety of loved ones can stabilize the situation and prevent 

further traumatization.

• Talking and play therapies using the principle of metaphor 

are also effective. Difficult or traumatic experiences can be 

processed through the brain by representation, either with 

words, play, or games. This indirect means allows the patient 

to control the level of arousal associated with the experiences 

and make sense of them through narrative in a way that is not 

emotionally overwhelming. 

° Play allows the experiences to be put in a larger context 

that “makes sense” without the experience fundamentally 

challenging the patient’s understanding of the world.

° With increasing age and sophistication, patients may be 

able to benefit more from cognitive therapies (as opposed 

to more “imaginative” play therapies). 

• There are virtually no psychotropic medications approved 

by the US Food and Drug Administration for small children, 

and only a few for adolescents. Psychotropic medications are 

frequently used “off-label” in children and are derivative of 

their uses in adults in smaller doses.

° Psychotropics should generally be thought of as adjuncts 

to other therapies. They should be used for treatment 

of targeted symptoms with clear understanding of 

their effects, side effects, dosing, benefits, and toxicities. 

Psychotropics are potentially quite dangerous. A clinician 

should be educated about psychotropic use and dosing in 

pediatric patients or seek expert psychiatric consultation 

before prescribing unfamiliar psychotropic medications. 

° The medications most commonly used are as follows: 

▶ Anxiety and depressive symptoms: selective serotonin 

reuptake inhibitors (eg, fluoxetine, sertraline, citalopram, 

etc). 

▶ Behavioral disorders, including agitation, aggression, 

and mood lability: “atypical” antipsychotic medications 

(eg, risperidone, aripiprazole, olanzapine, etc). 
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▶ Inattention and hyperactivity symptoms: stimulants 

(methylphenidate, dextroamphetamine, etc).

▶ Mood lability, aggression, and bipolar illness: mood 

stabilizers (eg, valproic acid, carbamazepine, topiramate, 

etc).

▶ Mood lability, aggression, and anxiety: consider sedation 

with benzodiazepines (eg, lorazepam, clonazepam).

▶ Other assorted medications may also be useful, such as:

▷ clonidine for aggression, tics, and Tourette syndrome; 

▷ anticholinergics (diphenhydramine and benztropine) 

for insomnia and acute agitation; 

▷ hydroxyzine (antihistamine) for anxiety; and 

▷ melatonin and/or zolpidem for insomnia.

• Restraints: Isolation and restraints should be a last resort

and only used to maintain the safety of the patient and the 

treatment team. The goal of isolation is to place the patient in 

a safer environment where he/she cannot endanger anyone.

° Isolation and “threatening” physical force can be highly 

alarming for patients and their families.

° Offer medications to a highly agitated patient before 

physically restraining the patient. 

° When dealing with agitated small children, a provider can 

wrap themselves around the child and use their weight 

gently to contain the child, applying “reassuring control” 

and preventing the child from hurting themselves or others.

° If the patient is older or larger, leather restraints may be 

required. Staff should be trained and organized into a “take 

down team,” ideally consisting of seven members: a leader, 

a person to manage each limb, one to manage the head, and 

one to administer medications. Any take down should be 

protocol-driven with established triggers and be preceded 

by a brief discussion by the team away from the patient. 

° Every effort should be made to de-escalate dangerous 

behaviors using a calm and quiet tone of voice; restraints 

are only used to maintain safety. 

° If absolutely necessary, deliberate overwhelming force can 

be used to take control of each limb and the patient’s head, 

taking care to avoid injury.
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° If the patient has refused oral medications, an intravenous 

(IV) or intramuscular (IM) cocktail can be administered to 

a restrained patient.

▶ A sedating cocktail of an antipsychotic, typical (eg, 

haloperidol) or atypical (eg, ziprasidone); a short-acting 

benzodiazepine (eg, lorazepam); and an anticholinergic 

(eg, diphenhydramine) can be administered: orally, IV, 

or IM.

▷ These require different preparations, so it is important 

before a take-down to have oral preparations ready 

(to offer the patient before the take-down) and IM/

IV preparations ready for after the patient has been 

restrained. 

▷ These medications are highly sedating; be prepared 

for the patient to become somnolent quickly and 

remain so for a period of time.

° Restraints carefully placed on each limb can secure the 

patient to a bed or stretcher and should be maintained for 

as brief a time as possible (less than 2 hours). 

° An attendant should be within an arm’s reach at all times 

and should regularly (every 15 minutes) check the restraints 

to ensure they are not too tight, that they allow for adequate 

perfusion, and that extremities are warm, with good 

capillary refill. 

° Once a patient is asleep, restraints should be carefully 

removed one limb at a time.

° Administering restraints can be a highly emotional 

experience. Afterward, separately debrief witnesses (such 

as family members), the restraint team, and the patient. 

Psychiatric Conditions

• Given the difficulties of translation and different cultural 

norms between Western medical providers and patients in 

austere or hostile environments, there is little use focusing 

on specific diagnoses as described in the Diagnostic and 

Statistical Manual of Mental Disorders. The focus should be on 

the approach to managing common symptom complexes.
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• Psychiatric syndromes tend to cluster. For example, anxiety 

disorders that may cluster together include posttraumatic 

stress, generalized anxiety, obsessive-compulsive disorder, 

panic, and specific phobias, as well as depression, grief, and 

bipolar illnesses. These conditions should be considered and 

treated.

• PsySTART, a behavioral health triage system (http://www.

cdms.uci.edu/PsySTART-cdms02142012.pdf) identifies 

patients at risk for trauma-related sequelae. It includes specific 

questions about: 

° death or injury of people close to the child,

° separation from loved ones,

° damage and destruction to the child’s home, and

° thoughts of harm (to self or others).

• Once determined to be at risk, a patient may receive preventive 

psychological services, if they are available.

Anxiety

• Anxiety is the most common psychiatric symptom that will 

confront a clinician in a deployed or austere environment. 

• Anxiety severity can range from mild nervousness to fullblown catatonia. It is a rare psychiatric emergency that can 

present in two dangerous forms: immobile or agitated. 

° Immobile catatonia manifests as unresponsiveness and 

rigidity. 

▶ Patients can cease to eat or function autonomically 

(including urinating and defecating).

▶ Patients can become dehydrated and develop 

rhabdomyolysis or kidney failure. 

▶ It is imperative that the clinician monitor the patient’s 

vital signs, get venous access, and provide fluids, as well 

as treat the anxiety. 

° In contrast, agitated catatonia is accompanied by wild 

and uncontrollable agitation, including flailing and 

aggressive behaviors. The uncontrolled movement can 

result in physical trauma, reduced intake, dehydration, 

hypoglycemia, and other metabolic abnormalities. 

° In both cases, the treatment of choice is IV benzodiazepines.
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• Causes of anxiety often involve traumatic events that frighten 

or threaten a person’s “bodily integrity” (eg, rape, injury, 

or witnessed death); the loss of a loved one or destruction 

of familiar objects (home, environment); or stimuli that 

overwhelm a person’s senses (eg, loud noises, shock, gore, 

destruction). A flood of neurotransmitters and neuroendocrine 

factors lead to hyperarousal and the formation of intense 

memories.

• Anxiety can present as or be accompanied by:

° specific phobias;

° “numbing,” or cognitive withdrawal from the circumstances 

(mutism or catatonia);

° hyperactivity and behavioral acting out (including attention 

deficit disorder-type behaviors);

° behavioral regression (including bedwetting and loss of 

behavioral milestones);

° compulsive or repetitive rumination about, or “acting out” 

of, actions related to the event; 

° severe agitation, crying, hysteria, disorganized behaviors, 

and simple nonresponsiveness to the environment; and

° symptoms of obsessive-compulsive disorder, such as a 

rigid need to have things said, done, or arranged in very 

precise and exact ways (from an outsider’s point of view, 

this appears irrational or strange).

• Acute stress reaction may also occur after a traumatic event. 

Psychiatric interventions should be environmental first 

(decrease stimulus in the environment, provide quiet, use 

soft light, ensure comfortable seating, provide food and soft 

“transitional” objects [ie, comforting soft toy], and maintain 

access to trusted adults).

° The goal when treating acute stress reaction is to decrease 

hyperarousal.

° If possible, clinicians should avoid direct questioning and 

history gathering. 

° Acute medications, such as anticholinergics, beta 

blockers, and sedatives, may be considered. However, 

anticholinergics and sedatives (such as benzodiazepines) 

can have a paradoxical effect in children (disinhibit rather 

than calm them).
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° Low-dose antipsychotic medications (such as risperidone) 

can be effective adjuncts. 

° If a patient is overwhelmed with anxiety, more extreme 

measures may be necessary to prevent self-harm. 

° Providing a quiet room or administering medications 

such as antipsychotics may be required (eg, risperidone 

sublingual or ziprasidone IM).

° Dosing regimens according to weight and agent should be 

carefully consulted (side effects of atypicals can include 

seizures, QTC prolongation, extra pyramidal symptoms, 

tardive dyskinesia, neuroleptic malignant syndrome, 

akathisia, and acute dystonia).

• Posttraumatic anxiety reactions can be accompanied by 

symptoms of psychosis, such as hearing the voices of or seeing 

the dead or wounded. These symptoms should be considered 

part of the anxiety process and not of an undiagnosed 

psychotic process (eg, schizophrenia), which is very rare in 

prepubescent children.

• Anxiety over the loss of an attachment figure can make it 

difficult to treat children. 

° Western providers often think of this as a variant of “school 

avoidance.” It is characterized by children having intense 

anxiety if they are required to be separated from their 

mothers or a member of their family.

° This type of anxiety should be managed the same way as 

other anxiety disorders. 

° This disorder is the result of both the child’s anxieties and 

those the caretaker “transmitted” to the child. Treat both 

the child and the context (including the person he/she is 

afraid of losing).

• Medium and long-term treatment of anxiety requires 

assessment of developmental needs, screening for the 

psychological effects of trauma, and effective communication.

° After a thorough evaluation of the patient and his/

her family, commence targeted treatment of medical 

conditions, including pain and delirium.
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Behavioral Healthcare of Children in Austere Environments

° Explore posttraumatic stress disorder symptoms 

(hyperarousal, numbing, avoidance, reliving the events). 

Avoid situations, people, or objects associated with the 

traumatic event, which can induce panic and extreme acting 

out, intense memories, flashbacks, and nightmares.

° Be aware of grief reactions, depression, and other disorders.

° Generally, talk therapy is indicated first, sometimes 

accompanied by medication (antidepressants or anxiolytics).

Disordered Sleep 

• Sleep is an essential aspect of psychological healing and overall 

well-being. Ensure patients are able to sleep, are physically 

comfortable, and are not being awakened unnecessarily or 

waking themselves.

• Sleep disorders can be characterized by:

° early, mid-, and late-cycle insomnias (ie, trouble falling 

asleep or staying asleep, or waking up early);

° nighttime activity (eg, night terrors or somnambulism); and

° fear of sleeping (as a result of fear of further trauma or of 

their nightmares).

• Although a child may naturally suffer from night terrors, he/

she may also be suffering from posttraumatic nightmares, 

which can resemble night terrors and include intense nighttime 

physical activity (restlessness), vocalizations, somnambulism, 

and evidence of intense distress. 

• Many patients wake themselves with panic symptoms (racing 

heart, shortness of breath, diaphoresis, and sense of impending 

doom) and then have trouble going back to sleep. 

• A normal fear of the dark can become exaggerated to 

the point that a child does not want to go to sleep and is 

afraid to do so. This needs to be addressed vigorously with 

interventions to ensure that the patient (and his/her family 

attendants) are physically comfortable, feel safe (have a person 

present, perhaps in the same bed), and, as a last resort, have 

medications that ensure sleep initiation (often anticholinergics, 

as long as they do not result in paradoxical arousal).

• For initial insomnia, ensuring the environment is conducive 

to sleep (low lighting, no noise) can be augmented with sleep 

aids, such as diphenhydramine, melatonin receptor agonists, 

and non-benzodiazepine hypnotics.
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Pediatric Surgery and Medicine for Hostile Environments 

• Low-dose antipsychotic medication (eg, risperidone or 

quetiapine) may ultimately be required to help the patient 

become drowsy and to decrease the intense ruminations and 

fear reactions that impair the capacity to stay asleep. Clonidine 

may also be useful.

• In adults, prazosin has proven effective for treating 

posttraumatic nightmares (it helps patients fall and stay 

asleep); however, there are currently no studies on the use of 

prazosin for nightmares in children.

Grief and Depression

• Symptoms of grief and depression are often not the same in 

children and adolescents as in adults, though children may 

exhibit some similar symptoms, such as becoming tearful and 

withdrawn or having decreased energy and appetite. Instead, 

children are often clingy, easily agitated, and complain of 

somatic problems, such as headaches, stomachaches, and 

nonspecific pains. 

• Children can be withdrawn or they can become oppositional, 

angry, or “bad,” breaking the rules and refusing to act 

according to specified norms. 

Antisocial Behaviors, Oppositionality, and Aggression

• Inappropriate behaviors can be difficult to manage in a clinic 

or a hospital. The roots of bad behavior can be far-ranging, 

from poor parenting to maladaptive reactions to acute stress.

• Fear may cause a child to be aggressive.

• Compulsively acting out traumatic events is a way of turning 

a passive experience (being a victim) into an active one (being 

the aggressor).

• First and foremost, maintain the safety of other patients, 

staff, and the child or adolescent who is behaving badly. Act 

aggressively to prevent harm, including assault, bullying, 

threatening, and stealing (food, possessions, or medications). 

Once safety has been adequately established, implement 

a well-delineated treatment plan to modify the aberrant 

behaviors. Depending on the developmental age of the child:

° A reward/punishment system can be put into place.
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° Medications, such as clonidine, low-dose risperidone, 

or ariprazole, can be used to manage aggression and 

outbursts.

• Other diagnoses can be ruled out or treated, such as toxins 

and ingestions, intracranial pathology (eg, traumatic brain 

injury), and metabolic causes.

Mass Casualty Events and Disasters

• One of the most profound effects a disaster can have on a 

local community is psychological. A disaster may best be 

understood as a terror-inducing event. The site of a mass 

casualty (MASCAL) event or a natural disaster is generally 

chaotic. For the clinician, it can be difficult to distinguish the 

patients with medical complications from the psychiatric 

casualties.

• Local medical facilities can be flooded with patients 

experiencing panic symptoms, such as shortness of breath, 

racing heart, diaphoresis, and a sense of impending doom. 

Symptoms can mimic nerve agent or other toxic exposures.

• It is important during MASCAL events for a clinician to 

step back from a traditional role and consider the broader 

perspective. Clinicians must be savvy to the larger implications 

of the event and tailor their approach to the nature and breadth 

of the disaster.

• A standard approach may be to use PsySTART or refer to the 

Psychological First Aid Field Operations Guide for psychological 

triage and first aid. 

• Many topics for consideration are covered in this book (see 

Chapter 42, Children in Disasters).

• The most effective way to manage anxiety and decrease the 

resulting behavioral health complications of a MASCAL event 

is to deal with the noninjured population.

• An effective public affairs office that can communicate 

information from the epicenter of the event to locals, family, 

and the media can minimize the problems associated with the 

aftermath of a MASCAL event (overloaded highways, access 

to the MASCAL site, overwhelmed phone and cellular lines, 

etc). 
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Pediatric Surgery and Medicine for Hostile Environments 

• For onsite disasters (eg, a plane crash or building collapse), 

establishing protocols for aid workers to have an area of 

respite (including food and beverage points) and “transition 

times” (for those coming on and off shift) to provide effective 

information for their replacements can be invaluable in 

helping workers debrief and process their experiences.

• Behavioral health workers can play effective roles in triaging 

and debriefing site victims; however, they may also be effective 

in helping at gathering points to assess and debrief aid workers 

and behind barriers to mingle with family and friends trying 

to reach the MASCAL site. 

• Often, the role of behavioral health provider is not as culturally 

welcome as other more innocuous roles. Some behavioral 

health providers may wish to introduce themselves as 

“security workers,” which allows them more entrée and 

creates a greater sense of safety.

Psychological Well-Being of Providers

• Injured children evoke more stress in staff than any other 

patients. Team resilience can be strengthened with special 

staff training and support for caretakers to reduce secondary 

traumatization and burnout.

• Self-monitoring for apathy, moodiness, overwork, insomnia, 

and demoralization, and aiding colleagues with such 

symptoms, is important in prevention.

• Self-care entails maintaining physical wellness; sustaining 

a balance of emotions, interests, and work; maintaining 

restorative personal relationships; knowing one’s own 

physical and emotional limits; and getting help when it is 

needed.

Conclusion

It is all too easy for a busy healthcare worker in an austere 

environment to focus solely on medical complaints, 

unintentionally neglecting the larger context and the impact of 

a patient’s subjective experience, which frequently determines 

the patient’s engagement in treatment. Healthcare providers 

must acknowledge that psychiatric symptoms exist and feel 

comfortable proceeding with treatment despite the limitations 
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Behavioral Healthcare of Children in Austere Environments

of the environment. Providers must also remember to manage 

their own anxiety and psychological stress so they can provide 

the best possible care to their patients. 

Online Resources

• The American Academy of Child and Adolescent Psychiatry 

has a large database of multilanguage handouts, practice 

parameters, and recommendations. 

° American Academy of Child and Adolescent Psychiatry. 

Facts for Families website. http://www.aacap.org/AACAP/

Families_and_Youth/Facts_for_Families/Home.aspx. 

Accessed January 30, 2015.

• The National Child Traumatic Stress Network offers resources 

for education and learning, including Psychological First Aid 

Online. 

° National Child Traumatic Stress Network. Learning Center 

for Child and Adolescent Trauma website. http://learn.nctsn.

org/course/. Accessed January 30, 2015. 

• The goal of the Nebraska Disaster Behavioral Health Project 

is to mitigate the psychosocial consequences of terrorism 

and disaster. It brings together many resources for disaster 

response. 

° University of Nebraska Public Policy Central. Nebraska 

Disaster Behavioral Health Project website. http://www.

disastermh.nebraska.edu/. Accessed January 30, 2015.

• The Inter-Agency Standing Committee coordinates 

humanitarian assistance for the United Nations and many 

nongovernmental organizations. 

° Inter-Agency Standing Committee website. http://www.

humanitarianinfo.org/iasc/. Accessed January 30, 2015.

• The Uniformed Services University of the Health Sciences 

Center for the Study of Traumatic Stress (accessed January 30, 

2015) has an educational campaign to facilitate communication 

about war injuries between healthcare providers and families. 

° The Uniformed Services University of the Health 

Sciences Department of Psychiatry. Center for the 

Study of Traumatic Stress website. http://www.

centerforthestudyoftraumaticstress.org. Accessed January 

30, 2015.
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° The Uniformed Services University of the Health Sciences. 

Courage to Care, Courage to Talk . . . About War Injuries 

website. http://www.couragetotalk.org. Accessed January 

30, 2015.

• PsySTART is a behavioral health triage system that identifies 

patients at risk for trauma-related sequelae. 

° Schreiber M. The PsySTART Rapid Mental Health Triage 

and Incident Management System. http://www.cdms.uci.

edu/PsySTART-cdms02142012.pdf. Accessed January 30, 

2015.

Further Reading

1. American Psychiatric Association. Diagnostic and Statistical Manual 

of Mental Disorders. 5th ed. Arlington, VA: American Psychiatric 

Publishing; 2013.

2. National Child Traumatic Stress Network and National Center 

for PTSD. Psychological First Aid Field Operations Guide. Rockville, 

MD: US Department of Health and Human Services; 2006. http://

www.nctsn.org/sites/default/files/pfa/english/1-psyfirstaid_final_

complete_manual.pdf.
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Pharmacotherapeutics

Chapter 38

Pharmacotherapeutics

Factors Affecting Pharmacokinetics

Children are not simply small adults. As they grow, children’s 

bodies undergo changes in absorption, distribution, metabolism, 

and excretion; all of which affect the pharmacokinetics of 

drugs. Many of the drugs and dosages used in infants and 

children are not specifically approved by the US Food and Drug 

Administration (FDA) for those indications in those patient 

populations. Some of the drugs and dosages recommended 

in this text are not FDA approved, but are widely accepted as 

appropriate.

Absorption

• Drug absorption is influenced by:

° age;

° physiologic condition;

° drug dosage, form, and physical properties; and

° interactions with concurrent medications and foods.

• Absorption of oral drugs mostly takes place in the small 

intestine, where pH ranges from 4 to 8. 

° The pH of neonatal gastric fluid is neutral to slightly acidic, 

but becomes more acidic as the infant matures.

▶ The pH of neonatal gastric fluid usually reaches adult 

values by 2 years of age, but may take until the child is 

up to 6 years of age.

▶ This higher gastric pH affects the absorption of some 

drugs (eg, phenytoin, phenobarbital, ampicillin, 

nafcillin, and penicillin G).

° Neonates have erratic, prolonged gastric emptying times 

and intestinal transit times, which leads to increased 

absorption. Gastric emptying time reaches adult values by 

6 to 8 months of age.
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° Most oral medications have been found to be safely and 

efficiently tolerated and absorbed by nonseptic neonates. 

° Older children have faster gastric emptying and transit 

time, which leads to decreased absorption.

° During the first few months of life, neonates have immature 

biliary function that results in a decreased amount of bile 

salts and decreased absorption of lipid-soluble drugs (eg, 

vitamin E).

° Concurrent administration of infant formulas or 

milk products temporarily increases pH and may 

impede absorption of acidic drugs (eg, furosemide and 

phenobarbital).

° Critical illness often shunts blood from the gut to the heart 

and brain, effectively decreasing the gut’s ability to absorb 

medication.

° Neonates, infants, and young children should receive 

oral medications on an empty stomach unless the 

pharmacokinetics for the specific medication will be 

affected by the presence of food and change in pH.

• Absorption of parenteral drugs

° Neonates and young infants have small skeletal muscle 

mass and variable blood flow; therefore, absorption of drugs 

administered via the intramuscular and subcutaneous 

routes may be unpredictable, especially in the context of 

shock or poor perfusion.

° Properties of some medications influence intramuscular 

absorption (eg, phenobarbital [rapid], diazepam [slow]).

• Absorption of topical drugs

° Neonates and infants have enhanced absorption of topical 

drugs due to the relative thinness and the high water 

concentration of their skin.

° Neonates and infants possess a high proportion of body surface 

area (BSA) to total body mass, which can lead to systemic, 

toxic, and adverse reactions to topical agents (eg, isopropyl 

alcohol, steroid ointments, and hexachlorophene soaps).

Distribution

• Developmental changes in body composition affect drug 

distribution.
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Pharmacotherapeutics

° Premature infants: body fluid equals up to 85% of total 

body weight.

° Term neonates: body fluid equals 55% to 70% of total body 

weight.

° During the first 12 months after birth, total body fluid 

decreases dramatically, then gradually decreases to adult 

proportions by 12 years of age.

▶ Body fluid equals 50% to 55% of an adult’s total body 

weight.

▶ Extracellular fluid is 40% of a neonate’s weight (as 

opposed to 20% of adult’s weight).

• Solubility in lipids versus water affects distribution of drugs 

and dosages.

° A higher proportion of fluid to body weight greatly 

enhances the distribution of water-soluble drugs.

° The low ratio of fat to muscle in children limits the 

distribution of fat-soluble drugs.

° Plasma protein binding affects distribution; only free 

(unbound) drugs, can exert a pharmacological effect.

▶ The affinity of plasma proteins to bind with drugs is 

reduced in neonates.

▶ Bilirubin and free fatty acids compete with drugs for 

binding sites on plasma proteins and further reduce 

the protein-binding abilities of drugs in neonates; 

sulfonamides, salicylates, penicillins, and furosemide 

displace bilirubin from plasma proteins.

▶ Children less than 3 months old have significantly 

less albumin and α-1-acid glycoprotein than adults; 

drugs that bind primarily to these proteins must be 

administered in reduced doses.

▶ Drug binding to plasma protein reaches adult levels by 

approximately 12 months of age.

° Immaturity of the blood–brain barrier in neonates results 

in greater drug penetration of cerebrospinal fluid (eg, 

aminoglycosides).

Metabolism

• Most drugs are metabolized in the liver.

° Some enzymes reach adult levels at a few months of age, 

while others may take years.
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Pediatric Surgery and Medicine for Hostile Environments 

° Neonates have a large liver (40% of body mass versus 2% 

in adults); therefore, they have a relatively larger surface 

area for metabolism.

° A neonate’s immature liver and enzyme system may 

impede metabolism. The ability of a child to metabolize 

many drugs may not be developed fully until 12 to 15 

months of age.

• Older infants and children metabolize some drugs more 

rapidly than adults (eg, carbamazepine, oxcarbazepine, 

quinidine, phenytoin) and may require larger doses to achieve 

a therapeutic effect.

• Enzymatic functions mature over time.

° Glucuronidation (a process the liver uses to eliminate and 

detoxify drugs) is not sufficiently developed until 1 month 

of age.

° Standard pediatric dosages of some drugs may produce 

adverse or toxic reactions in neonates (eg, chloramphenicol).

° Intrauterine exposure to drugs may induce early 

development of hepatic enzymes, which will result in 

increased capacity to metabolize drugs.

° Concurrent drug use can produce interactions that may

stimulate or reduce liver enzyme activity (eg, phenobarbital 

can increase metabolism of phenytoin, requiring an 

increased dose of phenytoin).

Excretion

• Most drugs and metabolites are excreted in the urine. 

• Glomerular filtration rate reaches adult levels by 12 months 

of age in most full-term infants; premature infants will 

take longer to reach adult levels. Renal tubular secretion 

mechanisms become fully functional after glomerular filtration 

rate has reached adult levels.

• Maturity of the renal system and presence of renal disease can 

affect drug dosage requirements.

• Renal function is much more developed in full-term neonates 

than in premature infants.

• Inadequate renal excretion results in drug accumulation and 

possible toxicity unless doses are reduced, dosing interval is 

increased, or both, depending on the medication.
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Pharmacotherapeutics

Administering Drugs to Children

• General rules

° Pediatric medication doses should not be extrapolated from 

adult doses.

° There are no standardized units for pediatric drug dosing. 

▶ Most drug dosages are expressed in mg/kg/dose or mg/

kg/day; some references list the units in “mg/kg/d.” The 

“d” may stand for dose or day. Confirm with source.

▶ Some dosages are calculated using BSA in units 

expressed as mg/m2/dose or mg/m2/day. BSA for children 

and adults (in m2) may be calculated using the following:

° Many drug regimens require modification because of renal

insufficiency or failure; usually the dose is decreased, the 

dosing interval is changed, or both.

▶ See Chapter 33, Pediatric Nephrology, to calculate the 

creatinine clearance (ClCr) using the Schwartz Formula. 

This formula may not provide an accurate estimation of 

ClCr for infants less than 6 months of age or for patients 

with severe starvation or muscle wasting.

▶ The change in medication regimen with renal insufficiency 

depends on the drug and extent of impairment. Common 

cut-off points for regimen modification are ClCr less 

than 70, less than 50, less than 25, and less than 10 mL/

minute/1.732.

▷ The lower the ClCr, the more severe the renal 

insufficiency.

▷ Consult a pharmacist or pediatric drug reference for 

specific regimen changes.

▷ Reevaluate dosages at regular intervals to ensure 

proper adjustment as renal function changes. 

° Ensure that the BSA or body weight dosage is ageappropriate. 

° Many liquid medication preparations will settle and 

require shaking before use to equally redistribute drug in 

suspension.

Ht (cm) × Wt (kg)

3,600
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Pediatric Surgery and Medicine for Hostile Environments 

° When calculating amounts per kilogram, do not exceed the 

maximum adult dosage or maximum daily dosing.

° Always check dosing in an appropriate, published, 

pediatric drug reference (eg, The Harriet Lane Handbook

or NeoFax [http://sites.truvenhealth.com/neofax/; Truven 

Health Analytics, Ann Arbor, Michigan] for neonates, and 

always double-check all computations).

Emergency Pediatric Drug Therapy

• Emergency pediatric drug therapy requires quick, accurate 

dosage calculations and proper administration techniques 

(Table 38-1).

• Refer to the Broselow tapes and PALS cards inside the covers of 

this book to assist with the dosing and sequence of medications 

for the various resuscitation algorithms. 

• Many drugs used for pediatric resuscitation are the same 

as those used for adults, but with different dosages or 

concentrations based on weight or BSA.

• Emergency drug sheets must be filled out individually and 

kept at the child’s bedside.

• Medication administered via peripheral vascular access 

(followed by a flush), a central line, or intraosseous access is 

equally efficacious.

• The endotracheal route may be used to administer epinephrine, 

atropine, and lidocaine. However, endotracheal administration 

of drugs is no longer recommended by the Neonatal 

Resuscitation Program (see Textbook of Neonatal Resuscitation

in Further Reading).

° Usually the dose is 1.5- to 10-fold that for the intravenous 

route.

° Follow drug administration with a 5-cc flush of normal

saline to aid in drug delivery to the peripheral airways.
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Pharmacotherapeutics

Table 38-1. Drugs Used During Pediatric Cardiopulmonary ArrestsDrug (generic) Class Indications Dose CommentsEpinephrine Catecholamine • Cardiac arrest; • Initial: 0.01 mg/kg • The volume given is always

with a & b effects symptomatic IV/IO; 0.10 mg/kg via ET 0.10 mL/kg (ie, 0.10 mL of

bradycardia; • Repeat every 3–5 min 1:10,000 solution = 0.01 mg/kg)PEA, VF, VT during resuscitation • For ET delivery (0.10 mL of • Use infusion 1:1,000 solution = 0.10 mg/kg)postarrest if • Follow with 5-cc NS flushintermittent • Can cause local tissue necrosisboluses failed to restore perfusing cardiac rhythm

Atropine Parasympatholytic Symptomatic • 0.02 mg/kg IV, IO, ETT • CO is HR-dependent

agent bradycardia • Min dose: 0.1 mg • Symptomatic bradycardia

refractory to Max dose: MUST be treatedoptimal airway child = 0.5 mg • Doses < minimummanagement adolescent = 1 mg recommend may cause 

bradycardia in infants

(Table 38-1 continues)
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Pediatric Surgery and Medicine for Hostile Environments Adenosine Antiarrhythmic Reentrant SVT • Initial: 0.1 mg/kg rapid • Short half-life; bolus rapidly agent IV/IO bolus and as centrally as possible • Repeat dose: 0.2 mg/kg • Follow immediately with • Max single dose: 12 mg 5–10-cc NS flush via 3-way stopcock • Be alert for possible asthma exacerbation Sodium Alkalinizing agent Documented • 1 mEq/kg IV or IO Infuse slowly and only if Bicarbonate severe metabolic • May empirically dose ventilation is adequate acidosis due to 0.5 mEq/L every 10 min • May decrease ionized Ca++ prolonged arrest; over 1–2 min if ABG levels hyperkalemia; results not available • May cause Na+ and H O2 TCA overdose overload Glucose Hypoglycemia • 0.5–1 g/kg IV • Hypertonic glucose (D25W (2–4 mL/kg D25W; or D50W) may harden 5–10 mL/kg D10W) peripheral veins if it • Max concentration: D25W extravasates

• Do not exceed 12.5% Dextrose in neonates

Table 38-1 continued

(Table 38-1 continues)
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Pharmacotherapeutics

Calcium Calcium salt Hypocalcemia, • 0.2 mL/kg of elemental • Infuse no faster than 100

chloride hyperkalemia calcium (20 mg/kg) mg/min. May induce

• Repeat after 10 min prn bradycardia or asystole, if ionized calcium especially if patient is alsodeficiency persists on digoxin

• Extravasation can cause chemical burn or sclerosis of peripheral veins

Naloxone Narcotic agonist Narcotic poisoning Birth–5 y (≤ 20 kg): • Rare side effects usually

0.1 mg/kg IV/ETT related to abrupt narcotic> 5 y (≥ 20 kg): reversal0.4–2 mg/dose IV/ETT • Administer with caution

Continuous infusion: immediately after birth to

0.04–0.16 mg/kg/h, infants of addicted motherstitrated to effect to avoid abrupt withdrawal 

and seizures in infant

Magnesium Antiarrhythmic Hypomagnesemia 25–50 mg/kg IV/IO • Monitor serum Mg++ levelsulfate agent; electrolyte torsades de (max dose: 2g/dose) • Use with caution in patients 

pointes also on digoxin (can lead to 

heart block)

Table 38-1 continued

(Table 38-1 continues)
638

Pediatric Surgery and Medicine for Hostile Environments Lidocaine Antiarrhythmic Ventricular Loading: 1 mg/kg • Toxic levels can cause agent dysrhythmias Infusion: 20–50 μg/kg/min myocardial, circulatory, (concentration: 120 mg and/or CNS depression lidocaine/100 mL D W) 5 • Metabolized by the liver ABG: arterial blood gas CNS: central nervous system CO: cardiac output D W: dextrose 5% in water 5 D10W: dextrose 10% in water D25W: dextrose 25% in water D50W: dextrose 50% in water ET: endotracheal ETT: endotracheal tube HR: heart rate IO: intraosseous IV: intravenous PEA: pulseless electrical activity PRN: pro re nata (as needed) NS: normal saline

SVT: supraventricular tachycardiaTCA:tricyclic antidepressantTable 38-1 VF: ventricular fibrillationVT: ventricular tachycardia

continued
639

Pharmacotherapeutics

Further Reading

1. Phelps SJ, HakEB, Crill CM. Pediatric Injectable Drugs: The Teddy Bear 

Book. 8th ed. Bethesda, MD: American Society of Health-System 

Pharmacists; 2007.

2. Taketomo CT, Hodding JH, Kraus DM. Pediatric Dosage Handbook: 

Including Neonatal Dosing, Drug Administration, & Extemporaneous 

Preparations. 16th ed. Hudson, OH: American Pharmaceutical 

Association-Lexicomp; 2009.

3. Custer JW, Rau RE, Lee CK. The Harriet Lane Handbook: Mobile 

Medicine Series, Expert Consult: Online and Print. 18th ed. 

Philadelphia, PA: Mosby; 2008.

4. Mosteller RD. Simplified calculation of body surface area. N Engl 

J Med. 1987;317(17):1098 (Letter).

5. Lam TK, Leung DT. Moreon simplified calculation of body surface 

area. N Engl J Med. 1998;318(17):1098 (Letter).

6. Pagliaro LA, Pagliaro AM. Problems in Pediatric Drug Therapy. 4th 

ed. Washington, DC: American Pharmaceutical Association; 2002.

7. Engorn B, Flerlage J. The Harriet Lane Handbook: A Manual for Pediatric 

House Officers. 20th ed. Philadelphia, PA: Saunders/Elsevier; 2014.

8. Kattwinkel J, ed. Textbook of Neonatal Resuscitation. 6th ed. Elk Grove 

Village, IL: American Academy of Pediatrics; 2011.
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Pediatric Surgery and Medicine for Hostile Environments 
641

Bites and Stings

Chapter 39

Bites and Stings

Introduction

Arthropod, insect, and snake envenomation are common medical 

problems but may be complex due to the variety of animals and 

the nature of exposures involved. Mortality rates in humans from 

most venom exposures are low.

There are specific problems with envenomation in children. 

Smaller children do worse with envenomation than adults 

because the snake or arthropod injects the same amount of venom 

into a much smaller host. Children are also poor historians, 

so a reliable story of the incident may be difficult to obtain. 

Unnecessary procedures, such as incision and suction over 

wounds and tourniquets, increase morbidity.

History

• Focus on the following when taking a history after 

envenomation:

° timing of the event,

° location of the bite or sting,

° nature of what happened, and

° whether or not spiders, snakes, or scorpions have been seen 

in the area or home.

• General symptoms of envenomation include pain, swelling, 

headache, and nausea. More severe symptoms may include 

necrosis, shock, and respiratory arrest. 

• Physical examination

° Examine the patient’s entire body, paying special attention 

to the hands, feet, legs, buttocks, and genitalia.

° Local tenderness and edema are common signs of 

envenomation. 
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Pediatric Surgery and Medicine for Hostile Environments 

• Edema and erythema should be measured repeatedly to assess 

progression.

Treatment for Common Sources of Envenomation

• General principles, regardless of etiology, are as follows:

° Give supportive care and monitor for complications of 

shock and respiratory arrest.

° Decontaminate the wound site, bandage it, and immobilize 

the area. 

° Assess the need for tetanus prophylaxis. 

° Evacuate patients with potentially severe bites and stings 

to definitive care. 

° Give antibiotics only for secondary infection. 

• Bees and wasps

° Bees, wasps, and other stinging insects account for roughly 

one-third of all envenomations. Stings may cause allergic 

symptoms and death from anaphylaxis.

° Treatment

▶ Remove stinger and decontaminate the area.

▶ Most reactions are local and can be treated with 

acetaminophen and antihistamines.

▶ Consider a steroid burst with antihistamine for large 

reactions.

▶ Treat anaphylaxis with epinephrine. 

▷ Epinephrine 0.01 mg/kg of a 1:1000 solution, OR

▷ A pediatric epinephrine autoinjector is available in a 

0.15-mg dose, but a 0.3-mg dose should be given to 

children 30 kg and larger.

▶ Steroids and antihistamines may prevent relapses.

• Snakes

° Snakebite is an important medical emergency, although 

25% to 49% of bites have no venom.

° Bites are commonly on the extremities, usually from 

stepping on or handling a snake.

° Signs and symptoms:

▶ General signs include pain, edema, vomiting, headache, 

and shock.

▶ Specific signs depend on the venom, the dose, and the 

site of injection.
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Bites and Stings

▷ Local effects include immediate pain, tender swelling 

spreading from the site of the bite, blisters, and 

necrosis. 

▷ Coagulation disturbances from hemotoxic venoms 

frequently present as bruising and bleeding from the 

gums or oozing from bite or venipuncture sites.

▷ Neurotoxic effects include weakness, paralysis, and 

respiratory failure.

▷ Rhabdomyolysis leading to renal failure can 

complicate bites.

° Treatment

▶ Immobilize the limb, remove jewelry, and evacuate the 

patient to a medical facility. 

▶ Do not use extraction, incisions, suction, tourniquets, or 

other unproven treatments.

▶ Treat symptomatically and with supportive care.

▶ Apparent hypovolemia is due to distributive shock. 

Treatment includes fluid boluses with isotonic fluid and 

may require vasopressors to restore perfusion.

▶ Anticholinesterases can be considered as an adjunct 

treatment for neurotoxic envenomation. Administer 

neostigmine 0.01 to 0.04 mg/kg intramuscularly, 

intravenously (IV), or subcutaneously every 2 to 4 hours, 

depending on symptom severity and clinical progress 

(adult dosing 0.5–2.5 mg every 1–2 hours, up to 10 mg/24 

hours). 

▶ For patients with an uncertain degree of neurotoxic 

envenomation, some experts advocate performing a 

“Tensilon test” first: administer atropine sulphate (50 

mg/kg IV for children, up to 0.6 mg for adults) followed 

by IV edrophonium chloride (0.25 mg/kg for children, 

up to 10 mg for adults). Those with clear symptom 

improvement can be managed as above.

▶ Antivenom (antivenin) should be used only for systemic 

or severe local envenoming. Dosage (number of vials) 

is based on the severity of symptoms and the patient’s 

response to therapy. The patient may need repeated 

doses over time.
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Pediatric Surgery and Medicine for Hostile Environments 

▷ Antivenin is typically carried only at Role 3 facilities. 

Small units deploying without that level of support 

should identify referral sites through the combatant 

command (COCOM) or embassy prior to deployment. 

▷ Vipera berus (European viper), eastern coral snake, 

and Crotalidae (pit viper) antivenins are available 

through US military medical supply companies. 

▷ The World Health Organization maintains a 

worldwide venomous snake distribution and 

antivenom website with an image library (http://apps.

who.int/bloodproducts/snakeantivenoms/database/).

▷ Local Ministry of Health officials can help identify 

indigenous venomous snakes and potential sources 

of antivenom.

▷ COCOMs have the authority to stock antivenom that 

has not been approved by the US Food and Drug 

Administration (FDA) at Role 3 facilities. A blanket 

investigational new drug application has been filed 

with the FDA for use of foreign antivenoms.

▷ Use of antivenom must be reported through the 

COCOM to US Army Medical Research and Materiel 

Command to ensure regulatory compliance.

▷ Epinephrine should be available to treat allergic 

reactions to antivenom.

• Scorpion

° Scorpions are common around the world; most bites are 

only as dangerous and painful as a bee sting.

° Most envenomations occur at night, mainly in bare-footed 

children or shepherds.

° Signs and symptoms

▶ “Tap test”: tapping over the inoculation site will elicit 

significant pain.

▶ The venom triggers an autonomic storm. Symptoms are 

more severe in young children and include neurotoxic 

symptoms, pulmonary edema, hyperthermia with 

rhabdomyolysis, and respiratory or heart failure. 

° Treatment

▶ Symptomatic and wound care, including 1% lidocaine 
645

Bites and Stings

injected into the wound for pain. For severe stings, 

provide sedation with short-acting benzodiazepines and 

opioid analgesia.

▶ Treat serious respiratory or neuromuscular symptoms 

with supportive measures.

▶ Antivenom is available in some countries. Centruroides 

antivenom was FDA-approved in the United States in 

2011.

▶ Consider prazosin (vasodilator therapy) for pulmonary 

edema.

• Black widow spider

° Black widows have a characteristic red hourglass on their 

abdomen.

° Death from a black widow bite is rare.

° Black widows are commonly found outside in privies or 

in piles of wood or trash. Venom contains a neurotoxin. 

° Signs and symptoms of a black widow spider bite include 

pain at the site of the bite, muscle fasciculations, weakness, 

and ptosis.

° Treatment

▶ Provide supportive care (including pain relief) and 

monitor for severe symptoms.

▶ Consider treatment adjuncts when indicated.

▷ Calcium gluconate (50–100 mg/kg for fasciculations; 

maximum dose of 2 g).

▷ Give muscle relaxants and benzodiazepines 

(diazepam) for severe muscle spasms.

▷ Administer horse-serum-based antivenom for severe 

symptoms (available through US military medical 

supply).

▷ Use of the antivenom is associated with a risk of 

anaphylaxis. Antivenom should be properly diluted 

per package insert instructions then infused over 30 

minutes. 

▷ Prior the antivenom, pretreat the patient with IV 

diphenhydramine and an H2-blocker. 

▷ Epinephrine should be available to treat allergic 

reactions to antivenom.
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Pediatric Surgery and Medicine for Hostile Environments 

• Brown recluse spider

° Nicknamed “fiddle back” for its dark violin shape.

° Generally found indoors, in dark areas like closets and 

basements.

° Signs and symptoms

▶ Classic lesion has an area of central necrosis within an 

erythematous ring (“blue-gray halo”). 

▶ Hemolysis and renal injury can be seen.

° Treatment

▶ Supportive care.

▶ Dapsone has been used in adults to reduce the extent 

of expanding necrotic lesions but may result in severe 

side effects (see Forks TP. Brown recluse spider bites. 

Am Board Fam Pract. 2000;13:415–23). 

• Other 

° Tick bite paralysis is a rare life-threatening disorder caused 

by envenomation from ixodid tick bites primarily seen in 

Eastern Australia. Sporadic cases of tick paralysis have been 

seen in North America and Africa but are associated with 

other ticks.

▶ Presents as a lower motor neuron paralysis progressing 

to respiratory failure similar to polio. 

▶ Removing the tick leads to rapid recovery. 

▶ Tick paralysis antivenom is available in Australia. 

° Caterpillars can have urticating hairs that cause dermatitis, 

and beetles can contain urticating substances that cause 

contact dermatitis (passive envenomation). Both exposures 

are treated symptomatically.
647

Hypothermia, Cold, and Heat Injuries

Chapter 40

Hypothermia, Cold, and Heat Injuries

Hypothermia 

• Hypothermia occurs when core temperature drops to 35°C or 

below. 

• Smaller children have larger surface-area-to-mass ratios and 

are more susceptible to hypothermia than adults.

• Hypothermia can occur rapidly in the setting of trauma 

regardless of ambient weather conditions.

• Heat is lost through four mechanisms: 

° radiation (roughly 60% of heat loss);

° evaporation (another 20%–25% of heat loss, usually from 

sweating and respiration);

° conduction, which is a concern with cold-water immersion 

or in the presence of wet clothing (clothes should be 

removed and the patient dried quickly); and

° convection, which increases with exposure to wind chill 

(eg, in the desert at night). 

Physiologic Effects

• Hematologic: in trauma patients, hypothermia exacerbates 

clotting dysfunction and is highly correlated with fatal 

outcomes. 

• Cardiovascular: tachycardia is the initial heat-generating 

protective measure, but heart rate and mean arterial 

pressure decrease as core temperature decreases. Atrial, then 

ventricular, dysrhythmias occur as the temperature decreases 

below 32°C.

• Neurological: neuronal enzyme activity declines with 

hypothermia, but cerebral perfusion pressure is maintained 

until temperature reaches 25°C.
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Pediatric Surgery and Medicine for Hostile Environments 

• Respiratory: initial tachypnea diminishes with a steady decline 

in minute ventilation and eventual cold bronchorrhea, which 

mimics pulmonary edema.

•	 Renal: as peripheral vasoconstriction creates total body fluid

overload, there is rapid diuresis of dilute fluid; effects are

enhanced by alcohol and cold-water immersion.

• Gastrointestinal: motility is decreased, leading to ileus.

Experience from Iraq and Afghanistan highlight the importance 

of preventing hypothermia during air evacuation. The 

Joint Theater Trauma System maintains a Clinical Practice 

Guideline on Hypothermia Prevention, Monitoring, and 

Management: available at http://www.usaisr.amedd.army.mil/

clinical_practice_guidelines.html. See Chapter 11, Aeromedical 

Evacuation, for more details and equipment available to avoid 

hypothermia during patient transport.

Treatment

• Emergency treatment areas should be maintained at a 

temperature of 85°–90°F during casualty resuscitation. 

• Check airway, breathing, and circulation; treat aggressively. 

• Hypothermia associated with icy water immersion can lead to 

the diving reflex, with good neurological outcomes even after

prolonged cardiopulmonary resuscitation and rewarming. 

This is not often the case with hypothermia occurring with 

complex polytrauma.

•	 The cold myocardium is resistant to defibrillation; continue

cardiopulmonary resuscitation.

• Some patients convert spontaneously when their temperature 

reaches 32°C or above.

• Actively rewarm.

° Remove all wet clothing, dry the patient, and wrap the 

patient with warm blankets. Use warming lights and/or a

forced-air warming device on exposed skin.

° Administer warmed intravenous fluids and consider warm

nasogastric fluids and warm rectal lavage.
649

Hypothermia, Cold, and Heat Injuries

Cold Injuries

Frostbite

• Frostbite is cold damage to the skin that causes vasoconstriction 

and eventual tissue freezing.

° Classify with a four-degree system, as for burns.

° Treat by immersion in warm water (104.0°F–107.6°F) over 

30 to 45 minutes. Rewarmed tissue is more susceptible 

to refreezing. If sustained thermal support is uncertain, 

consider delaying rewarming until the patient has reached 

definitive care.

° Tetanus prophylaxis is indicated.

° Pain is often severe and may require opioids.

° Both ibuprofen and aspirin are recommended as 

adjunct therapies because of antiplatelet activity. Tissue 

plasminogen activator and prostacyclin have also shown 

efficacy in a limited number of small trials, but optimal

medication management remains unclear.

° Rewarmed tissue is vulnerable to reperfusion injury, 

manifested by large blisters that may be hemorrhagic.

▶ These evolve into a hard eschar over 2 to 3 days and may 

appear similar to dry gangrene.

▶ Surgical debridement and amputation should be delayed 

until a clear demarcation line develops, except when 

reperfusion injury leads to compartment syndrome, or 

when secondary infection is also present.

Chilblains

• Chilblains are localized erythematous or violaceous skin 

lesions that develop after sustained exposure to cold air and 

are often pruritic or painful. 

• They can be precipitated by shorter periods of exposure in 

individuals with automimmune disorders. 

• The process is self-limited, despite it having the same 

pathophysiologic cascade as frostbite. 

• Manage by warming and preventing exposure.
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Pediatric Surgery and Medicine for Hostile Environments 

Warm Weather Injuries

Although heat injuries are common in deployed soldiers, infants 

and young children are also predisposed to these injuries because 

of their high body-surface-area-to-mass ratio. There are three 

types of heat illness (same as in adults).

Heat Cramps

• Heat cramps are muscle cramps from dilutional hyponatremia.

• There are no central nervous system signs.

•	 Treat by repleting fluids and sodium.

Heat Exhaustion

• Heat exhaustion manifests with dizziness, nausea, vomiting, 

and weakness without significant change to mental status.

• Skin is moist from excessive sweating.

• Mild elevation of core temperature to 39°C–40°C.

•	 Treat by replacing fluids and sodium.

Heatstroke

• Heatstroke is a true medical emergency with a high rate of 

mortality; it needs to be recognized and treated promptly.

• It presents as a combination of altered mental status, dry skin, 

and hyperpyrexia.

• Monitor for complications, including rhabdomyolysis, acute 

kidney injury, encephalopathy, and hepatic failure with 

associated coagulopathy.

• Treat by immediate active cooling (eg, ice to the neck and 

groin, fanning the skin after spraying with water, etc), and 

administering intravenous fluids and diazepam to lessen

shivering and cramping (which raise body heat) and to treat 

seizures.
651

Casualties of Chemical, Biological, Radiological, Nuclear, and Explosive Weapons

Chapter 41

Casualties of Chemical, Biological, 

Radiological, Nuclear, 

and Explosive Weapons

Background

War respects no age limits and children are inevitably innocent 

casualties in every conflict. Children are likely to be among the 

victims of future terrorist attacks, including those potentially 

involving chemical, biological, radiological, nuclear, and 

explosive (CBRNE) agents. Children have also even been 

specifically targeted for attack. It is imperative that clinicians 

be familiar with the needs of children exposed to the effects of 

CBRNE agents. 

Unique Considerations for Pediatric CBRNE Victims

Pediatric CBRNE victims differ from adults in myriad ways, 

which makes their care more problematic. Differences include:

• Anatomical and physiological differences. 

° Children have a higher surface-area-to-volume ratio, 

making them more susceptible to transdermal absorption 

of agents as well as to the effects of volume loss. 

▶ Children have a smaller relative blood volume than 

adults, which exacerbates the problem of fluid loss. 

▶ They have a less-well-keratinized epidermis, which 

enhances the problem of transdermal absorption.

° Increased minute ventilation increases children’s 

susceptibility to the effects of inhalational agents.

° Children’s less-mature blood–brain barrier permits greater 

penetration of certain toxins into the central nervous 

system.
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Pediatric Surgery and Medicine for Hostile Environments 

• Differences in presentation.

° Children may present with a different constellation of signs 

and symptoms or more intense disease than adults.

▶ Venezuelan equine encephalitis, an incapacitant in 

adults, can be lethal in young children.

▶ Melioidosis sometimes causes a parotitis in children but 

not in adults.

▶ Few, if any, children are immunized against smallpox, 

while many adults may have some degree of residual 

immunity from long-distant vaccination.

▶ Radiation injury disproportionately affects rapidly 

growing tissues, posing a special problem for young 

children.

• Treatment difficulties: Agents routinely used to treat adults 

may be contraindicated in young children (eg, fluoroquinolone 

and tetracycline antibiotics).

• Prophylactic difficulties. 

° Certain immunizations approved for adults are not licensed 

for use in children (eg, Anthrax Vaccine Adsorbed is only 

approved for those 18–65 years of age).

° Some vaccines (eg, vaccinia and yellow fever) have a higher 

incidence of complications in children.

• Developmental considerations. 

° Children “live closer to the ground.”

° They are less able to flee, follow the instructions of public 

safety personnel, or distinguish reality from fantasy (eg, 

repeated media broadcasts of an event may be seen by 

young children as multiple events).

° Children may be more prone to developing posttraumatic 

stress disorder than adults (see Gabbay, et al, in Further 

Reading).

° Drugs and antidotes are often unavailable in pediatric 

(liquid) dosing forms.

° Medical equipment is often unavailable in sizes suitable for 

children. In the domestic disaster response arena, National 

Disaster Medical System beds are often obtained through 

Department of Veterans Affairs hospitals, which have 

neither the facilities nor expertise to care for children. 
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Casualties of Chemical, Biological, Radiological, Nuclear, and Explosive Weapons

Pediatric Chemical Casualties

The use of chemical weapons dates back to antiquity. There are 

hundreds of chemical agents that may be employed by terrorists. 

Below are common military-grade agents.

Nerve Agents 

• Nerve agents are organophosphates that inhibit 

acetylcholinesterase; categorized as persistent nerve agents 

(eg, VX) and nonpersistent agents (eg, tabun, soman, and 

sarin).

• Signs and symptoms of exposure:

° Cholinergic crisis caused by the accumulation of 

acetylcholine at the neuromuscular junction. 

° Use the SLUDGE mnemonic to evaluate a patient: salivation, 

lacrimation, urination, defecation, gastrointestinal upset, 

and emesis. 

° Central effects include ataxia, seizures, coma, and 

respiratory depression.

• No laboratory findings are available rapidly enough to be 

of use in the acute clinical setting; diagnosis must thus be 

suspected on the basis of clinical findings.

• Treatment: Administer atropine and 2-pralidoxime chloride 

(20–50 mg/kg intravenous [IV] with a maximum of 2 g over 30 

minutes). There is no maximum dose for atropine, although 

experts recommend an initial dose of 0.05 mg/kg IV or 

intramuscular, titrating to effect (secretions are dry and the 

patient no longer shows signs of respiratory distress).

° Experts feel that adult autoinjectors may be safely used 

even in young children. 

° Seizures should be treated with benzodiazepines (either 

diazepam [0.3 mg/kg] or lorazepam [0.1 mg/kg] initially, 

titrating to effect). The IV preparation of diazepam can be 

delivered rectally.

Blister Agents (Vesicants) 

• Blister agents are cellular poisons that have been widely used. 

Mustard and lewisite are the most notable. 
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Pediatric Surgery and Medicine for Hostile Environments 

• Signs and symptoms of exposure to vesicants:

° Blister agents burn the eyes, skin, and respiratory tract, with 

higher exposures leading to systemic effects and eventual 

bone marrow suppression. 

° Mustard gas has a delayed onset of symptoms, whereas 

the onset following lewisite exposure is more rapid.

• No laboratory findings are available rapidly enough to be 

of clinical use. (According to the US Centers for Disease 

Control and Prevention [CDC], only five or six laboratories 

in the country can confirm presence of the chemical. Also, 

leukopenia can indicate vesicant exposure [nonspecific], as it 

usually begins 3–5 days after exposure. With a white blood 

cell count less than 500, the prognosis is poor.)

• Treatment includes:

° Rapid decontamination. Washing with soap and water is 

fine for most casualties. Dilute bleach from the standard 

military decontamination kit is equally effective. 

▶ The Reactive Skin Decontamination Lotion Kit (RSDL; 

Emergent BioSolutions Inc, Gaithersburg, MD) is 

available for use by the US military. It is intended 

to remove or neutralize vesicants, nerve agents, T-2 

mycotoxin, and many pesticide-related chemicals from 

the skin. 

▶ This reaction starts immediately and neutralization is 

usually complete within minutes, then the chemical can 

be rinsed from the skin with water. The RSDL kit has 

not been approved for use on children by the US Food 

and Drug Administration. 

° Supportive care. Meticulous attention to fluid requirements 

is necessary. Blister agent burns require less fluid 

resuscitation than conventional burns; however, they are 

likely to be more serious in children than in adults. 

Pulmonary Agents 

• Chlorine and phosgene are the two primary examples of 

pulmonary agents; however, perfluoroisobutylene can be 

inadvertently released from burning military vehicles due to 

the chemicals in the paint used on these tactical vehicles. 

• Signs and symptoms of exposure are as follows:
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Casualties of Chemical, Biological, Radiological, Nuclear, and Explosive Weapons

° Phosgene smells of newly mown hay. 

° The chemicals generate hydrochloric acid in the exposed 

victim and lead to an oxygen free-radical cascade. 

° The patient will first develop upper airway and conjunctival 

irritation, followed by wheezing and pulmonary edema.

° The more rapid the onset of symptoms, the more ominous 

the prognosis.

• No laboratory findings are specific, although monitoring of 

blood gases or transcutaneous oxygen saturation may help 

guide supportive therapy.

• Treatment is as follows: 

° Remove the victim from the area. 

° Provide supportive care.

▶ Oxygen, albuterol, and ipratropium bromide are the 

mainstays of treatment. Children will often require 

higher doses of albuterol than adults and they are more 

tolerant of the associated tachycardia. 

▶ Enforced bed rest may ameliorate the pulmonary 

edema associated with exposure to phosgene. This 

edema usually occurs 4 to 6 hours after exposure, but 

may be delayed for up to 24 hours. Pulmonary agents 

are denser than air; therefore, child victims will have a 

proportionately higher exposure than adults (because 

they are lower to the ground).

▶ Corticosteroid use is controversial and has not been 

shown to significantly improve outcomes from 

pulmonary edema. However, corticosteroids are known 

to diminish the inflammatory component of asthma, 

leading some experts to suggest their use (see Grainge 

C, and Rice P, in Further Reading). 

Blood Agents

• Cyanide and the cyanogens are blood agents. Cyanide is a 

volatile chemical that disperses easily in air.

• Signs and symptoms of exposure are as follows: 

° Cyanide inhibits cytochrome a3 and halts normal oxidative 

metabolism, leading to cellular hypoxia and acidosis.

° It strikes metabolically active tissues preferentially, 

specifically the heart and brain.
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Pediatric Surgery and Medicine for Hostile Environments 

° Cyanide’s toxicity is dose dependent, with mild exposures 

causing tachypnea, tachycardia, and dizziness. More 

substantial exposures lead to seizures, coma, apnea, cardiac 

arrest, and eventual death. 

• Laboratory findings: anion gap metabolic acidosis and 

elevated mixed venous oxygen saturation may be present, 

although treatment in an emergency situation must be based 

on clinical suspicion.

• Treatment includes movement to fresh air and administration 

of a cyanide antidote. 

° A traditional cyanide antidote kit consists of sodium or 

amyl nitrite followed by sodium thiosulfate.

° Administer amyl nitrite via inhalation. Crush a 0.3 mL 

ampul of amyl nitrite and have the patient inhale for 15 to 

30 seconds (may repeat in 3–5 minutes) until an IV sodium 

nitrite infusion is available.

° Administer 3% sodium nitrite (0.33 mL/kg for patients 

with a normal hemoglobin of 12) to a maximum dose of 

300 mg (10 mL of a 3% solution). Sodium nitrite should be 

infused slowly (over 5–10 minutes) to avoid hypotension. 

This causes the formation of methemoglobin, which in turn 

binds cyanide ion. 

° Follow with 25% sodium thiosulfate (1.65 mL/kg), to a 

maximum dose of 12.5 g (50 mL of a 25% solution). The 

liver uses the sodium thiosulfate to convert cyanide to 

thiocyanate, which is renally excreted.

° Nitrite-induced hypotension as well as excessive 

methemoglobin formation can be hazardous to pediatric 

patients. Weight-based dosing of antidotes is especially 

important. 

° Hydroxocobalamin (vitamin B12a) is a newly approved 

and licensed single-agent antidote that can be used as an 

alternative to dual-agent antidote kits.

▶ Recommended dose is 70 mg/kg (maximum 5 g) as a 

single infusion over 15 minutes. A second dose can be 

given in cases of severe intoxication.

▶ It works by binding cyanide to create cyanocobalamin, 

a nontoxic form of vitamin B12 that is readily excreted 

in urine. This detoxification reaction does not result in 
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Casualties of Chemical, Biological, Radiological, Nuclear, and Explosive Weapons

the generation of methemoglobin and does not interfere 

with the oxygen-carrying capacity of hemoglobin. 

Riot Control Agents

• CS gas (military-grade tear gas), CN gas (mace), and capsaicin 

(pepper spray) are riot control agents designed to incapacitate 

their victims rather than permanently injure them. 

• Signs and symptoms of exposure are as follows:

° Mild exposure: ocular pain and lacrimation with eventual 

blepharospasm. Irritation of the nose, throat, and upper 

airway also occur. 

° High-dose exposure: the victim can have blistering of the 

skin, tracheobronchitis, and eventual pulmonary edema. 

Death, though rare, has been reported.

• Laboratory findings are nonspecific. Laboratory tests (other 

than arterial blood gasses) are neither helpful nor relevant. 

• Treatment for riot control agents is supportive.

° Remove the victim from the area and remove potentially 

saturated clothing. 

° For patients with pulmonary symptoms, provide 

supplemental oxygen, as needed. 

° For patients experiencing airway reactivity (wheezing), use 

albuterol, ipratropium bromide, and steroids as indicated.

Pediatric Biological Casualties

In 1999, the CDC developed a list of those agents that, if employed 

as weapons of terror, would pose the greatest threats to public 

health. “Category A” agents are deemed to present the greatest 

risk and routinely appear at the top of state-sponsored biological 

weapons threat lists.

Category A Agents

• Anthrax (etiologic agent Bacillus anthracis, a gram-positive 

spore-forming rod) is acquired via the inhalational route and 

typically has an incubation period of 1 to 6 days.

° Signs and symptoms of exposure are as follows:

▶ A flu-like illness ensues, characterized by fever, myalgia, 

headache, and cough. 
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Pediatric Surgery and Medicine for Hostile Environments 

▶ A brief, intervening period of improvement sometimes 

follows 1 to 2 days of these symptoms. 

▶ Rapid deterioration then ensues; high fever, dyspnea, 

cyanosis, and shock mark this second phase. Hemorrhagic 

meningitis occurs in up to 50% of cases.

° Laboratory findings: anthrax should be suspected with the 

finding of sporulating gram-positive bacilli in skin biopsy 

material (in the case of cutaneous disease) or in blood, 

sputum, and stool cultures.

▶ Chest radiographs demonstrate a lung infiltrate 

with a widened mediastinum in the context of 

fever and constitutional signs, and in the absence of 

another obvious explanation (such as blunt trauma or 

postsurgical infection). 

▶ Confirmation is obtained by blood culture on standard 

media.

° Treatment and prophylaxis: see Table 41-1.

° Infection control: standard precautions. Anthrax is not 

contagious through the inhalational route.

• Plague (etiologic agent Yersinia pestis, a Gram-negative 

coccobacillary organism that demonstrates a “safety-pin” 

appearance with Gram or Wayson stain).

° Signs and symptoms are as follows:

▶ Symptoms of pneumonic plague include fever, chills, 

malaise, headache, and cough.

▶ A classic clinical finding is blood-streaked sputum. 

▶ Chest radiographs may reveal a patchy consolidation.

▶ Disseminated intravascular coagulation and 

overwhelming sepsis typically develop as the disease 

progresses, while meningitis occurs in 6% of cases. 

Without early therapy, plague can be rapidly fatal.

° Untreated pneumonic plague has a fatality rate approaching 

100%.

° Laboratory findings: a diagnosis of plague can be suspected 

by the finding of bipolar, “safety-pin”-staining bacilli in 

Gram or Wayson stains of sputum or aspirated lymph node 

material.

▶ Confirmation is obtained by culturing Y pestis from 

blood, sputum, or lymph-node aspirate. 
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Casualties of Chemical, Biological, Radiological, Nuclear, and Explosive Weapons

Table 41-1. Pediatric Therapy of and Prophylaxis Against 

Diseases Caused by Category A Biothreat Agents

Condition Appropriate Pediatric Regimens and Dosing*†

Anthrax Ciprofloxacin 10–15 mg/kg IV q12h, OR

(inhalational), Levofloxacin 8 mg/kg IV q12h, OR

therapy‡§ Doxycycline 2.2 mg/kg IV q12h,

AND

Clindamycin¥ 10–15 mg/kg IV q8h

AND

Penicillin G¶ 400–600k U/kg/d IV ÷ q4h

AND CONSIDER

Raxibacumab IV (> 50 kg: 40 mg/kg; 15–50 kg: 

60 mg/kg; < 15 kg: 80 mg/kg) 

Anthrax Ciprofloxacin 10–15 mg/kg PO q12h, OR

(inhalational), Levofloxacin 8 mg/kg PO q12h, OR

postexposure Doxycycline 2.2 mg/kg PO q12h

prophylaxis

(60-day course§)

Anthrax (cutaneous, Ciprofloxacin 10–15 mg/kg PO q12h, OR

in setting of Levofloxacin 8 mg/kg PO q12h, OR

terrorism), Doxycycline 2.2 mg/kg PO q12h

therapy**

Plague, therapy‡ Gentamicin 2.5 mg/kg IV q8h, OR

Doxycycline 2.2 mg/kg IV q12h, OR

Ciprofloxacin 15 mg/kg IV q12h, OR

Levofloxacin 8 mg/kg IV q12h

Plague, prophylaxis Doxycycline 2.2 mg/kg PO q12h, OR

Ciprofloxacin 20 mg/kg PO q12h, OR

Levofloxacin 8 mg/kg PO q12h

Tularemia, therapy‡ Gentamicin 2.5 mg/kg IV q8h, OR

Doxycycline 2.2 mg/kg IV q12h, OR

Ciprofloxacin 15 mg/kg IV q12h

Tularemia, Doxycycline 2.2 mg/kg PO q12h, OR

prophylaxis Ciprofloxacin 20 mg/kg PO q12h

Smallpox, therapy Supportive care

(Table 41-1 continues)
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Pediatric Surgery and Medicine for Hostile Environments 

▶ Y pestis grows on standard blood or MacConkey’s agar 

(often misidentified by automated systems).

° Treatment and prophylaxis: see Table 41-1.

° Infection control: droplet precautions. 

• Tularemia (etiologic agent Francisella tularensis, a gramnegative coccobacillus)

° Multiple clinical forms of endemic tularemia are known. 

Inhalational exposure in a terrorist attack would likely lead 

to pneumonia or to typhoidal tularemia, manifested as a 

variety of nonspecific symptoms, including fever, malaise, 

and abdominal pain.

Smallpox, Vaccination may be effective if given within the

prophylaxis first several days after exposure.

Botulism, therapy Supportive care; antitoxin may halt the 

progression of symptoms but is unlikely to 

reverse them.

Viral hemorrhagic Supportive care; ribavirin may be beneficial in 

fevers, therapy select cases.

*Do not exceed maximum recommended doses.

†

Patients who are clinically stable after 14 days can be switched to a single oral 

agent (ciprofloxacin or doxycycline) to complete a 60-day course.

‡ In a mass casualty setting, where resources are severely constrained, oral therapy 

may need to be substituted for the preferred parenteral option. 

§

Assuming the organism is sensitive, children may be switched to oral amoxicillin 

(80 mg/kg/d ÷ q8h) to complete a 60-day course. We recommend that the first 14 

days of therapy or postexposure prophylaxis, however, include ciprofloxacin, 

levofloxacin, or doxycycline regardless of age. A three-dose series of Anthrax 

Vaccine Adsorbed may permit shortening of the antibiotic course to 30 days. 

¥

Rifampin or clarithromycin may be acceptable alternatives to clindamycin 

as drugs that target bacterial protein synthesis. If ciprofloxacin or another 

quinolone is employed, doxycycline may be used as a second agent, as it also 

targets protein synthesis.

¶Ampicillin, imipenem, meropenem, or chloramphenicol may be acceptable 

alternatives to penicillin as drugs with good central nervous system penetration.

**Ten days of therapy may be adequate for endemic cutaneous disease. A full 

60-day course is recommended in the setting of terrorism, however, because of 

the possibility of a concomitant inhalational exposure.

Table 41-1 continued
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Casualties of Chemical, Biological, Radiological, Nuclear, and Explosive Weapons

° Laboratory findings: most findings (pneumonia, 

leukocytosis) are nonspecific. Confirmation can be obtained 

by the culture of F tularensis from blood using standard 

media.

° Treatment and prophylaxis: see Table 41-1.

° Infection control: standard precautions. Tularemia is not 

contagious.

• Botulism (etiologic agent can be any of seven toxins produced 

by Clostridium botulinum, a gram-positive anaerobic bacterium)

° Signs and symptoms are as follows: 

▶ A latent period ranging from 24 hours to several days 

following exposure to botulism toxin is required before 

clinical manifestations develop. Although naturally 

occurring botulism typically involves ingestion of 

pre-formed toxins in improperly canned foods (and, 

occasionally from wounds contaminated with C 

botulinum spores), aerosol exposure to these toxins 

produces an identical clinical syndrome. 

▶ Initial symptoms involve cranial nerve dysfunction, 

manifested as bulbar palsies, ptosis, photophobia, and 

blurred vision owing to difficulty in accommodation. 

▶ Symptoms progress to include dysarthria, dysphonia, 

and dysphagia.

▶ Finally, a descending symmetric paralysis develops and 

death may result from respiratory muscle failure.

° There are no specific laboratory findings. Antibody assays 

are not helpful.

° Treatment and prophylaxis: see Table 41-1.

° Infection control: standard precautions. Botulism is not 

contagious.

• Smallpox (etiologic agent Variola virus, a member of the 

Orthopoxvirus genus of large double-stranded deoxyribonucleic 

acid viruses)

° Signs and symptoms

▶ During the 7- to 17-day incubation period, the virus 

replicates in the upper respiratory tract, ultimately 

giving rise to a primary viremia.

▶ Amplification of the virus occurs following seeding 

of the liver and spleen, and a secondary viremia then 

develops.
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Pediatric Surgery and Medicine for Hostile Environments 

▶ Clinical illness begins abruptly and is characterized by 

fever, rigors, vomiting, headache, backache, and extreme 

malaise. 

▶ The classical exanthem begins 2 to 4 days later.

▷ Macules are initially seen on the face and extremities; 

these macules progress in synchronous fashion to 

papules, then to pustules, and finally to scabs.

▷ As the scabs separate, survivors can be left with 

disfiguring, de-pigmented scars. 

▷ The synchronous nature of the rash and its centrifugal 

distribution distinguish smallpox from chickenpox, 

which has a centripetal distribution.

▷ Death occurs in 30% of Variola major patients.

° Laboratory findings: the classic appearance of an 

Orthopoxvirus can be seen on electron microscopic 

examination of material obtained from lesions.

° Treatment and prophylaxis: see Table 41-1.

° Infection control: strict airborne and contact precautions.

• Viral hemorrhagic fevers (etiologic agents include a number 

of ribonucleic acid viruses belonging to one of four taxonomic 

families: the Arenaviridae, Filoviridae, Flaviviridae, and 

Bunyaviridae).

° Signs and symptoms: although the diseases produced 

by these agents differ considerably in their clinical 

manifestations, severity, and modes of transmission, they 

share a propensity to cause a bleeding diathesis.

° Although no laboratory finding is specific, many 

patients with viral hemorrhagic fever show evidence of 

disseminated intravascular coagulation.

° Treatment and prophylaxis: see Table 41-1.

° Infection control: contact precautions. Although viral 

hemorrhagic fever viruses are transmitted principally 

via blood and body fluids (thus necessitating contact 

precautions), the recent Ebola virus outbreak in West Africa 

has demonstrated the ease with which these body fluids 

(blood, diarrheal stool, vomitus) can be aerosolized and 

the uncompromising nature of small breaks in protective 

technique. The CDC thus recommends meticulous attention 

to the donning and doffing of personal protective equipment 
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Casualties of Chemical, Biological, Radiological, Nuclear, and Explosive Weapons

and the institution of a combination of airborne, droplet, 

and contact precautions when dealing with suspected Ebola 

patients.

Pediatric Nuclear and Radiological Casualties

Nuclear casualties result from the immediate effects of a nuclear 

detonation, which includes blast and thermal components. 

Radiological casualties result from exposure to ionizing radiation 

and contamination with radioactive material. Fallout containing 

these fission products is highly radioactive and exposure to it 

will result in severe irradiation injury. The majority of nuclear 

detonation fission products decay extremely rapidly. By 48 hours 

after detonation, the overall dose rate is less than 1% of the initial 

fallout output, although specific “hot spots” with higher dose 

rates will occur. A “dirty bomb” scatters a radioactive source 

across an area in a manner similar to local fallout. Radiation 

output decays at the steady half-life rate associated with the 

specific isotope.

Children’s body habitus and shorter distance from trunk to 

ground means they receive a radiation dose several times higher 

than adults from “ground shine.” This risk is compounded by 

the greater inhalation and ingestion hazards associated with 

the same anatomical (as well as developmental) differences (eg, 

the preponderance of pediatric thyroid injuries following the 

Chernobyl incident). Ionizing radiation exposure is responsible 

for total body injury and may be more hazardous to children 

due to their overall rapid cell turnover rate. Children are also at 

higher risk from exposure than adults because of their increased 

metabolism, higher caloric requirements, higher baseline 

respiratory rates, thinner skin, larger surface-to-mass ratio, 

increased fluid losses secondary to burns, and greater sensitivity 

to the volume and electrolyte deficits induced by diarrhea, 

nausea, and vomiting. Their small physical mass makes them 

less tolerant of radiation total-body injury.

Basic clinical management of children exposed to radiation does 

not differ from adults. Treatment should include symptomatic 

relief of nausea and vomiting, pain management, and infection 

control.
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Pediatric Surgery and Medicine for Hostile Environments 

Medical Effects of a Nuclear Detonation

• Blast

° Overpressure results in pulmonary, solid organ, and ear 

damage, as the instantaneous pressure change does not 

allow for internal stabilization. Consequently, pressure 

gradients that would ordinarily cause no damage result 

in structural injury. For instance, 

▶ A pressure wave of 5 psi is sufficient to rupture 

eardrums. 

▶ 15 psi can cause alveolar hemorrhage. 

° The physical effects of the blast include debris entrapment, 

crush injuries, translocation injury, and missile wounds 

caused by blast winds (eg, flying glass shards). 

° Nuclear detonation results in sudden hurricane-force winds 

sufficient to pick up a child and throw him or her into a 

solid structure.

° Collapse of buildings, walls, and other structures will cause 

entrapment.

° Disorientation due to sudden destruction of the normal 

environment, loss of family members, and trauma will 

diminish normal survival instincts. 

° Children will be particularly prone to an inability to 

distinguish potential escape routes. 

° Hiding in close quarters may offer immediate comfort, but 

may result in fatal entrapment.

• Thermal 

° Partial and full-thickness burns will occur both from 

secondary fires and from the direct thermal pulse. 

° In the detonation of a weapon of 10 kilotons or less, most 

casualties who receive direct infrared burns due to the 

thermal pulse will also receive lethal-dose irradiation. 

° The infrared burns will “mature” similar to sunburn and 

may not be immediately evident. 

° Fires caused by the blast will ignite rubble and cause 

traditional thermal injuries. These burns must be treated 

aggressively, as any concomitant irradiation injury will 

worsen the total prognosis for a given “combined injury” 

patient.
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Casualties of Chemical, Biological, Radiological, Nuclear, and Explosive Weapons

° Retinal burns will occur if a child looks directly at the 

detonation. 

▶ These burns result from the lens focusing the infrared 

pulse on the retina. 

▶ Total foveal destruction may occur, resulting in 

permanent loss of central vision. 

▶ Flash blindness is a temporary condition lasting several 

minutes and is due to massive overstimulation of the 

retinal cells. The brilliance of the detonation is reflected 

in the atmosphere and off of structures and can cause 

temporary “flash-bulb” effects at a distance of tens of 

miles at night. During daylight, the effect still occurs 

but with a lesser range.

° Children may be subject to additional injury due to a 

parent’s loss of control of motor vehicles in the immediate 

aftermath of a nuclear detonation.

• Ionizing radiation exposure

° Effects are directly dose-related; the sooner physical effects 

are expressed, the more severe the damage. 

° Early nausea and vomiting within 4 to 12 hours indicates 

that immune system failure may occur at 5 to 10 weeks 

postexposure. 

° Acute local skin erythema in the first hours secondary to the 

infrared pulse indicates a high probability of lethal injury. 

° Radiation dermatitis is related to effective dose. 

▶ Erythema occurs at 6 to 20 Sv (600–2,000 rem). 

▶ After 20 to 40 Sv, the skin will ulcerate in approximately 

14 days, beginning in the highest-dose region and 

progressing to lower dose areas. 

▶ Above 3,000 Sv, the skin will blister immediately. This 

local dose will probably be associated with a concomitant 

gamma total-body injury. 

▶ Survival following exposure to doses above 10 Sv 

(1,000 rem) is generally only possible when exposure is 

localized (as opposed to whole-body exposure).

° Laboratory findings: leucopenia may be seen within 2 to 4 

days of a radiation exposure; anemia and thrombocytopenia 

are later findings.
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Pediatric Surgery and Medicine for Hostile Environments 

° Treatment: the need for acute management is generally 

limited to patients experiencing dose rates greater than 1 

cGy per hour. 

° Treatment and prevention of neutropenia with colony 

stimulating factors (CSFs) may prevent death from sepsis 

and lessen the duration of the need for prophylactic 

antibiotics.

▶ CSF administration may need to be initiated at a lower 

estimated radiation dose (eg, 2 Gy) than has been 

recommended for adults. 

▶ Bone marrow stimulation with enhancement of 

neutrophil recovery is based on cancer chemotherapy 

clinical experience with CSFs, as well as limited case 

histories of accidental irradiation.

▶ Both filgrastim (5 μg/kg/day subcutaneous) and 

sargramostim (250 mg/m2/d subcutaneous) have been 

used in radiation accident victims; neutrophil recovery 

appeared to be hastened, but no definitive conclusions 

regarding the effectiveness can be made (see NATO 

Handbook on the Medical Aspects of Defensive Operations 

[Nuclear], in Further Reading). 

▶ Use of fluoroquinolone antibiotics is appropriate during 

the period of absolute neutropenia; these agents are 

currently available in the Strategic National Stockpile. 

° Specific infections should be treated in accordance with 

standard practice.

Radiological Contamination 

Contamination evaluation and therapy must never take 

precedence over the treatment of acute injury. Unlike with 

exposure to persistent chemical agents, caregivers are not at risk 

of irradiation from contamination on a patient. Normal clothing 

serves as a barrier and significantly limits cross-contamination. 

Life- and limb-saving interventions should thus be initiated prior 

to decontamination.

• External contamination

° External contamination is usually in the form of dust and 

can be washed off the skin using the local institution’s 
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Casualties of Chemical, Biological, Radiological, Nuclear, and Explosive Weapons

standard gentle cleansing protocols or soap and water. 

A human body cannot be so contaminated as to preclude 

simply washing the radiological contaminants down the 

drain, although the local sewage treatment system provider 

should be notified when time permits. Specimens of effluent 

and large particulates can be saved in a segregated location 

for later forensic analysis.

° Contaminated clothing should be removed, individually 

bagged, and transported to a location away from patients 

and responders. 

° Signs and symptoms of external contamination

▶ When beta particles are emitted on or close to the skin, 

they cause direct cell damage. The skin damage becomes 

evident as the cells migrate to the surface via normal 

desquamation (“beta burns”). 

▶ The stratum corneum consists of dead tissue, so there is 

normally no initial visible effect.

° Laboratory findings: standard radiac instruments (such as 

a Geiger counter) detect and measure gamma radiation; 

many also detect and measure alpha and beta activity.

° Treatment and prophylaxis: thorough decontamination will 

prevent further injury and should be undertaken as soon 

as is practical. Decontamination should not be so intense 

as to cause skin irritation.

• Internal contamination

° Internal contamination will occur when children ingest, 

inhale, or are wounded by radioactive material. 

° Signs and symptoms of internal contamination

▶ Normal metabolism of the nonradioactive isotope of 

the same element determines the metabolic pathway of 

a radionuclide. 

▶ Once a radionuclide is absorbed, it crosses capillary 

membranes through passive and active diffusion 

mechanisms and then is distributed throughout the 

body. The rate of distribution to each organ is related to 

organ metabolism, the ease of chemical transport, and 

the affinity of the radionuclide for chemicals within the 

organ. 
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Pediatric Surgery and Medicine for Hostile Environments 

▷ The liver, kidney, adipose tissue, and bone have 

higher capacities for binding radionuclides due to 

their high protein and lipid makeup.

▷ Nursing mothers should discontinue breast-feeding 

when maternal internal contamination is suspected, 

as radionuclides are concentrated and excreted in 

breast milk. 

▷ Inhaled particles less than 5 μm in diameter may be 

deposited in the alveoli and microbronchioles. 

▷ Larger particles will be cleared to the oropharynx 

by the mucociliary apparatus, where they will be 

swallowed and processed through the digestive tract.

▷ Soluble particles will either be absorbed into the 

bloodstream directly or pass through the lymphatic 

system.

▷ Most radioisotopes in nuclear weapons, such as 

plutonium, uranium, radium, and strontium, are 

insoluble and, when ingested, pass through the 

gastrointestinal tract unabsorbed. They will continue 

to irradiate surrounding tissue (eg, alpha- and betaemitting isotopes are the most damaging to the 

alveoli) until they are cleared. Fibrosis and scarring 

are more likely to occur due to resultant localized 

inflammatory response. 

▶ Swallowed radioactive materials are handled like any 

other elements in the digestive tract, although they do 

provide a source of continuing radiation exposure while 

in transit though the intestine. Absorption depends 

on the chemical makeup of the contaminant and its 

solubility. 

▷ Certain radioactive elements, such as cesium (a 

potassium analogue) and iodine, are readily absorbed.

▷ Avoiding contaminated food and eating only 

packaged foodstuffs significantly decreases internal 

contamination by this route.

▷ Infants, with their predilection for placing items in 

their mouths, must be kept away from contaminated 

surfaces.
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Casualties of Chemical, Biological, Radiological, Nuclear, and Explosive Weapons

▶ The skin is impermeable to most radionuclides, but any 

element that is in a water-soluble form may pass through. 

▷ Skin is particularly vulnerable to water containing 

tritium as the hydrogen moiety. 

▷ Open wounds and burns provide a direct route for 

absorption, allowing particulate contamination to 

bypass the epithelial barrier. Thorough irrigation 

and cleansing is mandatory to diminish uptake by 

this route; wounds must be meticulously cleaned 

and debrided when they occur in a radiological 

environment. After the surrounding skin is clean, 

wounds should be carefully examined with an 

appropriate radiation detector (note that any fluid in 

the wound may hide weak beta and alpha emissions 

from detectors).

° Laboratory findings: standard radiac instruments (such 

as Geiger counters) detect and measure gamma radiation; 

many also detect and measure alpha and beta activity.

° Treatment and prophylaxis 

▶ Mobilizing or chelating agents should be initiated as 

soon as practical when the probable exposure is judged 

to be significant, since they are more effective the sooner 

they are given. Unfortunately very few clinicians have 

any experience in the use of many of these drugs. 

Clinicians should carefully review the label guidance, 

and consultation with radiation countermeasure experts 

should be sought, if possible. Assistance can be obtained 

from the Armed Forces Radiobiology Research Institute 

(Uniformed Services University) in Bethesda, MD 

(http://www.usuhs.edu/afrri/), and from the Radiation 

Emergency Assistance Center/Training Site (Oak Ridge 

Associated Universities, PO Box 117, MS-39, Oak Ridge, 

TN 37831; www.orise.orau.gov/reacts).

▷ Propylthiouracil or methimazole may reduce the 

thyroid’s retention of radioiodine. 

▷ Chelating agents may be used to remove many metals 

from the body. 

▶ Gastric lavage and emetics can be used to empty the 

stomach promptly and completely after the ingestion 

of poisonous materials.
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Pediatric Surgery and Medicine for Hostile Environments 

▶ Purgatives, laxatives, and enemas can reduce the 

residence time of radioactive materials in the colon. 

▶ Ion exchange resins limit gastrointestinal uptake of 

ingested or inhaled radionuclides. 

▶ Ferric ferrocyanide (Prussian blue) and alginates have 

been used in humans to accelerate fecal excretion of 

cesium-137. 

▶ Blocking agents, such as stable iodide compounds, 

must be given as soon as possible after exposure to 

radioiodine. Potassium iodide blocks radioiodine 

incorporation by the thyroid gland, but does not afford 

protection against acute irradiation injury. 

▶ Calcium ethylenediaminetetraacetic acid (EDTA) is 

used primarily to treat lead poisoning and must be used 

with extreme caution in patients with preexisting renal 

disease.

▶ Diethylenetriaminepentaacetic acid (DTPA) is more 

effective in removing many of the heavy metal 

multivalent radionuclides. 

▷ Chelates are water soluble and are excreted in urine.

▷ DTPA metal complexes are more stable than those of 

EDTA and are less likely to release the radionuclide 

before excretion.

▷ Repeated use of calcium salt can deplete zinc and 

cause trace metal deficiencies. 

▷ Ca-DTPA should be used carefully in infants and 

children and only as an initial dose.

▷ Dimercaprol (British anti-Lewisite) forms stable 

chelates with mercury, lead, arsenic, gold, bismuth, 

chromium, and nickel, and therefore may be 

considered for treating internal contamination with 

the radioisotopes of these elements. 

▷ Penicillamine chelates copper, iron, mercury, lead, 

and gold. 
671

Casualties of Chemical, Biological, Radiological, Nuclear, and Explosive Weapons

Further Reading

Biological & Chemical 

1. Baker MD. Antidotes for nerve agent poisoning: should we 

differentiate children from adults? Curr Opin Pediatr. 2007:19:211–

215.

2. Bravata DM, Wang E, Holty JE, et al. Pediatric anthrax: implications 

for bioterrorism preparedness. Evid Rep Technol Assess (Full Rep). 

2006;141:1–48.

3. Centers for Bioterrorism Preparedness Program Pediatric Task 

Force. Children in Disasters: Hospital Guidelines for Pediatric 

Preparedness. 3rd ed. New York, NY: New York City Department of 

Health and Mental Hygiene; 2008. http://www.nyc.gov/html/doh/

downloads/pdf/bhpp/hepp-peds-childrenindisasters-010709.pdf. 

Accessed June 5, 2015.

4. Cieslak TJ, Henretig FM. Bioterrorism. Pediatr Ann. 2003;32:154–165.

5. Cieslak TJ, Henretig FM. Ring-a-ring-a-roses: bioterrorism and its 

peculiar relevance to pediatrics. Curr Op Pediatr. 2003;15:107–111.

6. Cieslak TJ, Henretig FM. Biological and chemical terrorism. In: 

Kliegman RM, Stanton BMD, St Geme J, Schor NF, Behrman RE, 

eds. Nelson Textbook of Pediatrics. 19th ed. Philadelphia, PA: WB 

Saunders; 2011. Chap 704.

7. Hall AH, Dart R, Bogdan G. Sodium thiosulfate or hydroxocobalamin 

for the empiric treatment of cyanide poisoning? Ann Emerg Med. 

2007;49:806–813.

8. Henretig FM, Cieslak TJ. Chemical and biological terrorism. 

In: Selbst SM, ed. Pediatric Emergency Medicine Secrets. 3rd ed. 

Philadelphia, PA: Elsevier; 2015.

9. Kales SN, Christiani DC. Acute chemical emergencies. N Engl J Med. 

2004:350:800–808.

10. Markenson D, Reynolds S. American Academy of Pediatrics 

Committee on Pediatric Emergency Medicine, Task Force on 

Terrorism. The pediatrician and disaster preparedness. Pediatrics. 

2006;117:340–362.
672

Pediatric Surgery and Medicine for Hostile Environments 

11. Meyer MT, Spinella PC, Cieslak TJ. Agents of biological and 

chemical terrorism. In: Wheeler DS, Wong HR, Shanley TP, eds. 

Pediatric Critical Care Medicine. 2nd ed. New York, NY: Springer; 

2014. Chap 46.

12. Rotenberg JS, Newmark J. Nerve agent attacks on children: 

diagnosis and management. Pediatrics. 2003;112:648–658.

13. Russell D, Blaine PG, Rice P. Clinical management of casualties 

exposed to lung damaging agents: a critical review. Emerg Med J. 

2006;23:421–424.

Radiological

14. Kiang JG, Fukumoto R. Ciprofloxacin increases survival after 

ionizing irradiation combined injury: γ-H2AX formation, cytokine/

chemokine, and red blood cells. Health Phys. 2014;106(6):720–726. 

15. Brook I, Elliott TB, Ledney GD, Knudson GB. Management of 

postirradiation sepsis. Mil Med. 2002 Feb;167(2 Suppl):105–106.

16. Brook I, Ledney GD. Quinolone therapy in the management of 

infection after irradiation. Crit Rev Microbiol. 1992;18(4):235–246.

17. National Council on Radiation Protection and Measurements. 

Management of Persons Accidentally Contaminated With Radionuclides. 

Bethesda, MD: NCRP; 1980. NCRP Report 65.

18. National Council on Radiation Protection and Measurements. 

Management of Terrorist Events Involving Radioactive Material. 

Bethesda, MD: NCRP; 2001. NCRP Report 138.

19. National Council on Radiation Protection and Measurements. 

Management of Persons Contaminated With Radionuclides: Handbook. 

Bethesda, MD: NCRP; 2008. NCRP Report 161 I.

20. National Council on Radiation Protection and Measurements. 

Population Monitoring and Radionuclide Decorporation Following a 

Radiological or Nuclear Incident. Bethesda, MD: NCRP; 2010. NCRP 

Report 166.

21. Armed Forces Radiobiology Research Institute. Medical Management 

of Radiological Casualties Handbook. Bethesda, MD: AFRRI; April 2003.

22. Ciottone GR, ed. Disaster Medicine. Philadelphia, PA: Mosby 

Elsevier; 2006.
673

Casualties of Chemical, Biological, Radiological, Nuclear, and Explosive Weapons

23. Mettler F, Upton A. Medical Effects of Ionizing Radiation. Philadelphia, 

PA: AWB Saunders; 1995. 

24. Radiation Emergency Assistance Center/Training Site. The Medical 

Aspects of Radiation Incidents. Oak Ridge, TN: REAC/TS; 2013. https://

orise.orau.gov/files/reacts/medical-aspects-of-radiation-incidents.

pdf. Accessed June 9, 2015.

25. Radiation Emergency Assistance Center/Training Site. Use of Clinical 

Decision Guidance (CDG) in the Triage and Treatment of Persons 

Internally Contaminated With Fission Product Radionuclides in Mass 

Casualty Incidents. Oak Ridge, TN: REAC/TS.

https://orise.orau.gov/

files/reacts/rapid-internal-external-dose-magnitude-estimation.pdf.

26. Goans RE, Waselenko JK. Medical management of radiological 

casualties. Health Phys. 2005;89(5):505–512.

27. Waselenko JK, MacVittie TJ, Blakely WF, et al. Medical management 

of the acute radiation syndrome: recommendations of the Strategic 

National Stockpile Radiation Working Group. Ann Intern Med. 

2004;140(12):1037–1051.

28. Gabbay V, Oatis MD, Silva RR, Hirsch G. Epidemiological aspects 

of PTSD in children and adolescents. In: Silva RR, ed. Posttraumatic 

Stress Disorder in Children and Adolescents: Handbook. New York, NY: 

WW Norton; 2004.

29. Grainge C, Rice P. Management of phosgene-induced acute lung 

injury. Clin Toxicol (Phila). 2010;48(6):497–508. 

30. US Departments of the Army, Navy, Air Force. NATO Handbook on 

the Medical Aspects of Defensive Operations (Nuclear). Washington, 

DC: DA, USN, USAF; 1996. NATO STANAG 2461, AMedP-6. Army 

Field Manual 8-9, Navy Medical Publication 5059, Air Force Joint 

Manual 44-151.

31. Schwartz MD, Hurst CG, Kirk MA, Reedy SJ, Braue EH Jr. Reactive 

skin decontamination lotion (RSDL) for the decontamination 

of chemical warfare agent (CWA) dermal exposure. Curr Pharm 

Biotechnol. 2012;13(10):1971–1979.

32. Braue EH Jr, Smith KH, Doxzon BF, Lumpkin HL, Clarkson ED. 

Efficacy studies of Reactive Skin Decontamination Lotion, M291 

Skin Decontamination Kit, 0.5% bleach, 1% soapy water, and 

skin exposure reduction paste against chemical warfare agents, 

part 2: guinea pigs challenged with soman. Cutan Ocul Toxicol. 

2011;30(1):29–37. 
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Pediatric Surgery and Medicine for Hostile Environments 
675

Children in Disasters

Chapter 42

Children in Disasters

Background

•	 An estimated 350 million people are affected by natural

disasters annually, of which 50% to 60% are children.

•	 Children have unique physiological, anatomical, and

psychosocial vulnerabilities, responses, and needs in a

disaster, particularly in a chemical, biological, radiological,

nuclear, or explosive situation (see Chapter 41, Casualties of

Chemical, Biological, Radiological, Nuclear, and Explosive

Weapons, for further details), including:

° shorter height/larger head (trauma risk),

° higher minute ventilation (inhalation risk),

° larger body-surface-area-to-mass ratio (exposure and

hypothermia risks),

° lower developmental stage (inability to escape), and

° more immature psychological stage (separation anxiety).

•	 In the acute phase, mortality from a disaster reflects the age

distribution of the population.

•	 Subsequently, mortality increases in the most vulnerable

populations, including children, women, and the elderly,

particularly for children under 5 years of age.

•	 Leading causes of death in a disasterinclude trauma, diarrhea

and dehydration, communicable diseases (measles, malaria,

acute respiratory infections), and malnutrition.

•	 As a result of weak infrastructure, poor early warning systems,

and inadequate risk-reduction strategies, developing nations

are disproportionately affected by disasters.

Definitions

•	 A disaster is defined as a sudden phenomenon or hazard

that impacts a population, leading to increased morbidity,

mortality, and loss of livelihood.
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Pediatric Surgery and Medicine for Hostile Environments

•	 A disaster exceeds the internal capacity of a population to

respond without additional external aid or resources.

•	 Disasters may be natural or human-provoked in etiology.

° Natural disasters: cyclones, earthquakes, floods, tornados,

tsunamis, volcanoes, and wildfires.

° Human-provoked disasters: industrial or technological

events, terrorism, violence, complex emergencies (conflict,

genocide, famine), pandemics, and epidemics.

•	 The impact of a disaster is proportional to the severity,

duration, and vulnerability of the effected population.

° Impact = Vulnerability × Phenomenon.

° Vulnerability factors can be human, ecological, economical,

social, legal, or political.

° Characteristics of phenomena include timing (rapid versus

slow onset), natural disasters, and human-provoked events.

•	 The disaster cycle is a predictable continuum useful for

characterizing the phase of a disaster as well as for organizing

planning, preparation, and response (Figure 42-1).

•	 Challenges that are unique to disaster response include:

° warning and evacuation;

° urban search, rescue, and recovery;

° triage and casualty distribution;

° large-scale victim and responder mental health issues; and

° communication and coordination.

Military Disaster Response

•	 The US government responds to 70 to 80 disasters per year.

•	 Of these, the Department of Defense (DoD) provides some

form of assistance—ranging from a single aircraft to larger

task forces—to only 10% to 15%.

• DoD acts in support of the Department of State. The United

States Agency forInternational Development (USAID) Office

of Foreign Disaster Assistance (OFDA) leads the response.

• DoD is generally not a first responder in foreign disaster

response (FDR). DoD is involved when:

° host-nation capacity is overwhelmed;

° a unique, clearly defined service can be provided; and

° civilian authorities request assistance.
677

Children in Disasters

• DoD’s mission is short and limited in focus such that it can

be handed over to the host nation or US civilian agencies as

soon as the situation is stabilized to avoid “mission creep.”

•	 For further details of DoD concept of operations and tactics,

techniques, and procedures for FDR, see Department of 

Defense Support to Foreign Disaster Relief (US Department of

Defense. Department of Defense Support to Foreign Disaster Relief.

Washington, DC: DoD; July 13, 2011. http://fas.org/irp/doddir/

dod/disaster.pdf).

Planning

•	 Beyond standard force health protection plans, FDR planning

is a complex process with many critical steps requiring

coordination with USAID/OFDA and the joint task force

(Exhibit 42-1).

Figure 42-1. The disaster cycle is a predictable continuum useful for

characterizing the phase of a disaster as well as for organizing planning, preparation, and response.

Disaster

Respond Recovery

Prepare Mitigate &

 Prevent

• Reestablishment of services

• Temporary shelter

• Reconstruction

• Rehabilitation

• Emergency medical services

• Command, control, and 

• coordination

• Initial assessment

• Evacuation

• Search and 

• rescue

• Prediction/

• warning

• Response 

• planning

• Stockpile supplies

• Communications

•Training and drills

• Risk 

assessment

• Minimize hazards

• Reduce vulnerabilities

(development)
678

Pediatric Surgery and Medicine for Hostile Environments

•	 Pediatric triage, emergency care, hospital planning, and

supplies need to be addressed as part of all command disaster

response plans.

•	 Unique challenges to a planning a response may include:

° adequate variety and number of pediatric supplies,

° pediatric decontamination equipment and protocols,

° pediatric assessment training,

° availability of pediatric specialists,

° medications specific to children, and

° limited operating room, intensive care unit, postanesthesia

care unit, and inpatient beds.

•	 Disaster response training should include an “all-hazards”

approach that is standardized and consistent.

Pediatric Triage

•	 Pediatric triage is a critical element of systematically

responding to a mass casualty incident (MCI) and surge.

•	 The goal of triage is the same for children as for adults: to

prioritize patients for treatment and transport and save as

many patients as possible with the resources available.

Exhibit 42-1. Pre-Deployment Medical Officer Disaster 

Planning

• Conduct medical intelligence preparation of the operational

environment (MIPOE).

• Obtain and interpret pertinent information on host nation

and nongovernmental organization medical infrastructure,

capabilities, and needs.

• 	 Assess for and mitigate operational health threats.

• 	 Establish a mass casualty plan.

• 	 Develop a patient-tracking system.

• 	 Establish an evacuation policy for patient movement.

• 	 Estimate medical supply needs and preplan initial resupply.

• 	 Ensure medical staff health and cultural education.

• 	 Conduct medical staff training and drills.

Adapted from: Department of Defense. Department of Defense Support to 

Foreign Disaster Relief. Washington, DC: DoD; July 13, 2011. https://www.

jllis.mil/JSCC/index.cfm.
679

Children in Disasters

•	 The most basic triage algorithm is the pediatric assessment

triangle used to rapidly classify a patient based on appearance,

color, and breathing (see Chapter 1, Basic Approach to

Pediatric Trauma).

•	 MCI triage algorithms sort patients into color-identified care

categories, including minor(green), immediate (red), delayed

(yellow), and dead (black).

•	 Triage is readily tracked with color-coded tags that record

identification, vitals, assessment, categorization, and

interventions.

•	 If triage tags are unavailable, medical report can be directly

marked on a patient or wound dressing, though not on bed

sheets because loss of data in transfer.

•	 The SALT (sort, assess, life-saving interventions, treatment

and/ortransport) triage, supported by the Centers for Disease

Control and Prevention (Figure 42-2), is the nationally

accepted, all-hazards, mass casualty triage for all populations

(adult and pediatric).

•	 For pediatric patients, the combined START/JumpSTART

algorithm (Figure 42-3) is preferred, as it provides a

decision-making process that explicitly accounts for pediatric

physiology and normative values.

•	 Retriage should be performed at each new level of care.

Additionally, triage is a bidirectional process and should

allow for the recategorization of a patient at any point in the

process as either higher or lower priority.

Hospital Planning and Surge Capacity

•	 In a disaster or pediatric MCI, there may be the unexpected

need to rapidly surge inpatient capacity, particularly critical

care, beyond normal operations.Additional disasterresponse

and mass critical care supplies and equipment needs for

children must be considered (see the Comprehensive Pediatric

Equipment Sizing table in Appendix C; Exhibit 42-2).

•	 Contents of service-specific supply augmentation kits

(eg, Pediatric Augmentation Set [625A]; see Resources for

Deployed Physicians in Appendix A of this book) should be

compared to the Comprehensive Pediatric Equipment Sizing

table in Appendix C and to Exhibit 42-2 to identify additional

supplies, equipment needs, and gaps.
680

Pediatric Surgery and Medicine for Hostile Environments

Step 1: Sort:

Global Sorting

Step 2: Assess:

Individual Assessment

Walk

Assess 3rd

Wave / Purposeful Movement

Assess 2nd

Still / Obvious Life Threat

Assess 1st

Breathing? Dead

Lifesaving

Interventions:

• Control major hemorrhage

• Open airway (if child,

• consider 2 rescue breaths)

• Chest decompression

• Auto injector antidotes

Minor

injuries

only?

Minimal

Delayed

Expectant

Likely to survive

given current

resources?

• Obeys commands or makes

• purposeful movements?

• Has peripheral pulse?

• Not in respiratory distress?

• Major hemorrhage is controlled?

Any No

No

No

No

Yes

Yes

Yes

All

Yes

Immediate

Figure 42-2. The SALT (sort, assess, life-saving interventions, treatment and/or transport) triage, supported by the Centers for Disease

Control and Prevention, is the nationally accepted, all-hazards, mass

casualty triage for all populations (adult and pediatric).

Reproduced with permission from: US Department of Health and Human Services, National Institutes of Health, US National Library of

Medicine. Chemical Hazards Emergency Medical Management website. SALT Mass Casualty Triage Algorithm. http://chemm.nlm.nih.gov/

salttriage.htm. Accessed April 9, 2015.
681

Children in Disasters

Position Upper Airway

5 Rescue Breaths

MINOR

PEDI ADULT

DECEASED

IMMEDIATE

IMMEDIATE

DELAYED

IMMEDIATE

Mental

Status

Able to

walk?

Breathing?

NO

YES

YES

YES

NO

NO PULSE

BREATHING

BREATHING

+ PULSE

APNEIC

APNEIC

<30 ADULT

15–45 PEDI

Doesn’t obey commands

(ADULT)

“P” (inappropriate), Posturing or “U”

(PEDIATRIC)

Obeys Commands (ADULT)

“A”, “V” OR “P” (Appropriate) (PEDIATRIC)

Perfusion IMMEDIATE CR > 2 sec (ADULT)

No palpable pulse (PEDI)

Respiratory IMMEDIATE

Rate

>30 ADULT

<15 OR >45 PEDI

Secondary Triage*

*Using the JS algorithm

evaluate first all children

who did not walk under

their own power. 

Figure 42-3. The combined START/JumpSTART algorithm is preferred

for pediatric patients.

Reproduced with permission from: Lou Romig MD, FAAP, FACEP.

A: alert

CR: capillary refill

JS: JumpSTART

P: responds to painful stimuli

PEDI: pediatric

U: unresponsive to noxious stimuli

V: responds to verbal stimuli
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Pediatric Surgery and Medicine for Hostile Environments

Exhibit 42-2. Additional Disaster and Critical Care Supplies

Airway Management

• 	 Nasal cannulas and simple face masks

• 	 Oxygen source with flow meter

• 	 Self-inflating bags, child and adult sizes

• 	 Laryngoscope handles with batteries

• 	 Ventilators with humidifiers and pediatric circuits (inspiratory

flow/pressure sensor sensitive enough to ventilate infants)

Intravascular Access and Fluid Management

• 	 Boards, adhesive tape, tourniquets

• 	 Buretrol chambers and IV tubing, pediatric sizes

• 	 Butterfly needles (21 and 23 gauge)

• 	 Fluids: D5 NS, D5 1/2NS, NS, and lactated Ringer’s

• 	 Intraosseous needles (15 and 18 gauge)

• 	 Vasoactive drugs (dopamine, epinephrine)

Miscellaneous

• 	 Broselow Pediatric Emergency tapes

• 	 Chest drains

• 	 Geiger counter (if there is suspected radioactive contamination)

• 	 Personnel protective equipment (gloves, masks, gowns)

• 	 Splints and gauze padding

• 	 Supply carts, portable

• 	 Thermal control (blankets, radiant warmer/cradle, lamp)

• 	 Warm water source, with showers for decontamination

Monitoring Equipment

• 	 Electrocardiogram electrodes, pediatric sized

• 	 End-tidal CO2 monitor

• 	 Portable monitor/defibrillator with pediatric paddles

• 	 Pulse oximeter with reusable and nonreusable sensors

• 	 Pediatric sphygmomanometer

• 	 Testing: blood gas, glucose, and urinalysis

• 	 Thermometers

Sedation, Analgesics, Antimicrobials, and Nutrition

• 	 Narcotics, ketamine, benzodiazepines

• 	 Antibiotics, antifungals, antitoxins

• 	 Age-appropriate enteral feeding formulas

CO2: carbon dioxide	

IV: intravenous

NS: normal saline
683

Children in Disasters

•	 In extenuating circumstances, consideration should be given

to the reuse of some consumable goods following sterilization,

particularly during a pandemic outbreak.

•	 Altered standards of care may be required. An altered

standards-of-care policy is best determined prior to an MCI

and should allow forin-hospital triage to lowerlevels of care,

early transfer to lower levels of care, and early discharge.

•	 “Reverse triage” risk-stratifies patients according to readiness

to discharge and seeks to discharge minimal- and moderaterisk patients to expand inpatient capacities.

Assessment

•	 Following a disaster, the initial assessment is one of the most

important functions of the disaster response team.

•	 The initial assessment focuses on the situation or needs,

establishing:

° extent and scope of the disaster,

° vulnerable populations,

° food and nonfood needs,

° host-nation internal response capacities, and

° extent of other nations’ and agencies’ responses, as well as

° identifies priorities for intervention.

•	 Monitoring the crude mortality rate (CMR) in a disaster is a

key indicator of disaster acuity, phase, and response efficacy.

•	 CMR is measured in deaths per 10,000 inhabitants per day.

•	 The emergency threshold is an increase of more than double

the baseline CMR, generally greater than 1 death/10,000/day

or an under-five mortality rate of 2 deaths/10,000/day.

•	 Refer to the USAID OFDA Field Operations Guide for Disaster 

Assessment and Response (https://scms.usaid.gov/sites/default/

files/documents/1866/fog_v4.pdf) for greater detail on how to

conduct a disaster assessment, and Chapter 43, Humanitarian

Operations, for additional information on postdisaster disease

assessment, surveillance, and prevention.
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Pediatric Surgery and Medicine for Hostile Environments

Emergency Relief and Vulnerability Reduction

•	 Essential emergency relief measures should include the

elements identified by theWorld Health Organization (Exhibit

42-3).

Exhibit 42-3. Essential Emergency Relief Measures

•	 Perform a rapid assessment

•	 Provide adequate shelter and clothing

•	 Provide adequate nutrition

•	 Provide elementary sanitation and clean water

•	 Institute a diarrheal disease control program

•	 Immunize against measles

•	 Provide vitamin A supplementation

•	 Reestablish and improve primary medical care

•	 Organize human resources and coordinate activities

Adapted from: Berman S. Pediatric Education in Disasters Manual. Buenos

Aires, Argentina: AAP/ACINDES; 2009. http://www.aap.org/disasters/

index.cfm. Accessed February 2, 2015.

Exhibit 42-4. Measures to Reduce Pediatric Vulnerability

• 	 List all vulnerable populations

• 	 Provide identification tags for all children

• 	 Identify local community leaders, especially females, who can

care for vulnerable populations

• 	 Place families and groups of neighbors together

• 	 Guarantee care and safety

• 	 Include considerations for vulnerable populations in distribution

systems

• 	 Prioritize searches for parents and family of vulnerable children

Adapted from: Berman S. Pediatric Education in Disasters Manual. BuenosAires,

Argentina: AAP/ACINDES; 2009. http://www.aap.org/disasters/index.cfm.

Accessed February 2, 2015.

•	 Measures to reduce pediatric vulnerability are reviewed in

Exhibit 42-4.
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Children in Disasters

Patient Evacuation

•	 The following should be considered as part of determining

need to evacuate a patient:

° eligibility criteria and sponsorship guidelines,

° available evacuation resources and routes,

° ability to ensure accompanying guardian,

° pediatric capabilities of medical treatment facilities within

(and adjoining) the operational area, and

° capacities of host nation/nongovernmental organization

facilities that will assume care at transfer/discharge.

Psychological Impact

•	 Disasters have a profound psychological impact on children

due to direct impact or injury, perceived threat, caregiver

separation, witness to injury or death, and other factors.

•	 In addition to normalreactions, children may experience both

acute and chronic sequelae, such as stress, anxiety, depression,

and posttraumatic stress disorder, among others.

•	 Refer to Chapter 37, Behavioral Healthcare of Children

in Austere Environments, for further information and

interventions.

Further Reading

	 1. 	 Berman S. Pediatric Education in Disasters Manual. Buenos

Aires, Argentina: American Academy of Pediatrics; 2009.

http://www.aap.org/disasters/index.cfm.Accessed January

22, 2015.

	 2. 	 US Department of Defense. Department of Defense Support 

to Foreign Disaster Relief. Washington, DC: DoD; 13 July

2011. http://fas.org/irp/doddir/dod/disaster.pdf.Accessed

January 22, 2015.

	 3. 	 Department of Defense. Foreign Humanitarian Assistance.

Washington, DC: DoD; 03 Jan 2014. Joint Publication 3-29.

http://fas.org/irp/doddir/dod/jp3_29.pdf.Accessed January

22, 2015.
686

Pediatric Surgery and Medicine for Hostile Environments

	 4. USAgency forInternational Development. Field Operations 

Guide for Disaster Assessment and Response, Version 4.0.

Washington, DC: USAID; Sept 2005. https://scms.usaid.

gov/sites/default/files/documents/1866/fog_v4.pdf.

Accessed January 22, 2015.

	 5. The Sphere Project. Humanitarian Charter and Minimum 

Standards in Humanitarian Response. 2001. http://www.

sphereproject.org. Accessed January 22, 2015.

	 6. 	 Landesman LY. Public Health Management of Disasters: The 

Practice Guide. 3rd ed. Washington, DC: American Public

Health Association; 2012.
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Humanitarian Operations and Medical Civil-Military Activities

Chapter 43

Humanitarian Operations and 

Medical Civil-Military Activities

There are several situations in which militaries may be tasked 

with providing humanitarian assistance to foreign civilians. 

Military physicians may provide direct patient care, be involved 

with public health projects, or serve as field surgeons who guide 

commanders in planning and executing humanitarian activities. 

US military personnel may be authorized or ordered to treat 

nonmilitary patients and address the health needs of foreign 

civilian populations in the following situations:

• incidental activities during combat operations,

• support for counterinsurgency and stability operations,

• disaster response (see Chapter 42, Children in Disasters),

• mass migration events, and

• training activities.

General Principles of US Military Medical Humanitarian 

Activities

Command-directed medical rules of engagement (MEDROEs) and 

funding authorities regulate US military medical humanitarian 

activities. Activities are determined at echelons above the local 

tactical command. They are typically published in plans and 

orders for operations. Questions should be directed to the unit 

medical planner or the medical plans and operations cell at the next 

higher headquarters. Objectives may include relieving suffering, 

promoting health, improving security, providing readiness 

training, or a combination of these purposes. Medical activities are 

sometimes viewed as another tool in a commander’s “tool box” and 

may be used to support a larger mission. Keys to success include:
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Pediatric Surgery and Medicine for Hostile Environments

• Clarity of goals and objectives of the activity, including any 

non-health–related objectives, such as improved security, 

“winning hearts and minds,” and training US medical forces. 

° This may require an honest conversation between the 

commander and his or her senior medical advisor regarding 

the appropriateness of medical activities to achieve the 

commander’s desired effects.

° Medical activities may not be the best “tool” to achieve the 

desired effect and can have undesired or unanticipated 

second- and third-order effects. 

• Adequate coordination with host-nation medical personnel 

and, where appropriate, nongovernmental organizations 

(NGOs) working in the area.

• Using medical intelligence to understand the local 

population’s disease and injury. Sources of medical 

intelligence include: 

° World Health Organization (WHO) and its regional 

suborganizations.

° Host-nation ministry of health (MoH) at national, regional, 

and local levels.

° National Center for Medical Intelligence.

• Understanding the host-nation health system and key leader 

health priorities.

• Awareness of important cultural patterns that affect health, 

including:

° cultural beliefs about causes of disease, and

° cultural “hot buttons” (eg, treatment of women and 

children, gender roles in health care).

• Avoiding a US medical-centric viewpoint; understanding 

global health initiatives from organizations such as the WHO 

or host-nation MoH.

• Planning at strategic, operational, and tactical levels. 

Answering the following questions will help achieve this:

° Does the particular activity support larger host-nation 

health campaigns?

° Does the activity build upon a series of events designed to 

create larger or more sustained effects? Is it appropriately 

synchronized to maximize benefit?
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° Is the activity vetted by the host-nation health authorities 

at national, regional, and local levels?

° Does the activity use health strategies that are similar to 

those used by the host nation?

° Will the activity complement the host-nation health 

system and contribute to improved relations between the 

host-nation government and health system and the local 

population? 

° Does the team/unit have all the required skills to achieve 

the desired effects (including both medical and nonmedical 

skills, such as adequate linguists, logistics, transportation, 

communication, and security expertise)? 

° Are medications and equipment appropriate for the 

anticipated operating environment (eg, is refrigeration 

available if required)?

° Have referral and transfer networks been established? 

° Are there established mechanisms for follow-on patient 

care?

• Upholding ethical standards, regardless of the objectives; 

all medical activities must be in accordance with the highest 

ethical standards.

° First, do no harm. Be aware of unintended consequences of 

interventions, such as danger to patients at treatment areas 

and after they leave the secured area. 

° If providing direct care, each individual patient must 

be provided the best possible care under the specific 

conditions.

° Aim for a standard of care that is aligned with that of the 

local system and, to the extent possible, sustainable with 

local resources. Trying to practice US-style, high-tech 

medicine may not be appropriate.

° Practice educated empiricism. Practicing medicine using 

observations and clinical skills informed by knowledge of 

local health conditions without laboratory and radiological 

confirmation is frequently the norm.

° Strive for utilitarianism by providing the greatest good for 

the greatest number in an equitable way. Military medical 

personnel need to adhere to their role under the law of 

war and avoid blurring the lines between medical care and 

combatant roles.
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• Understanding funding, because operational planning 

requires a sound understanding of funding streams and the 

legal authorities that govern use of each. Judge Advocate 

General guidance may be needed. Common funding streams 

used in military medical operations include:

° Humanitarian Civic Assistance (HCA) funds (used to care 

for host-nation patients in authorized HCA activities). 

° Overseas Humanitarian Disaster Assistance and Civic 

Aid. These funds must benefit host-nation civilians, not 

militaries.

° Commanders Emergency Relief Funds. Operational 

funding that is used for humanitarian purposes as part of 

combat or stability operations.

Global Health: Systems and Principles in Developing Countries

Humanitarian medical activities require at least a basic 

understanding of healthcare systems in developing countries. 

There are many similarities between systems in developing 

countries, usually related to WHO programs that are implemented 

to provide low-cost, high-impact solutions to the health problems 

of the poor. 

• Developing countries provide care through a hierarchal, 

bureaucratic government system commonly referred to as the 

MoH.

° Primary care is based on MoH geographic sectors.

° Thorough coordination with local-sector health leadership 

is generally required.

° The hierarchy of authority flows from the central MoH to 

the regional office, and then to local health workers.

° Unless an activity is vetted by “higher headquarters,” local 

MoH workers may be reluctant to support the activity, even 

if they are actually interested in the project. 

° Most developing countries have echelons of care that go 

from small rural clinics to larger clinics, to small local 

hospitals, to regional hospitals, to large teaching hospitals.

° Although MoH doctrine may support the idea of patient 

movement to higher levels of care, the capacity is frequently 

lacking.
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Humanitarian Operations and Medical Civil-Military Activities

• Primary care is usually less “doctor-centric” in developing 

countries.

° Local MoH care is frequently delivered primarily by nurses, 

who provide preventive services and a limited number of 

curative services. 

° Lay health workers (sometimes called “promoters”) may 

work under the direction of MoH nurses. 

° In some countries, lay nurse midwives provide most rural 

obstetric care. Helping Babies Breathe is a training program 

from the American Academy of Pediatrics that is aimed at 

improving the capacity of rural midwives to resuscitate 

newborns.

• Most MoH systems in developing countries rely on part-time 

physician support. 

° Newly trained physicians provide “social service” time in 

underserved areas prior to going on to private practice or 

specialization.

° Most do “sick call” for a few hours in the morning for 

the MoH, but make most of their income through private 

practice in the evenings.

° Military physicians do not work for the MoH, but frequently 

have similar pay schemes and also tend to “moonlight” in 

private practice.

° Medications and supplies left behind by US medical teams 

to aid the local populace may be diverted or misused unless 

they are delivered into trusted hands. Donations should 

generally only be given to the appropriate MoH personnel 

that can legally accept them and take responsibility for the 

use of the medications or other items. Donations typically 

require formal paperwork and should be cleared by the 

responsible US commander or legal authority prior to 

transfer.

° Depending on the population being served and the cultural 

context, local physicians’ motivations may not mirror those 

of US-based physicians.

• Medical systems in developing countries tend to provide care 

through WHO treatment protocols. They are:

° Used to standardize and simplify treatments for health 

workers with limited medical training.
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° Evidence-based and provide care through syndromic 

empiric treatment.

▶ Identifying the syndrome, such as diarrhea or fever and 

cough, is sufficient to provide treatment.

▶ Treatments rely on inexpensive, no-frills medications 

when needed.

• The most commonly used pediatric WHO protocol is the 

Integrated Management of Childhood Illness, which:

° Focuses on children less than 5 years old and the most 

common causes of mortality in developing countries.

° Stresses assessing all ill children for preventive medicine 

needs, such as vaccines and nutritional problems, in 

addition to providing curative care.

Classification of Medical Humanitarian Operations

US Military Operations

• Civil military operations: military operations that support 

civil society. 

• HCA: operations that involve a component of US military 

readiness training. HCA operations must: 

° increase the operational readiness of US forces, and

° improve security for the host nation and the US, or 

contribute to the economic and social welfare of the host 

nation.

▶ Medical HCA generally consists of short-term exercises 

that provide direct care to local populations. These may 

include local civilian or military medical personnel. 

▶ Engineering HCA may involve construction or 

renovation of small health facilities.

• Humanitarian Assistance Disaster Relief: includes foreign 

disaster relief and a variety of programs that primarily benefit 

host nation civilians, including:

° disaster preparation (capacity-building programs),

° humanitarian demining program (training local personnel 

to handle injuries related to mines and unexploded 

ordinance),

° excess (nonlethal) property donation program (surplus 

military items, including medical equipment, may be 

donated), and
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Humanitarian Operations and Medical Civil-Military Activities

° The Denton Program (“Space A” military transportation of 

humanitarian supplies).

• Medical Civil Action Patrols (MEDCAPs): catchall for medical 

care provided to rural civilian populations in short-term 

operations. Medical readiness training exercises are similar 

programs in the US Southern Command area of responsibility.

• Ad hoc military medical activities can be authorized under a 

variety of settings.

Nonmilitary Operations

Nonmilitary organizations define “humanitarian operations” 

differently than the DoD. 

• The United States Agency for International Development 

distinguishes between long-term development and 

humanitarian operations. 

° Long-term projects are intended to improve health, 

governance, economic development, and education.

° Humanitarian operations are only those activities that 

support acute needs, such as disaster response. The US 

Agency for International Development Office of Foreign 

Disaster Assistance takes the lead.

• NGOs include thousands of organizations that operate in the 

humanitarian community. 

° NGOs have a wide variety of capacities, motivations, and 

specialty niches. 

° Each should subscribe to a set of ethical principles (see 

the Sphere Project at http://www.sphereproject.org/

handbook/). 

° NGOs act strictly for humanitarian purposes and aspire to 

complete political neutrality. 

Humanitarian Activities in Specific Scenarios

• Humanitarian medical activities during combat operations:

° Must account for the specific tactical situation and take a 

backseat to combat operations when necessary.

° Must conform to the theater MEDROEs. These:

▶ generally allow military medical personnel to respond 

to situations where life, limb, or eyesight of civilians is 

acutely threatened;
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Pediatric Surgery and Medicine for Hostile Environments

▶ must pose no significant increase in risk to US and 

friendly military security and have no significant impact 

on medical support to the force; and

▶ intend to allow response for acute, emergent conditions, 

not chronic, life-threatening conditions, such as heart 

disease, cancer, or chronic infections (eg, tuberculosis 

or human immunodeficiency virus).

° Must ensure that actions will be sustainable by the host 

nation after stabilization.

° Allow for combat medics to be trained for “Band-Aid 

ops,” providing care for minor injuries and illnesses of 

local civilians that they may encounter (eg, providing oral 

rehydration packets or over-the-counter pain medications 

and cleaning and bandaging minor wounds). 

Humanitarian Operations in Support of Counterinsurgency 

Operations

• These are primarily intended to get the majority of the 

population to reject the insurgents and support the host-nation 

government.

• Protecting the population from insurgents and restoring basic 

services (including medical and public health systems) are key 

components of these operations.

• Medical activities are sometimes viewed as a means to win 

“hearts and minds.” Although they may influence hearts, 

unless they demonstrate host-nation competence, medical 

activities may not help win minds. 

• Legitimizing the host-nation government is paramount in 

counterinsurgency operations.

° Host-nation forces and government services should be the 

face of any humanitarian operations and be credited with 

any good that results. 

° Any action that puts host-nation institutions in a bad light, 

such as providing a higher standard of care than the local 

health system, may be counterproductive.

° Simple medical and public health activities that the local 

forces can execute well may assist with building rapport 

with the civilian population. Examples include:
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Humanitarian Operations and Medical Civil-Military Activities

▶ Helping host-nation medics set up a simple, schoolbased community education program (tooth brushing, 

hand washing etc). 

▶ Helping host-nation military medical personnel improve 

their capacity to respond to civilian trauma.

• Tactical commanders may request that medical personnel 

evaluate and treat specific children.

° Each situation is different and requires thoughtful guidance 

to the commander.

° Evaluate the child, specifying up front that a cure or 

treatment may be impossible, repeating phrases like “no 

promises” often.

° Explore all possible solutions allowable under theater 

MEDROE.

° As long as expectations are carefully managed, a 

compassionate evaluation and explanation of the child’s 

condition will be well received.

• Medical activities that directly support intelligence operations 

should be avoided.

° The senior medical advisor, such as the brigade or battalion 

surgeon, should help the commander understand secondand third-order effects of medical activities, such as:

▶ loss of trust when medical activities are not sustained, 

and

▶ risk to patients and medical personnel that participate.

° A line must be drawn between any medical activities and 

intelligence or military purposes.

° Medical personnel, including enlisted medics, should 

only engage in activities that are consistent with their 

noncombatant role.

Humanitarian Medical Support for Stability Operations

• Doctrine lists restoration of essential services, including public 

health systems, as a primary goal.

° Planning methodology for restoration or improvement 

of host-nation essential services is a gap analysis, which 

requires assessment of current medical and public health 

needs and the existing capacity to meet those needs.
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Pediatric Surgery and Medicine for Hostile Environments

▶ Gaps can be categorized using the DOTMLPF format: 

Doctrine, Organization, Training, Materiel (equipment 

and supplies), Leadership, Personnel, and Financing.

▶ Training host-nation personnel is usually the biggest 

“bang for the capacity-building buck.”

▶ Training alone will not raise capacity if other needs, such 

as equipment, are not addressed.

▶ For sustainment, host-nation leadership must be on 

board and address organizational and long-term 

financing issues.

• Building health facilities may be part of stability operations.

° These must be fully vetted by host-nation health leadership.

° Staffing, equipping, and logistic sustainment of the facility 

must be considered up front, not after the fact.

° It may be better to renovate or enlarge an existing healthcare 

facility that is already staffed and sustained by the host 

nation, since it is already accepted by the local population.

° Commanders’ medical advisors, such as field or command 

surgeons, should be involved with the development of 

medical infrastructure programs. They may:

▶ Liaise with host-nation medical authorities or providers 

to ensure they are fully on board and have a voice in the 

project.

▶ Provide medical subject-matter expertise to planners 

and engineers.

Mass Migration Events

Historically, the US military has been tasked with responding to 

mass migration events. The main mission for the forces assigned 

is providing for a large displaced population, and primarily 

involves logistics, security, medical, and engineering aspects. The 

goal is to keep the population safe and healthy until a solution 

can be worked out.

• Medical personnel in mass migration focus on:

° public health and preventive medicine,

° primary care services to a diverse population that is likely 

to be medically fragile and afflicted by diseases of poverty 

and acute and chronic illnesses, and
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Humanitarian Operations and Medical Civil-Military Activities

° some tertiary care services for seriously ill and injured 

migrants.

• Patient movement beyond the camp setting may not be 

possible due to political considerations.

• Logistics

° Start with a complete census of migrants, with demographic 

breakdown into age and sex groups.

° Adequate food, water, and shelter requirements, according 

to international standards are: 

▶ Food: 2,100 kcals of culturally acceptable food per 

migrant.

▶ Water: minimum of 4 L/day/migrant to stay alive, 20 to 

30 L/day for cooking, cleaning, and washing.

▶ Shelter: 3.5 to 4 m2 below roof (tarps) and 30 m2/person 

for total camp space.

° Hygiene requirements: 1 latrine per 30 migrants. Adequate 

washing areas. 

° WHO international emergency health kits can provide 

medical supplies to meet the primary care needs of 10,000 

migrants for 3 months.

▶ Kits may be ordered with or without a malaria treatment 

module.

▶ Modules are also available for postexposure prophylaxis 

following sexual assault. 

° Security: separate unaccompanied children and provide 

care. Family units should be kept intact, but single men 

should be separated to deter acts of violence against women 

and children in competition for resources. 

• Medical care should follow international standards using 

WHO-style primary care and health protocols. See the end 

of the chapter for references.

° Combat medics fill roles traditionally provided by village 

nurses and health promoters in WHO-style medical care.

° Small, rudimentary health dispensaries are located near 

camps.

° Caregivers need to be prepared for pediatric, obstetric, and 

elderly patients.
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Pediatric Surgery and Medicine for Hostile Environments

° Tertiary care services will be provided by a deployed 

military field hospital. Both the Army and the Air Force 

have humanitarian medical packages for field hospitals to 

cover the needs of children and obstetrics.

• See Chapter 29, Infectious Diseases, for a review of 

common medical problems encountered during large-scale 

humanitarian crises. 

Humanitarian Activities During Training and Exercises

• Humanitarian activities that take place during training and 

exercises usually fall under the HCA program.

• Large, land-based exercises, such as Cobra Gold (Thailand), 

Balikatan (the Philippines), or New/Beyond the Horizons 

(Latin America and Caribbean) are planned years in advance. 

° These exercises are usually bilateral or multilateral, with 

the host nation and other nations participating.

° Medical support consists primarily of short-term medical 

clinics. Some capacity-building training is possible. 

Components of military field hospitals may also be 

deployed. 

° Local health workers can be employed to assist.

• Navy sea-based operations are similar, with the exception 

that they involve deployment of a hospital or other ships and 

travel from port to port.

° These offer more surgical capability than land-based 

exercises, and operating rooms are brought with the ship. 

The focus is on high-impact surgeries with minimal longterm follow up.

° Efforts are being made to increase the capacity-building 

focus during these missions (eg, using these as a platform 

for training courses and disaster exercises).

° Predeployment planning using needs assessment 

methodology and ensuring the full support of the hostnation medical community and leadership is key to success. 

• Surgical stand-alone exercises

° These provide both a service to the host nation and training 

for US military surgical residents and staff.

° Surgical stand-alone exercises are ongoing programs that 

work in host-nation hospitals.
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Humanitarian Operations and Medical Civil-Military Activities

° US surgeons learn and practice techniques that are 

important wartime skills. 

° Participants practice using the equipment that is used in 

deployable field hospitals.

° The host nation benefits by decreasing the backlog of 

indigent surgical care patients.

° Pediatric surgical procedures are a common focus of these 

programs.

Short-Term Medical Civil Action Program Clinics

• MEDCAP clinics are short-term ad hoc clinics. They have 

generally fallen out of favor in most recent counterinsurgency 

operations.

• These activities are controversial; many weaknesses have 

been noted over the years. Documented problems with some 

MEDCAPs have included:

° undermining local health systems,

° lack of coordination with health systems to provide followon care,

° use of medications that are not used locally,

° lack of sufficient expertise in local health conditions,

° insufficient focus on public health,

° a lack of long-term benefits, and

° loss of trust when expectations are raised and then not 

sustained.

• Adequate preparation, planning, and coordination, as well 

as following sound execution principles, can mitigate the 

above weaknesses and maximize the benefit to host-nation 

participants.

° Preparation focuses on understanding the epidemiology 

of local health conditions and the health system, cultural 

aspects, and roles of each team member.

° Planning involves several factors. 

▶ Team selection: The team should be selected based on a 

needs assessment. 

▷ Most MEDCAPs will serve a disproportionate number 

of children and women. 

▷ Dental and optometry services are also helpful, if 

available. 
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Pediatric Surgery and Medicine for Hostile Environments

▷ Caregivers arepublic health and preventive medicine 

practitioners.

▷ Veterinary services are sometimes included. 

Improving the health of agricultural animals can be 

extremely helpful in some situations.

▶ Site selection: Security is the first determinant in site 

selection. When possible, work areas should be directed 

by host-nation health officials. 

▷ Support for DoD and other US government objectives 

may influence the area of operations or specific 

worksites.

▷ Match team capability to the worksite. A typical 

MEDCAP team can provide care for up to 500 patients 

per day, and it can be easily overwhelmed by large 

numbers of patients in urban areas.

▶ Formulary: If possible, the formulary should mirror 

local health services. Also, consider the WHO essential 

formulary and the WHO international emergency health 

kits for guidance.

▷ Invest in preventive services, like toothbrushes, 

vitamin A, and dewormers. 

▷ Let host-nation personnel provide vaccines to ensure 

they fit with national programs.

▷ Stockno-frills, inexpensive antibiotics, pain relievers, 

medications for skin conditions, and allergy and acute 

asthma medications.

▷ Dental medications, including local anesthetic, should 

be included.

▷ Some medications and equipment should be provided 

for urgent needs (epinephrine, injectable antibiotics, 

intravenous fluids, etc).

▷ Generally do not provide medications for chronic 

conditions. Treatment that cannot be sustained should 

not be begun. 

▷ Stock oral rehydration packets.

▷ There is no requirement to provide cough and cold 

medications to young children.

▷ Children do not necessarily need liquid medications; 

crushed pills may suffice in many situations. 
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Humanitarian Operations and Medical Civil-Military Activities

▷ First do no harm: do not provide large amounts of 

dangerous medications.

▶ Coordination: Unless the security situation does not 

allow it, ensure that the host-nation health system is 

fully supported and involved up front; it is their country 

and their population, a respectful attitude and desire to 

support the local system is paramount.

▷ A good strategy is to use the MEDCAP as a “magnet” 

to attract the local population and facilitate hostnation public health programs.

▷ Plan to work side by side with local health workers. 

Support their needs and value their time investment. 

▷ Ensure that records of patient encounters and 

surveillance data will be gathered in accordance with 

host-nation norms.

▷ Plan with the host nation for referrals to higher 

echelons of care, follow-on care, and chronic care 

needs.

▷ Coordinate for capacity-building activities that 

will support local needs (eg, continuing education 

activities or mass casualty exercises).

▷ Any planned surgical services should be coordinated 

with host-nation health authorities based on 

population needs and must include a plan for any 

needed follow on postoperative care.

▷ Ensure that emergency evacuation plans are prepared 

for moving US and friendly forces that may become 

injured during the MEDCAP.

• Conducting a MEDCAP

° Worksite set-up should provide security and a logical 

patient flow.

▶ Maintain controlled entry and exit points. 

▶ If possible, have host-nation security personnel manage 

crowds and staff the entry and exit points.

▶ A medical person should periodically “cruise the fenceline,” observing the crowd for seriously ill patients. 

▶ Provide water and shade for waiting patients if lines are 

long.
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Pediatric Surgery and Medicine for Hostile Environments

▶ Most patients will first go to a large area for community 

education and other preventive services. Have hostnation personnel direct and provide most preventive 

services.

▶ Patients will then go to the triage area. Seriously ill 

patients can bypass preventive services, while healthy 

school-age children may leave directly from the 

preventive services area if they do not need medical or 

dental care.

▷ Host-nation personnel are frequently better suited 

than US personnel to take the patient’s chief complaint 

and record the needed demographics. 

▷ Patients then proceed to medical, dental, and 

optometric stations, as needed.

▷ Patients take scripts to the pharmacy area to collect 

medications.

▷ After pharmacy, patients proceed directly to the 

controlled exit point to leave.

▷ Security personnel and local volunteers assist with 

directing patients to various stations within the 

worksite.

° MEDCAP medical care

▶ Local health personnel and school officials should be 

asked to bring any seriously ill or injured children 

directly to the medical facility for evaluation.

▶ Most children will have no significant illness, especially 

older children.

▶ Focus on infants and toddlers. Rely on physical 

examination and “gut” empirical evaluation and 

treatment in most situations. Labs and radiographs are 

usually not available. 

▶ Providers may have 5 minutes or less to evaluate most 

children.

▶ Common conditions include minor wounds, burns, 

and skin conditions, as well as upper respiratory and 

diarrheal infections.

▶ “Exotic, tropical” infections are usually relatively 

uncommon, even in endemic areas, but the healthcare 

team should be prepared to treat and evaluate diseases 
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Humanitarian Operations and Medical Civil-Military Activities

that are reasonably possible. If malaria is prevalent, the 

team must ensure it is prepared to treat according to the 

local standard of care.

▶ Consider keeping a small amount of funds in reserve to 

purchase local medications that cannot be anticipated.

▶ There is no requirement for “everyone to get something.” 

Patients can be given vitamins, toothbrushes, and 

preventive medicine items up front.

▶ It isbest to dispense medications only in the designated 

pharmacy area, not at the clinical work area. 

▷ This prevents patients from observing which “stories” 

are more likely to receive medications. 

▷ This also facilitates better education about medication 

without bogging down the clinical providers.

▷ The exception is preventive medications, such as 

dewormers and vitamins, that can be provided in the 

preventive medicine area prior to reaching medical 

treatment areas. 

▷ Only provide medications that are reasonably safe 

and in safe amounts.

References, Further Reading, and Resources

1. The Sphere Project Board. The Sphere Project Handbook. 

Rugby, Warwickshire, UK: Practical Action Publishing; 

2011.

2. US Agency for International Development. Field Operations 

Guide for Disaster Assessment and Response. Washington, DC: 

USAID; 2005.

3. World Health Organization. WHO Integrated Management of Childhood Illness. Geneva, Switzerland: WHO 

Press; 2005. http://apps.who.int/iris/bitstream/10665/42939/

1/9241546441.pdf. Accessed January 8, 2016.

4. Stuart MC, Kouimtzi M, Hill SR. WHO Model Formulary

2008. Geneva, Switzerland: WHO Press; 2008. http://www.

who.int/selection_medicines/list/WMF2008.pdf. Accessed 

December 19, 2014.
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Pediatric Surgery and Medicine for Hostile Environments

5. World Health Organization, International Committee of 

the Red Cross, International Federation of Red Cross and 

Red Crescent Societies, Médecins Sans Frontières, United 

Nations Children’s Fund, United Nations Population 

Fund, United Nations High Commissioner for Refugees. 

The Interagency Emergency Health Kit 2011: Medicines and 

Medical Devices for 10,000 People for Approximately Three 

Months. Geneva, Switzerland: WHO Press; 2011.

6. US Department of the Army. Tactics in Counterinsurgency. 

Washington, DC: DA; 2009. Field Manual 3-24.2. 
705

Appendices

Appendix A

RESOURCES FOR DEPLOYED 

PHYSICIANS CARING FOR CHILDREN

The authors and editors of this book are keenly aware that 

the majority of pediatric healthcare delivered by US military 

medical personnel in hostile or austere environments is not in 

a hospital setting. Even the limited resources of a Role 3 facility 

like a combat support hospital seem lavish in comparison to the 

equipment, supplies, and medications available to a Role 1 or 2 

provider. While this text focuses on applying hospital resources 

to critically ill and injured children, we wanted to support 

the efforts to care for children in more resource-constrained 

environments.

The following list gives medical providers additional 

clinical, administrative, and doctrinal resources to support 

decision-making in a deployed or austere environment. The 

clinical resources draw from a vast body of literature but focus 

principally on World Health Organization and nongovernmental 

organization standards and treatment protocols. Developed on 

a solid foundation of clinical experience and research, these 

documents are invaluable sources of internationally accepted 

best practices for both inpatient and outpatient clinical settings 

with limited resources. They also provide a model of minimum 

standards of care that developing nations aspire to and 

deployed military forces may emulate when seeking to provide 

contextually appropriate medical care that is consistent with 

(and does not undermine) local health systems.

The military medicine resources provided draw from the 

robust clinical experience of more than a decade at war. Spanning 

the spectrum of care from the point of injury to the Role 3 facility, 

these references emphasize prehospital trauma care as well as 

the inpatient management of critical care patients. Written with a 
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Pediatric Surgery and Medicine for Hostile Environments 

solid understanding of the capabilities available to the deployed 

clinician, these resources reflect the needs and daily realities for 

deployed medical teams. 

Disaster response remains one of the most common 

contingency operations executed by the Department of Defense. 

As such, commanders, clinicians, and medical planners must be 

well versed in both international standards to which the United 

States subscribes and the doctrinal underpinnings of both the 

Department of Defense and Department of State responses. 

The works cited in this list represent how the military plans 

and executes foreign disaster assistance missions and reflect 

recent emphasis on enhanced coordination at the interagency 

and intergovernmental levels as well as with nongovernmental 

organizations. The military publications represent a rapidly 

evolving body of doctrine. The reader is advised to seek out new 

and expanded publications. 

Medical Care in Resource-Limited Settings

World Health Organization. Integrated Management of Childhood 

Illness: IMCI Chart Book. Geneva, Switzerland: WHO Press; 2013. 

http://www.who.int/maternal_child_adolescent/documents/

IMCI_chartbooklet/en/. Accessed January 9, 2015. 

World Health Organization. Pocket Book of Hospital Care for 

Children: Guidelines for the Management of Common Illnesses With 

Limited Resources. 2nd ed. Geneva, Switzerland: WHO Press; 2013. 

http://www.who.int/maternal_child_adolescent/documents/

child_hospital_care/en/. Accessed January 9, 2015. 

Clinical Guidelines: Diagnosis and Treatment Manual for Curative 

Programmes in Hospitals and Dispensaries. 8th ed. Paris, 

France: Mèdecins Sans Frontières; 2013. http://apps.who.int/

medicinedocs/documents/s17078e/s17078e.pdf. Accessed 

January 9, 2015. 

World Health Organization. WHO Model Formulary for Children. 

Geneva, Switzerland: WHO Press; 2013. http://www.who.

int/medicines/publications/essentialmedicines/en/. Accessed 

January 9, 2015. 
707

Appendices

World Health Organization. Recommendations for Management 

of Common Childhood Conditions: Evidence for Technical Update 

of Pocket Book Recommendations. Geneva, Switzerland: WHO 

Press; 2012. http://www.who.int/maternal_child_adolescent/

documents/management_childhood_conditions/en/. Accessed 

January 9, 2015. 

Military Medicine

Savitsky E, Eastridge B, eds. Combat Casualty Care: Lessons Learned 

from OEF and OIF. Fort Detrick, MD: Borden Institute; 2012. 

http://www.cs.amedd.army.mil/borden/book/ccc/CCCFull.pdf. 

Accessed January 9, 2015.

US Department of Defense. Tactical Combat Casualty Care 

Course. Washington, DC: DoD. http://www.health.mil/tccc 

(common access card required). Accessed September 2014.

Department of Defense, US Special Operations Command. Special 

Operations Forces Medical Handbook. Washington, DC: DoD; 2008. 

eBook available at: http://bookstore.gpo.gov/products/sku/008-

070-00810-6. Accessed January 9, 2015. 

Surface Warfare Medicine Institute. Fleet Medicine Pocket 

Reference. San Diego, CA: Surface Warfare Medicine Institute. 

http://www.med.navy.mil/sites/nmotc/swmi/Documents/

FleetMedicinePocketReference2010.pdf. Accessed January 9, 

2015.

The US Army has developed three specialty augmentation sets 

to support hospital-based medical operations for a population of

10,000 people for 10 days in humanitarian assistance/disaster 

relief operations. They include a pediatric augmentation set 

(625A) and a surgical set (624A), as well as an adult set (623A), 

which specifically includes items to care for the chronically 

ill and elderly. All the sets are “pull items” initially, and then 

demand supported.
708

Pediatric Surgery and Medicine for Hostile Environments 

International Guidelines and Online Resources for Disaster 

Response

The Sphere Project. The Sphere Handbook: Humanitarian Charter and 

Minimum Standards for Disaster Response. Geneva, Switzerland: 

The Sphere Project; 2011. http://www.sphereproject.org. 

Accessed January 9, 2015. 

World Health Organization. Communicable Disease Control 

in Emergencies: A Field Manual. Geneva, Switzerland: WHO; 

2005. http://www.who.int/diseasecontrol_emergencies/

publications/9241546166/en/. Accessed January 9, 2015. 

US Agency for International Development. Field Operations Guide 

for Disaster Assessment and Response. Washington, DC: USAID; 

2005. https://scms.usaid.gov/sites/default/files/documents/1866/

fog_v4.pdf. Accessed January 9, 2015.

Interagency Standing Committee. [Various resources]. http://

www.humanitarianinfo.org/iasc/. Accessed January 9, 2015. 

ReliefWeb. [Various resources]. Available at http://reliefweb.int/. 

Accessed January 9, 2015.

Berman S, ed. Pediatrics Education in Disasters (PEDS): A Course 

of the “Helping the Children” Program. Elk Grove Village, IL: 

American Academy of Pediatrics; 2009. 

http://www.aap.org/en-us/advocacy-and-policy/aap-healthinitiatives/Children-and-Disasters/Documents/peds-fulleng_2012.pdf. 

National Disaster Life Support Foundation. SALT Mass Casualty 

Triage On-line Training. National Disaster Life Support 

Foundation. 2013. http://register.ndlsf.org/mod/page/view.

php?id=2056. Accessed January 9, 2015.
709

Appendices

Military Doctrine Related to Humanitarian Assistance

US Joint Chiefs of Staff. Foreign Humanitarian Assistance. 

Washington, DC: Department of Defense; 2014. Joint Publication 

3-29. http://www.dtic.mil/doctrine/new_pubs/jp3_29.pdf. 

Accessed January 9, 2015. 

US Joint Chiefs of Staff. Civil-Military Operations. Washington, 

DC: Department of Defense; 2013. Joint Publication 3-57. http://

www.dtic.mil/doctrine/new_pubs/jp3_57.pdf. Accessed January 

12, 2015. 

US Joint Chiefs of Staff. Health Service Support. Washington, 

DC: Department of Defense; 2012. Joint Publication 4-02. http://

www.dtic.mil/doctrine/new_pubs/jp4_02.pdf. Accessed January 

12, 2015. 

US Department of Defense. Department of Defense Support to 

Foreign Disaster Relief: Handbook for JTF Commanders and Below. 

Washington, DC: DoD; 2011. Graphic Training Aid 90-01-030. 

http://www.fas.org/irp/doddir/dod/disaster.pdf. Accessed 

January 12, 2015. 

US Department of the Army. Multi-Service Techniques for Civil 

Affairs Support to Foreign Humanitarian Assistance. Washington, 

DC: DA; 2013. Army Training Publication 3-57.20/Marine Corps 

Reference Publication 3-33.1C. http://armypubs.army.mil/

doctrine/DR_pubs/dr_a/pdf/atp3_57x20.pdf. Accessed January 

12, 2015.

US Department of the Navy. Disaster Response Operations. 

Norfolk, VA: Navy Warfare Development Command; 2011. Navy 

Warfare Publication 3-29.

https://community.apan.org/cfs-file.ashx/__key/telligentevolution-components-attachments/13-7591-00-00-00-11-

27-57/3_2D00_29_5F002800_Dec_5F00_2011_29005F002800_

NWP_2900_.pdf. Accessed January 12, 2015. 
710

Pediatric Surgery and Medicine for Hostile Environments 

US Department of the Air Force. Camp Planning for Displaced 

Persons. Washington, DC: USAF; 2011. Air Force Handbook 10-

222, Volume 22. http://static.e-publishing.af.mil/production/1/

af_a3_5/publication/afh10-222v22/afh10-222v22.pdf. Accessed 

January 12, 2015. 

US Department of the Army. Army Health System Support to 

Maneuver Forces. Washington, DC: DA; 2014. Army Training 

Publication 4-02.3. http://armypubs.army.mil/doctrine/DR_pubs/

dr_a/pdf/atp4_02x3.pdf. Accessed January 12, 2015. 

Lawry L, ed. Guide to Nongovernmental Organizations for the 

Military. Bethesda, MD: The Center for Disaster and Humanitarian 

Assistance Medicine, Uniformed Services University of the 

Health Sciences; 2009. www.fas.org/irp/doddir/dod/ngo-guide.

pdf. Accessed January 12, 2015. 
711

Appendices

Appendix B

CONTRIBUTORS TO FIRST EDITION

Karla Au Yeung, MAJ, MC, USA

Kenneth S. Azarow, COL, MC, USA (Ret) 

Hans E. Bakken, MAJ, MC, USA

Randy S. Bell, LCDR, MC, USN 

Paul L. Benfanti, COL, MC, USA

Richard H. Birdsong, COL, MC, USA

Scott E. Brietzke, LTC, MC, USA

Thomas R. Burklow, COL, MC, USA

Kathryn Camp, MS, RD, CSP

Wayne A. Cardoni, LCDR, MC, USN

Lisa Cartwright, LCDR, MC, USN 

Debora S. Chan, PharmD, FASHP

Theodore J. Cieslak, COL, MC, USA 

Bernard A. Cohen, MD 

Annesley W. Copeland, COL, MC, USA (Ret) 

James E. Cox, Jr., COL, MC, USAF (Ret)

Stephen J. Cozza, COL, MC, USA (Ret)

Kevin M. Creamer, COL, MC, USA

Arthur J. DeLorimier, COL, MC, USA

William C. DeVries, COL, MC, USAR

Robert L. Elwood, MAJ, MC, USAF

Nathan L. Frost, CPT, MC, USA

Charles J. Fox, LTC, MC, USA

Michael M. Fuenfer, COL, MC, USA

Satyen Gada, LCDR, MC, USN

Rebecca A. Garfinkle, MAJ, MC, USA

Curtis Goho, COL, DC, USA

Matthew D. Goldman, MAJ, MC, USAF

Gregory H. Gorman, LCDR, MC, USN

John Hanna, DDS

Patrick W. Hickey, MAJ, MC, USA

Alex Holston, LCDR, MC, USN
712

Pediatric Surgery and Medicine for Hostile Environments 

Nancy G. Hoover, LTC, MC, USA

Cheryl Issa, MS, RD, CSP, CNSD

David Jarrett, COL, MC, USA

Timothy K. Jones, COL, DC, USA (Ret) 

Matthew Kelly, MAJ, MC, USA

Ryan J. Keneally, MAJ, MC, USA

Brent L. Lechner, LTC, MC, USA

Martha K. Lenhart, COL, MC, USA

Rebecca B. Luria, MAJ, MC, USA

Robert Mansman, MAJ, DC, USA

Chad Mao, LCDR, MC, USN

Jonathan E. Martin, MAJ, MC, USA 

Donald R. McClellan, COL, MC, USA

Michael McCown, MAJ, MC, USA

Kathleen McHale, COL, MC, USA (Ret) 

Margret E. Merino, LTC, MC, USA

Michael H. Mitchell, COL, MC, USA 

Marisa G. Mize, DNP

Houman Motamen-Tavaf, LTC, MC, USA

Dawn D. Muench, MAJ, MC, USA

Harlan S. Patterson, COL, MC, USA

Philip L. Rogers, COL, MC, USA (Ret)

Shawn D. Safford, CDR, MC, USN 

Erik P. Schobitz, MD

Cynthia H. Shields, COL, MC, USA

Elizabeth Shin, DDS

Steven E. Spencer, LTC, MC, USA

Phillip C. Spinella, MD

Robert Steelman, MD, DMD

Allen I. Stering, MAJ, MC, USAF

Frederick J. Stoddard Jr, MD

Carolyn A. Sullivan, COL, MC, USA

Deena Sutter, MAJ, MC, USAF

Sarah K. Taylor, MAJ, MC, USA

Martin E. Weisse, COL, MC, USA
713

Appendices

Appendix C

COMPREHENSIVE PEDIATRIC 

EQUIPMENT SIZING
714

Pediatric Surgery and Medicine for Hostile Environments Comprehensive Pediatric Equipment Sizing Laryngeal Endotracheal Mask Size Oral/Nasopharyngeal Mask Laryngoscope Tube Tracheostomy Suction Age / Weight for BVM Airways Airway Blade (Cuff or Not) Tube (ID mm) Catheter Premature 0–1 Premie (40 mm)/12 F 1 0 straight 2.5–3.0 uncuffed 2.5 5 F infant (< 3 kg) (premie– NBN) Newborn (< 28 0–1 Premature infant 1 0–1 straight 3.0–3.5 uncuffed 3.0–3.5 6 F days; ≥ 3 kg) (premie– (40–50 mm)/ 14 F 6 F stylet NBN) Infant (1 month– 1–2 (NBN– Infant–small (50–60 mm)/ 1–1.5 1 straight 3.5–4.0 uncuffed 3.5–4.0 8 F 1 y; 4–10 kg) infant) 14–16 F 6 F stylet Toddler (1–2 y; 2 (infant) Small (60 mm)/18–20 F 1.5–2 1–2 straight 4.0–4.5 consider 4.0–4.5 8–10 F 10–13 kg) cuffed 8 F stylet Preschool 3 (infant– Small–medium 2 2 straight or 4.5–5.0 consider 5.0 10 F (3–5 y; 13–18 kg) child) (60–70 mm)/22 F curved cuffed 8 F stylet School age 3–4 (child– Medium (70–80 mm)/ 2.5–3 2 straight or 5.5–6.0 cuffed 5.5 10–12 F (6–9 y) 18–25 kg small adult) 24–26 F 2–3 curved 8 F stylet

School age 4 (small adult) Medium-large (80 mm)/ 3–4 2–3 straight 6.0–6.5 cuffed 6.0–6.5 12 F

(10–12 y) 25–40 kg 26–30 F 3 curved 8–14 F stylet

Adolescent 4–5 (small Large (80–100 mm)/ 3–5 3 straight or ≥ 7.0 cuffed 14 F 7.0–9.0 14 F

(13–18 y) > 40 kg adult–adult) > 30 F curved stylet

BP: blood pressure, BVM: bag valve mask, ET: endotracheal, F: French, ID: internal diameter, IJ: internal jugular, IV: intravenous, NBN: newborn, NG: nasogastric, OG: orogastric, UAC: uterine artery catheter, UCV: uterine vein catheter 
715

Appendices

BP Cuff Central Line

Chest Bladder Peripheral (If between sizes Arterial Line Nasogastric Foley

Age / Weight Tube Width/Length IV Catheter chose the smaller line) Peripheral/Central Tube CatheterPremature 8–10 F 2.5–4.5 cm/ 24 g 5 F UVC, 5 F feeding 5 F UAC or 5 F Feeding 5 F 5 F

infant (< 3 kg) 5 cm–9 cm tube, or central 3–4 tube as UAC

F (5–8 cm)

Newborn (< 28 10–12 F 2.5–4.5 cm/ 24 g 5 F UVC, 5 F feeding 2.5 F 2.5 cm or 24 g IV/ 5–8 F 6 F

days; ≥ 3 kg) 5 cm–9 cm tube, or central 3–4 5 F UAC or 2.5–3 F 5 

F (5–8 cm) cm femoral

Infant (1 m–1 y; 10–12 F 4–6 cm/ 24–22 g 3–4 F 8–12 cm or 2.5 F 2.5 cm or 24 g IV/ 8–12 F 6–8 F

4–10 kg) 11.5–18.5 cm 20 g 12 cm 18 g or 3–3.5 F 5 cm

Pediatric IJ kit

Toddler (1–2 y; 14–20 F 4–6 cm/ 24–22 g 4 F 8–12 cm or 20 g 2.5 F 2.5 cm or 22 g IV/ 12 F 8–10 F

10–13 kg) 11.5–18.5 cm 12 cm Pediatric IJ 18 g or 3.5–4 F 5 cm

kit

Preschool 18–24 F 7.5–9 cm/ 22–20 g 4–5 F 8–12 cm 22 g IV/18 g or 4–4.5 F 12–14 F 10–12 F

(3–5 y; 13–18 kg) 17–19 cm

School age 20–26 F 7–9.5 cm/ 20 g 5–6 F 8–12 cm 22 g IV/16 g or 5 F 14–16 F 12–14 F

(6–9 y) 18–25 kg 17–19 cm

School age 26–32 F 7–9.5 cm/ 20–18 g 5–6 F 8–12 cm 22 g IV/16 g or 5 F 16 F 14 F

(10–12 y; 25–40 kg) 17–19 cm or

>9.5 cm/

22–26 cm

Adolescent > 32 F >9.5 cm/ 20–16 g 6–7 F 12–15 cm adult 22–20 g IV/16–14 g or 16–18 F 14–18 F 

(13–18 y; > 40 kg) 22–26 cm triple lumen 5–6 F

Rules of thumb: (1) depth ET tube at lip = 3 × ET tube size; (2) OG, NG, and Foley size = 2 × ET tube size; (3) chest tube size = 4 × ET tube size; (4) tracheostomy tube ID = age (y)/3 + 3.5 
716

Pediatric Surgery and Medicine for Hostile Environments 
717

Author Bios

Kevin M. Creamer, MD, FAAP 

Colonel Kevin Creamer graduated from the Uniformed Services 

University of the Health Sciences and completed his pediatric 

residency at Tripler Army Medical Center. After 3 years of general 

pediatric practice at the 121st Hospital in Korea and Madigan 

Army Medical Center, Washington, Dr Creamer returned to train 

in critical care at the Medical College of Georgia. He subsequently 

served as the medical director 

of the pediatric intensive care 

units at Tripler Army Medical 

Center, Hawaii, and Walter 

Reed Army Medical Center, 

Washington, DC, where he 

finished his career as the 

chief of pediatric inpatient 

services and the pediatric 

subspecialty consultant to the 

Army Surgeon General. Dr 

Creamer’s interests include 

pediatric resuscitation and justin-time education for deploying 

medical providers to hostile 

and austere environments. His 

team’s first project, the Hostile 

Environments Life-Saving 

Pediatrics (HELP) CD, was 

circulated annually to thousands of triservice deploying medical 

personnel. It included the necessary video presentations, brief 

handouts, and weblinks to facilitate care for critically ill and 

injured children by nonpediatric providers. Kevin also created 

and served as the medical director of the web-based PICU.

consult service, which fielded hundreds of critical care consults 

from Iraq and Afghanistan. His latest projects have been serving 

as author and editor of the original and subsequent editions 

of Pediatric Surgery and Medicine for Hostile Environments. Dr 

Creamer is board certified in pediatrics and pediatric critical 
718

Pediatric Surgery and Medicine for Hostile Environments 

care. Since retirement in 2010, he has worked as a pediatric 

hospitalist in New Zealand and currently at Children’s National 

Medical Center in Washington, DC. He is an associate professor of 

pediatrics at George Washington University School of Medicine 

and the Uniformed Services University of the Health Sciences.
719

Author Bios

Michael M. Fuenfer, MD, FAAP, FACS

Colonel Michael M. Fuenfer graduated from the University of 

Louisville School of Medicine. Dr Fuenfer completed a pediatric 

residency at Kosair Children’s Hospital in Louisville, a fellowship 

in perinatal-neonatal medicine at the University of Connecticut, 

a general surgery residency at Yale University, a fellowship in 

pediatric surgery at the University of Alabama, and a fellowship 

in pediatric critical care 

medicine at the Massachusetts 

General Hospital. He was 

commissioned in the US Air 

Force Reserve in 1981, serving 

in the Kentucky Air National 

Guard as an F-4 squadron 

flight surgeon until 1984, 

when he transferred to the 

US Army Reserve. Colonel 

Fuenfer completed training as 

an Army flight surgeon and 

graduated from the US Army 

Airborne School and the US 

Army Special Forces Detachment Officer Qualification Course. 

From 1985 to 1998 Dr Fuenfer served as a Green Beret in the 

11th and 20th Special Forces Groups (Airborne). He served 

in Afghanistan (Operation Enduring Freedom) in 2003–2004 

as a combat surgeon at the 452nd Combat Support Hospital 

(Bagram), commanded a forward surgical team (Kandahar), 

and served as a Special Forces surgeon at a firebase in Helmand 

Province. From 2005 to 2009, Dr Fuenfer volunteered to be 

mobilized, and served as a pediatric surgeon and the deputy 

chief of general surgery at Walter Reed Army Medical Center in 

Washington, DC. He holds FAA ratings as a commercial pilot 

and certificated flight instructor, and has authored a popular 

book for pilots currently in its 6th edition. In 2007 he completed 

the US Air Force basic and advanced critical care air transport 

team (CCATT) courses. He is certified by the American Board of 
720

Pediatric Surgery and Medicine for Hostile Environments 

Surgery in general surgery, surgical critical care, and pediatric 

surgery, and by the American Board of Pediatrics in general 

pediatrics and perinatal-neonatal medicine. Dr Fuenfer has held 

academic appointments at the University of South Alabama and 

Yale University and currently holds appointments as associate 

pediatrician at Massachusetts General Hospital in the Division 

of Pediatric Critical Care Medicine, instructor in pediatrics at 

Harvard Medical School, and assistant professor of surgery and 

pediatrics at the Uniformed Services University of the Health 

Sciences. Dr Fuenfer has numerous publications and serves as a 

reviewer for the journals Pediatrics and Military Medicine. He is 

currently involved in developing new curricula for teaching basic 

surgical skills to students, house staff, and attending staff in the 

Massachusetts General Hospital Simulation Lab, treating patients 

in hyperbaric therapy and wound care, developing innovative 

medical devices with collaborators at the Massachusetts Institute 

of Technology, and serving as author and senior surgical editor 

for the original and this second edition of Pediatric Surgery and 

Medicine for Hostile Environments. Colonel Fuenfer is assigned 

as an Army Reserve flight surgeon to the US Army Research 

Institute of Environmental Medicine (USARIEM) at Natick Army 

Soldier Systems Center, Natick, Massachusetts.
xxvii

Index

A

ABC: airway, breathing, and circulation

AC/A: accommodative convergence to accommodation

ADH: antidiuretic hormone

AE: aeromedical evacuation

AMP: ampicillin

APSA: American Pediatric Surgical Association

aPTT: activated partial thromboplastin time

ATLS: Advanced Trauma Life Support 

AV: arteriovenous 

AVM: arteriovenous malformation

B

BLS: basic life support

BP: blood pressure

bpm: beats per minute 

BSA: body surface area

BUN: blood urea nitrogen

BVM: bag-valve-mask

BWt: body weight 

C

CAR: cabin altitude restriction 

CBC: complete blood count

CBRNE: chemical, biological, radiological, nuclear, and explosive

CCATT: critical care air transport team

CHF: congestive heart failure

ClCr: creatinine clearance

CMR: crude mortality rate 

CMV: continuous mandatory ventilation 

CMV: cytomegalovirus 

CNS: central nervous system

CO2: carbon dioxide

CPAP: continuous positive airway pressure

ABBREVIATIONS andACRONYMS
xxviii

Pediatric Surgery and Medicine for Hostile Environments 

CPP: cerebral perfusion pressure

CPR: cardiopulmonary resuscitation

CRP: C-reactive protein

CSF: cerebrospinal fluid

CT: computed tomography

CV: cardiovascular

CVC: central venous catheter

CVP: central venous pressure

D

D5W: 5% dextrose in water

D10W: 10% dextrose in water 

D25W: 25% dextrose in water

DIC: disseminated intravascular coagulation

DKA: diabetic ketoacidosis 

DM1: diabetes mellitus type 1 

DM2: diabetes mellitus type 2

DNA: deoxyribonucleic acid

DoD: Department of Defense

DTPA: diethylenetriaminepentaacetic acid 

E

EA: esophageal atresia 

ECG: electrocardiogram

ECG: electrocardiography

EDTA: ethylenediaminetetraacetic acid

EEG: electroencephalogram

eGFR: estimated glomerular filtration rate

ENT: ear, nose, and throat

ERCP: endoscopic retrograde cholangiopancreatography

ESR: erythrocyte sedimentation rate

ET: endotracheal

ETT: endotracheal tube

EVD: extraventricular drain

F

FAST: focused assessment with sonography for trauma

FDR: foreign disaster response

FFP: fresh frozen plasma
xxix

Abbreviations and Acronyms Index

FiO2:fraction of inspired oxygen

Fr: French size

FS: fractional shortening

G

GABHS: group A β-hemolytic streptococci 

GCS: Glasgow Coma Scale

GI: gastrointestinal

GN: glomerulonephritis 

H

HCT: hematocrit 

Hgb: hemoglobin 

Hib: Haemophilus influenzae type B

HIV: human immunodeficiency virus

HPS: hypertrophic pyloric stenosis 

HR: heart rate 

HSV: herpes simplex virus

I

ICP: intracranial pressure

ICU: intensive care unit

IM: intramuscular

IMV: intermittent mandatory ventilation 

IO: intraosseous

IOP: intraocular pressure

ITP: idiopathic thrombocytopenic purpura

ITP: immune thrombocytopenic purpura

IU: international units

IV: intravenous 

IVC: inferior vena cava

IVIG: intravenous immunoglobulin

L

LDH: lactate dehydrogenase

LPM: liters per minute

LR: lactated Ringer’s

LV: left ventricular
xxx

Pediatric Surgery and Medicine for Hostile Environments 

M

MAP: mean arterial pressure

MASCAL: mass casualty

MCI: mass casualty incident 

MCV: mean corpuscular volume

MEDROE: medical rules of engagement

MMF: maxillary-mandibular fixation

MRI: magnetic resonance imaging

MRSA: methicillin-resistant Staphylococcus aureus

MT: massive transfusion

MTF: medical treatment facility

MUAC: mid-upper arm circumference

N

NG: nasogastric

NPH: neutral protamine Hagedorn

NS: normal saline

NSAID: nonsteroidal antiinflammatory

O

OFDA: Office of Foreign Disaster Assistance

ORS: oral rehydration solution

P

PALS: pediatric advanced life support

PaO2:partial pressure of oxygen in arterial blood

PC: pressure control

PCA: patient-controlled analgesia

pCO2: partial pressure of carbon dioxide

PCR: polymerase chain reaction

PEEP: positive end expiratory pressure

PGE1: prostaglandin 

PIP: peak inspiratory pressure

PMRC: patient movement requirements center

PO: per os 

Posm: plasma osmolality

PRBC: packed red blood cell

PT: prothrombin time

PTU: propylthiouracil

PVC: premature ventricular contraction
xxxi

Abbreviations and Acronyms Index

R

RBC: red blood cell

RC: reticulocyte count

RDW: red blood cell distribution width

ROP: retinopathy of prematurity

RSDL: Reactive Skin Decontamination Lotion Kit 

RSE: refractory status epilepticus 

RSI: rapid sequence intubation

RUG: retrograde urethrogram

S

SAM: severe acute malnutrition

SaO2: oxygen saturation

SBP: systolic blood pressure

SCH: subconjunctival hemorrhage

ScvO2: central venous oxygen saturation

SE: status epilepticus

SIADH: syndrome of inappropriate antidiuretic hormone

SIPRNet: Secure Internet Protocol Router Network

SJS: Stevens-Johnson syndrome 

SPT: suprapubic tube 

SQ: subcutaneous

SVR: systemic vascular resistance

T

TB: tuberculosis

TBI: traumatic brain injury

TBSA: total body surface area 

TEF: tracheoesophageal fistula 

TEG: thromboelastography 

TEN: toxic epidermal necrolysis

tid: three times daily

TMP/SMX: trimethoprim-sulfamethoxazole

TPN: total parenteral nutrition

TRAC2ES: TRANSCOM Regulating and Command and Control 

Evacuation System

TRANSCOM: United States Transportation Command

TXA: tranexamic acid 
xxxii

Pediatric Surgery and Medicine for Hostile Environments 

U

UDT: undescended testicle

UGI: upper gastrointestinal

UPJ: ureteropelvic junction 

URI: upper respiratory infection

US: ultrasound

USAF: US Air Force

USAID: United States Agency for International Development

UTI: urinary tract infection

UVC: umbilical vein catheter 

V

VACTERL: vertebral defects, anal atresia, cardiac defects, 

tracheo-esophageal fistula, renal anomalies, and limb

VC: volume control

VF: ventricular fibrillation

Vt: tidal volume

VT: ventricular tachycardia

W

WBC: white blood cell

WHO: World Health Organization
xxxiii

Index

A

Abbreviations and acronyms, xxvii–xxxii

ABCDE assessment, 7

Abdominal compartment syndrome, 304

Abdominal organs

pediatric considerations, 5

Abdominal pain

acute, 454

chronic, 453

Abdominal wall defects

anomalies, 300–303

gastroschisis, 87, 298–299, 300

incidence, 299

intestinal atresia, 303

newborn infant care, 87

omphaloceles, 87, 299, 300–302

postoperative considerations, 184–185

steps for primary closure, 183–184

treatment, 181

Abrasions, corneal, 195–196

Abscesses. See also Infections

amebic, 358

dentoalveolar, 210–211

lung, 275

parapharyngeal, 458

pyogenic, 357–358

splenic, 371–372

Absent lens, 187–188

Acalculous cholecystitis, 360–361

Accessory spleen, 370

Accommodative esotropia, 190

Acetaminophen

with codeine, 23–24

headache treatment, 511

postoperative pain management, 23–24

Acid burns. See also Chemical burns

esophageal injuries, 315–316

eye injuries, 194–195

Acidosis, 544

Acidosis, respiratory

anesthesia and, 16

Acinetobacter baumannii infections, 246

INDEX
xxxiv

Pediatric Surgery and Medicine for Hostile Environments 

Acquired immunodeficiency syndrome, 478

Acronyms, xxvii–xxxii

Acute abdominal pain, 454

Acute bacterial sinusitis, 244

Acute burn care

tangential excision, 619

total body surface area, 597–598, 606, 610

traumatic rhabdomyolysis, 612

triage criteria, 598

wound care, 615–627

wound evaluation, 603–630

wound excision, 617–21

Acute chest syndrome

sickle cell disease and, 532–533

Acute coronary syndrome, 155–159

Acute hemolytic transfusion reaction, 484–485

Acute inflammatory splenomegaly, 371

Acute kidney injury, 544–546

Acute purulent conjunctivitis, 184

Acute rheumatic fever. See Rheumatic fever

Acute tubular necrosis, 165–166, 168

Acute vaginal hemorrhage, 297–298

Acyclovir

chickenpox treatment, 431

neonatal conjunctivitis and, 345

Addison disease

hypotonia in infants and, 394

Adenosine, 560, 636

ADH. See Antidiuretic hormone

Adolescents

ventilator respiratory rates, 17–18

vital signs, 4

Adrenal disorders, 502–503

Advanced Trauma Life Support, 7

Aeromedical evacuation. See also Patient evacuation

aircraft used, 121

cabin altitude restriction and, 123, 125

decreased cabin pressure and, 123

environmental factors, 124–125

hazards of, 122–125

humanitarian transport requests, 126–27

humidity factors, 123–124

hypoxia and, 122

mission duration and, 124–125

noncertified equipment, 125

patient clearance, 127–128

patient movement precedence, 128

Patient Movement Requirements Centers, 127–128

special considerations, 125–126
xxxv

Index

steps for requesting, 127–128

thermal stress, 123–124

transport structure, 122

unstable patients, 125–126

ventriculostomy catheters and, 172–173

Agency for International Development, 676–677

Aggression, 624–625

AIDS. See Acquired immunodeficiency syndrome

Air evacuation. See Aeromedical evacuation; Patient evacuation

Air Force

aeromedical evacuation system, 121–128

Critical Care Aeromedical Transport Team, 173

Air Mobility Command, 122

Airway. See also Mechanical ventilation

anesthesia considerations, 15

estimating endotracheal tube size, 17

newborn infant care, 76

nursing assessment, 597

surgical airways, 17

trauma assessment, 7–9

upper airway disorders, 217–222

Airway management

endotracheal intubation indications, 7–8

newborn infant care, 88

positioning, 7

rapid sequence intubation, 8–9

Airway obstructions

acute epiglottitis, 224–225

croup, 225

establishing an airway, 230

foreign bodies, 221–222, 225228

postintubation subglottic tracheal stenosis, 226–227

Albuterol

pulmonary agent exposure treatment, 655

Aldosterone

changes due to critical illness, 407–408

Alkali burns

esophageal injuries, 315

eye injuries, 194–195

Allergic colitis, 446–447

Allergies

anaphylaxis, 422–424

atopic dermatitis and, 468–469

Allied contractors

triage considerations, 33

Allograft, 618–619

Alternating pressure release ventilation, 553

Altitude illness

acute mountain sickness, 416–418
xxxvi

Pediatric Surgery and Medicine for Hostile Environments 

altitude basics, 414–415

descent basics, 415–416

high-altitude bronchitis, 419

high-altitude cerebral edema, 423–425

high-altitude peripheral edema, 419

high-altitude pharyngitis, 419

high-altitude pulmonary edema, 421–423, 425

high-altitude retinal hemorrhage, 419–420

subacute mountain sickness, 420–421

thromboembolic events, 420

Alveolar pressure, 645

Amblyopia, 187, 190

Amebiasis, 470

Amebic abscesses, 358

American Heart Association Basic Life Support, 6

American Society of Anesthesiologists, 20

Amitriptyline, 512

Amniotic fluid

meconium-stained, 83–84

Amoxicillin

dosages, 474

gastroesophageal reflux disease and, 451

Ampicillin

dosages, 476

newborn infant dosage, 89

orbital cellulitis treatment, 457

sepsis and meningitis treatment, 471–472

Amputations

compartment syndrome, 251–253

indications for, 248

managing local amputees, 250–251

mechanisms of injury, 247

open length preserving amputations, 248

principles of, 248–249

reconstruction, 248–249

stockinette skin traction, 250–251

technique for, 249–250

Amyl nitrite

blood agent exposure treatment, 656

Anal disorders. See also Rectal disorders

anal fissures, 351–352

fistulas-in-ano, 352

imperforate anus, 352–353

perianal abscesses, 232

preoperative mechanical bowel preparation, 353

Analgesia, patient-controlled, 22–23

Anaphylaxis, 422–424

Anemia

acute blood loss and, 531
xxxvii

Index

aplastic, 529

bone marrow infiltration, 529

bone marrow stress or failure and, 529

chronic inflammation and, 527

chronic lead poisoning and, 525

disseminated intravascular coagulation, 539

dyserythropoiesis syndromes, 529

folic acid deficiency and, 528–529

glomerular filtration rate and, 544

glucose-6-phosphate dehydrogenase deficiency and, 531

hemolytic, 530

hemolytic uremic syndrome, 538

hypothyroidism and, 529

immune thrombocytopenic purpura, 537–538

iron deficiency anemia, 524–525

laboratory examination, 524

liver disease and, 529

macrocytic, 527–529

medical history and, 521–523

microcytic, 524–527

myelodysplastic syndromes, 529

normal red blood cell values, 522

normocytic, 530–537

packed red blood cell transfusion, 48

physical examination, 523–524

renal disease and, 531–532

sickle cell disease, 532–534

symptoms, 521

thalassemia, 526–527

thrombocytopenia, 534–537

transient erythroblastopenia of childhood, 531

vitamin B12 deficiency and, 527–528

Anesthesia

airway formulas, 17

anatomical considerations, 15

blood therapy and, 20–21

burns and, 21

dosing for caudal or epidural blocks, 24

dosing for single-injection peripheral nerve block, 25

equipment sizing, 18

hypotension and, 16

hypothermia and, 18–19

hypoventilation and, 16

initial ventilator settings, 17–18

intravenous narcotics, 22

intubation, 16–18

monitoring, 20

patient-controlled analgesia dosing, 23

physiological considerations, 16
xxxviii

Pediatric Surgery and Medicine for Hostile Environments 

postoperative pain management, 22–24

preoperative sedation, 21–22

regional, 24–25

respiratory acidosis and, 16

spinal dosing, 25

surgical airway, 17

trauma resuscitation, 18–21

Aneurysms, visceral, 284

Angle fractures, 232

Aniridia, 192

Ankle fractures, 263

Annular pancreas, 365–366

Anorchism, 395

Anterior uveitis, 186

Anthrax, 574–575, 657–658

Antibiotics. See also specific drugs

common intramuscular antimicrobial medications used in children, 476

common oral liquid antimicrobial medications used in children, 474–475

enterocolitis prophylaxis, 440–441

septic shock treatment, 62

Anticholinesterases, 643

Antidiuretic hormone. See also Syndrome of inappropriate antidiuretic hormone

changes due to critical illness, 407–408

Antiepileptic drugs, 515–517

Antimicrobial agents. See Antibiotics

Antisocial behaviors, 624–625

Antivenom, 643–644

Anxiety disorders, 620–623

Anxiolytics, 21

Aortic injuries, 272–273

Apgar scores

evaluation of newborn infants, 77–78

Aphthous ulcers, 212–213

Aplastic anemia, 529

Apnea

neonate risk, 5

Appendicitis, acute, 340–346

Appendix epididymis torsion, 399–400

Appendix testis torsion, 399–400

Arenaviruses, 484–485, 662–663

Armed Forces Radiobiology Research Institute, 669

Arrhythmias

atrial fibrillation, 435–436

atrial flutter, 435

bradycardia, 433–434

tachycardia, 434–435

ventricular dysrhythmias, 436

Artemisinin, 482

Arterial hemangiomas, 280
xxxix

Index

Arterial venous lines

anesthesiology and, 20

pediatric line sizes, 33

Arteriovenous fistulas, congenital, 280

Arteriovenous malformations, 283, 284

Artesunate

malaria treatment, 481

Arthritis

arthritis, 460

Ascites

biliary, 363

peritoneal, 305

Aspart, 498

Asplenia, 370

Asthma

acute asthma severity (table), 418

acute asthma treatment for mild to moderate attacks, 419

acute asthma treatment for severe attacks, 420

asthma education, 420, 422

chronic asthma severity and suggested treatment, 423

classifying severity, 417–419

inpatient management plan, 421

management of, 417–422

medication toxicity profile, 422

triggers, 419–420

Atopic dermatitis, 568–569

Atovaquone

malaria treatment, 482

Atresia

biliary, 362

intestinal, 303, 328–330

laryngeal, 221

Atrial fibrillation, 435–436

Atrial flutter, 435

Atropine

cardiopulmonary resuscitation and, 635

nerve agent exposure treatment, 653

for rapid sequence intubation, 9

Author biographies, 717–720

Autografts

burn care, 146

Avulsed teeth, 214–215

Azithromycin

dosages, 474

trachoma treatment, 456

B

B-mode ultrasound, 95–96

Bacillus anthracis, 657–658
xl

Pediatric Surgery and Medicine for Hostile Environments 

Bacterial keratitis, 196

Bacterial sinusitis, acute, 244

Bacterial tracheitis, 429

Bag-valve-mask ventilation, 36–37

Bechwith-Wiedemann syndrome

macroglossia, 219–220

omphalocele and, 300

Bee and wasp stings, 642

Beetles, 646

Behavioral healthcare

aggression, 624–625

antisocial behaviors, 624–625

anxiety disorders, 620–623

communication and, 612, 614–615

cultural issues, 611

depression, 624

discharge planning, 615–616

effects of mass casualty events, 5–6, 625–626, 685

grief, 624

online resources, 627–628

oppositionality, 624–625

principles of, 609–616

providers’ well-being, 626

psychiatric conditions, 619–620

sleep disorders, 623–624

therapeutic modalities, 617–619

treatment phases, 616

Bell clapper deformity, 398

Benzodiazepines

for mechanical ventilation sedation, 43

status epilepticus treatment, 73

Beta burns, 667

Bezoars, 324

Biliary ascites, 363

Biliary atresia, 362

Biliary hypoplasia, 363

Biliary tract trauma, 359–360

Binocularity, 178

Biological agent casualties

anthrax, 657–658

botulism, 661

category A agents, 657–663

plague, 658, 660

smallpox, 661–662

therapy and prophylaxis for diseases caused by category A agents, 659–660

tularemia, 660–661

viral hemorrhagic fevers, 662–663

Birthmarks, 279
xli

Index

Bites and stings

bees and wasps, 642

beetles, 646

black widow spiders, 645

brown recluse spiders, 646

caterpillars, 646

patient history, 641–642

physical examination, 641

scorpions, 644–645

snakes, 642–644

ticks, 646

WHO venomous snake distribution and antivenom website, 644

Black widow spider bites, 645

Bladder injuries

urethral catheter size estimation, 384

Bladder injury, 382

Bladder neck injuries, 382–385

Blast injuries, 664

Bleeding. See Hemorrhage

Blepharitis, 181

Blister agents, 653–654

Blood agents, 655–657

Blood-brain barrier

neonate risk, 5

Blood disorders. See Hematology

Blood loss

anemia and, 531

Blood pressure. See also Hypotension

assessment of, 11

delta pressure, 144

intracranial pressure and, 65

normal, by age group, 4

Blood products

cytomegalovirus-safe products, 50

irradiation of, 50

leukocyte reduction, 50

transfusion of, 11, 50

Blood therapy. See also Transfusion medicine

anesthesia and, 20–21

Blood transfusions. See Transfusion medicine

Blowout fractures, 200–201

Blue sclera, 192

Bochdalek hernia, 306

Body height

assessment methods, 577–578

WHO age-based norms, 577–578

Body surface area

burns and, 21, 138

drug dosages and, 633
xlii

Pediatric Surgery and Medicine for Hostile Environments 

Body temperature

newborn infants, 86

Body weight

assessment methods, 577–578

expected newborn weight by gestational age, 86

infants who are large or small for gestational age, 89–90

normal, by age group, 4

WHO age-and length-based norms, 577–578

Bone fractures. See also Orthopedics

cervical spine, 5

evaluation of, 253–255

facial, 230–234

long bone, 255–256

lower extremities, 260–263

mandibular, 230–232

maxillofacial, 232–233

nasal, 233–235

open, 255

pediatric considerations, 5

ribs, 269–270

Salter-Harris classification, 254

skull base, 234

temporal bone, 234

upper extremities, 256–260

Bone infections, 459–461

Bone marrow infiltration, 529

Bone marrow stress or failure, 529

Botulism, 661

Bowel disorders

newborn infant care, 87

Bowman probe, 182–183

Bradycardia

causes of, 433–434

management of, 434

neonate risk, 5

pediatric considerations, 3

Bradypnea

pediatric considerations, 3

Brain injuries

assessment of, 12

management goals, 69

traumatic brain injuries, 518–519

Branchial cleft cysts, 239–240

Breast-feeding

adding additional calories and protein to, 583–584

LactMed, 90

medication safety, 90

newborn infants, 90

Breathing assessment, 10
xliii

Index

Bronchial injuries, 273

Bronchiolitis, 424–426

Bronchoscopy

procuring an emergency airway and, 230

Broselow Pediatric Measuring Tape

emergency medication dosing, 6

equipment size determination, 18

estimating height and weight, 577–578

Brown recluse spider bites, 646

Browns syndrome, 191

Brudzinski sign, 470

BSA. See Body surface area

Bullous drug reactions, 564–568

Bullous staphylococcal impetigo, 559, 562

Bunyaviridae, 662–663

Bupivacaine

dosing for caudal or epidural blocks, 24

dosing for spinal anesthesia, 25

toothache pain treatment, 206

Burns. See also Chemical agent casualties

burn depth determination, 134–138

burn surface area, 138–139

chemical burns, 132, 148

circumferential chest wall burns, 144

circumferential extremity burns, 144, 145

electrical burns, 132, 147–149

escharotomy, 144–145, 147

fasciotomy, 144, 146

fire, 132

first degree, 134, 135

fluid resuscitation, 141–143

fourth degree, 136–138

hospitalization guidelines, 141

hypothermia prevention, 132

inhalation injuries, 140–141

initial treatment, 133

metabolic responses, 131

minor burns, 143

modified Lund and Bowder chart for estimating burn severity, 138–139

nutritional support, 150

pain management, 150

pathophysiological considerations, 131–132

patient history, 132

physical examination, 133

point-of-injury care, 132

rehabilitation, 150–151

rule of nines, 138

second degree (partial thickness), 134, 136

surgical treatment, 145–147
xliv

Pediatric Surgery and Medicine for Hostile Environments 

third degree (full thickness), 134–135, 137

total body surface area, 21, 138, 141–142

transfer guidelines, 141

trauma resuscitation, 21

wound care, 143–144

BVM. See Bag-valve-mask ventilation

C

Cabin altitude restriction

aeromedical evacuation and, 123, 125

Calcium chloride

cardiopulmonary resuscitation and, 637

hypocalcemia prevention, 20

Calcium disorders

hypercalcemia, 504

hypocalcemia, 503–504

Calcium ethylenediaminetetraacetic acid

radiological contamination treatment, 670

Calcium gluconate

hypocalcemia prevention, 20

Caloric requirements

burns and, 150

Calorie requirements, 578–579

Cancer. See Oncology; specific types of cancer and tumors

Capillary hemangiomas, 280

Capsaicin, 657

CAR. See Cabin altitude restriction

Carbamazepine, 517

Carbon monoxide toxicity

inhalation injuries and, 141

Carboxyhemoglobin

levels in carbon monoxide toxicity, 141

Cardiac disease. See Cardiology

Cardiac syncope, 441

Cardiogenic shock, 58, 59

Cardiology

acquired heart disease, 438–440

arrhythmias, 433–436

cardiac syncope, 441

chest pain and, 442

congestive heart failure, 436–437

cyanotic newborns, infants, and children, 432–433

examination, 431

infective endocarditis prophylaxis, 40–441

Kawasaki disease, 439–440

myocardial infarction, 442–443

rheumatic heart disease, 438–439

Cardiopulmonary arrests

drugs used during resuscitation, 635–638
xlv

Index

Cardiopulmonary resuscitation

drugs used during, 635–638

pediatric assessment, 6

Cardiovascular access, 597–599

Caries, dental

cause of, 205

complications of, 205

pain management, 206–208

preventing, 205–206

toothache and, 206–208

treatment of, 205

Cataracts

congenital, 186, 192

infantile, 187

Catecholamine-resistant shock, 61

Caterpillars, 646

Caudal blocks

dosing for, 24

Cavernous hemangiomas, 280

Cavities. See Caries, dental

CBRNE injuries. See Chemical, biological, radiological, nuclear, and explosive 

injuries

CCATT. See Critical Care Air Transport Teams

CDC website, 484, 488, 489

Cefazolin

dosages, 476

Cefepime

dosages, 476

Cefotaxime

sepsis and meningitis treatment, 472

Ceftriaxone

dosages, 476

meningitis treatment, 471–472

neonatal conjunctivitis treatment, 455

orbital cellulitis treatment, 457

Celiac disease, 447

Cellulitis, 459

Centers for Disease Control and Prevention, 679–680

Central veins, congenital anomalies of, 283

Central venous catheters

line sizes, 33

percutaneous, 32

Cephalexin

dosages, 475

Cephalosporin

periorbital cellulitis treatment, 456

Cerebral edema

diabetic ketoacidosis and, 496

Cerebral perfusion pressure
xlvi

Pediatric Surgery and Medicine for Hostile Environments 

intracranial pressure and, 65, 68–69, 163

Cerebral salt wasting, 409

Cervical lymphadenitis, 238

Cervical spine injuries

pediatric considerations, 5

Chemical, biological, radiological, nuclear, and explosive injuries. See also Disasters

biological casualties, 657–663

chemical casualties, 653–657

nuclear and radiological casualties, 663–670

unique considerations for pediatric victims, 651–652

Chemical agent casualties

blister agents, 653–654

blood agents, 655–657

nerve agents, 653

pulmonary agents, 654–655

riot control agents, 657

Chemical burns

management of, 148

point-of-injury care, 132

Chemical conjunctivitis, 184

Chemical eye injuries, 192–195

Chest injuries. See Thoracic injuries

Chest pain

cardiac causes, 442

Chest wall burns, 144

CHF. See Congestive heart failure

Chikungunya virus, 487–488

Chilblains, 649

Childhood epilepsy, 514

Children. See also Adolescents; Infants; Neonates; Toddlers; Trauma

Glasgow Coma Scale, 12

growth and development, 593–595

modified Lund and Bowder chart for estimating burn severity, 138

patient-controlled analgesia, 22–23

ventilator respiratory rates, 17–18

Chlamydia trachomatis

neonatal conjunctivitis and, 455–456

ophthalmia neonatorum and, 184–185

Chloramphenicol

meningitis treatment, 471

Chlorine gas, 654–655

Choanal atresia, 217–219

Cholecystectomy

biliary tract trauma management, 359–360

gallbladder disease management, 360

Cholecystitis

acalculous cholecystitis, 360–361

Choledochal cyst, 361–362
xlvii

Index

Choledocholithiasis, 361

Cholelithiasis, 454

Chorioretinitis, 192

Chronic abdominal pain, 453

Chronic daily headaches, 512

Ciprofloxacin

biological agent treatment, 659

meningitis treatment, 471

Circulation assessment, 10–11

Circumcision, 394

Civil action program clinics, 699–703

Clarithromycin

dosages, 475

gastroesophageal reflux disease and, 451

Clavulanic acid

dosages, 474

Clear cell sarcoma, 402–403

Cleft lip/palate, 88

Clindamycin

biological agent treatment, 659

dentoalveolar abscess treatment, 210–211

dosages, 475

malaria treatment, 482

orbital cellulitis treatment, 457

toxic shock syndrome treatment, 62

Clinical Practice Guideline on Hypothermia Prevention, 123, 648

Clonazepam, 517

Clonidine

dosing for caudal or epidural blocks, 24

Closed wounds

spinal injuries, 170–171

Clostridium botulinum, 661

Clostridium perfringens infections, 247

Cluster headaches, 512

CMR. See Crude mortality rate

CMV. See Continuous mandatory ventilation

Coagulopathy

blood transfusions and, 20–21

Factor VIII and IX levels following replacement, 540

hemophilia, 539–541

treatment of, 540–541

Von Willebrand’s disease, 541

Codeine

postoperative pain management, 23–24

Cold injuries

chilblains, 649

frostbite, 649

Colitis

allergic, 446–447
xlviii

Pediatric Surgery and Medicine for Hostile Environments 

Colony stimulating factors, 666

Commanders Emergency Relief Funds, 690

Communication

nursing tips, 595–596

Compartment syndrome

amputation and, 251–253

Compensated shock, 57

Computed tomography

cystography, 382–384

head injury assessment, 157, 158

pancreatic trauma, 232

spinal injury assessment, 169

status epilepticus complication diagnosis, 72

Concussions, 518–519

Congenital anomalies of central veins, 283

Congenital arteriovenous fistulas, 280

Congenital cataracts, 186, 192

Congenital diaphragmatic hernias, 306–311

Congenital esotropia, 190

Congenital heart disease

screening newborn infants, 91–92

Congenital megacolon, 349–351

Congenital wryneck, 243

Congestive heart failure, 436–437

Conjunctival injuries

foreign bodies, 197

Conjunctivitis, 184

neonatal, 455–456

Connective tissue disorders, 284–285

Consecutive strabismus, 191

Constipation

anatomical defects and, 450

encopresis, 448–449

functional, 448

meconium plug syndrome, 348

organic disorders, 449–450

Contamination, radiological, 666–670

Continuous mandatory ventilation, 38–39

Contributors, 711–712

Corneal injuries

abrasions, 195–196

chemical, 192–195

foreign bodies, 197

ulcers, 196

Corrosive esophageal injuries, 315–317

Corticosteroids

pulmonary agent exposure treatment, 655

Counterinsurgency operations, 694–695
xlix

Index

CPP. See Cerebral perfusion pressure

Crackles/rales, 416

Craniotomy

bone flap preservation, 167, 168

positioning, 166

scalp incision, 166–167

Creatinine clearance, 543, 633

Cricothyroidotomy

adverse effects of, 17

as rescue airway option, 8, 221, 228–229

Critical care. See Resuscitation

Critical Care Aeromedical Transport Team, 173

Critical Care Air Transport Teams, 122

Crotalidae, 644

Croup, 225, 426–427

Crude mortality rate, 683

Cryoprecipitate

coagulopathy minimization, 20–21

hemophilia treatment, 541

transfusion of, 49–50

Cryptorchidism, 394–397

CS gas, 657

CSW. See Cerebral salt wasting

CT scans. See Computed tomography

Curvilinear array transducers, 93–95

Cushing’s triad, 11

Cutaneous candidiasis, 459

CVC. See Central venous catheters

Cyanide, 655–657

Cyanogens, 655–657

Cyanosis

evaluating newborns, infants, and children, 432–433

newborn infant care, 89

Cyproheptadine, 512

Cystic hygromas, 240–241, 282

Cystograms, 382–384

Cysts

choledochal, 361–362

hydatid, 358–359

laryngoceles, 223

mesenteric, 305

omental, 305, 454

splenic, 370–371

thyroglossal duct, 239

urachal, 292–293

Cytomegalovirus

ocular manifestations, 192

special blood product preparation, 50
l

Pediatric Surgery and Medicine for Hostile Environments 

D

Decompensated shock, 57–58

Dehydration

diabetes and, 495

Delta pressure, 144

Dengue, 486–487

Dental caries. See Caries, dental

Dentistry

aphthous ulcers, 212–213

avulsion of teeth, 214–215

caries, 205–206

dentoalveolar abscesses, 210–211

dentoalveolar trauma, 213–214

eruption hematoma, 211

first dental visit recommendation, 205

herpetic gingivostomatitis, 213

intrusion of teeth, 215–216

luxation of teeth, 216

natal and neonatal teeth, 212

oral pathology, 210–213

pyogenic granuloma, 212

Riga-Fede disease, 213

tooth decay risk factors, 205–206

tooth extraction, 208–210

toothaches, 206–208

Dentoalveolar abscesses, 210–211

Denton Program, 693

Deployed physicians

resources for, 705–710

Depression, 624

Depth perception, 178

Dermatitis, atopic, 568–569

Dermatology

anthrax, 574–575

atopic dermatitis, 568–569

bullae, erosions, and desquamation in neonates and young children, 559–575

bullous drug reactions, 564–568

descriptive terms, 550–551

disseminated intravascular coagulation, 574

febrile child with rash, 552–559

Kawasaki disease, 557–558

Lyme disease, 559, 560

measles, 483, 553–555, 556

meningococcemia, 552–553

necrosis, 573–574

purpura, 571–573

radiation dermatitis, 665

rickettsial diseases, 552

scarlet fever, 555–557
li

Index

skin infections, 459–461

skin lesions, 550–551

smallpox, 569–571

teledermatology consultation, 549–551

toxic shock syndrome, 558–559

US Army consultation service, 549

Desmopressin acetate, 540, 541

Dextrose, 499

Diabetes mellitus

assessing dehydration in the pediatric patient with diabetes, 495

diabetic ketoacidosis, 494–496

diagnostic criteria, 493

management of, 497–498

symptoms, 493–494

Diabetic ketoacidosis, 494–496

Diaphragmatic disorders

congenital diaphragmatic hernias, 306–311

ruptured diaphragmatic hernia, 271–272

Diarrhea

diagnosis, 468

etiology, 467–468

humanitarian issues, 467–470

osmotic, 446

symptoms, 467

treatment of, 468–470

Diazepam

status epilepticus treatment, 73

DIC. See Disseminated intravascular coagulation

Diet. See also Nutrition

diabetes mellitus management, 497

Diethylene-triaminepentaacetic acid

radiological contamination treatment, 670

Dimercaprol

radiological contamination treatment, 670

Diphtheria, 477–478

Dirty bombs, 663

Disability assessment, 11–12

Disasters

assessment, 683

definitions, 675–676

emergency relief, 684

hospital planning and surge capacity, 679–683

international guidelines, 708

military response, 676–677

online resources, 708

patient evacuation, 685

pediatric triage, 678–679, 680–681

planning, 677–678

psychological impact of, 5–6, 625–626, 685
lii

Pediatric Surgery and Medicine for Hostile Environments 

SALT triage system, 679–680

START/JumpSTART algorithm, 679, 681

vulnerability reduction, 684

Disseminated intravascular coagulation, 539, 574

Distributive shock, 58, 59

Dobutamine

shock treatment, 63

Dopamine

shock treatment, 63, 64

Double elevator palsy, 191

Doxycycline

biological agent treatment, 659

Drug absorption, 629–630

Drug administration

dosage calculations, 633–634

inhalants, 607–608

intramuscular injection, 606–607

intravenous infusion, 606

intravenous narcotics, 22–23

oral, 604–605

rectal, 605–606

tips for, 633–634

Drug distribution, 630–631

Drug excretion, 632

Drug metabolism, 631–632

Drug reactions, bullous, 564–568

Drugs. See Medication; Pharmacotherapeutics

DTPA. See Diethylene-triaminepentaacetic acid,

Duane syndrome, 191

Duodenal obstruction, 325–326

Dysentery, 468

Dyserythropoiesis syndromes, 529

E

Ear, nose, and throat disorders

acquired airway obstructions, 224–228

acute otitis externa, 242

cysts, 223

establishing an airway, 230

general principles in hostile environments, 217

hearing evaluations, 242–243

hearing loss, 243–244

lymphatic malformations, 240–242

masses, 238–240

otorrhea, 242

surgical procedures for procuring emergency airway, 228–230

trauma, 230–237

tumors, 223

upper airway disorders, 217–222
liii

Index

Early status epilepticus, 71

Eastern coral snake, 644

EBV. See Estimated blood volume

ECG. See Electrocardiograms

Echocardiography

online tutorials, 106

Ectopic cryptorchidism, 394

Ectopic pancreatic tissue, 365

Ectopic spleen, 374

Eczema, 568–569

EDTA. See Ethylenediaminetetraacetic acid

Elbow dislocations, 258

Electrical burns

fourth degree, 138

high-voltage injuries, 147

low-voltage injuries, 147

metabolic acidosis and, 148

myoglobinuria and, 148, 149

point-of-injury care, 132

treatment of, 148

Electrocardiograms, 431

Electrocautery

burn care, 144

Electrolytes. See Fluids and electrolytes

Elliptocytosis, 372

Emboli, 285

Emergency relief measures, 682, 684

Empyema, 276

Encephalitis

increased intracranial pressure and, 65

Japanese encephalitis, 478–479

Encopresis, 448–449

Endocarditis

retinal hemorrhages and, 192

Endocrinology

adrenal disorders, 502–503

calcium disorders, 503–505

diabetes management, 497–498

diabetes mellitus, 493–494

diabetic ketoacidosis, 494–496

hypoglycemia, 499–500

thyroid disorders, 500–502

vitamin D disorders, 503–505

Endoscopic retrograde cholangiopancreatography

biliary tract trauma management, 359

Endotracheal intubation

confirmation of tube placement, 8

failure to intubate, 8

indications for, 7–8

tube size, 37
liv

Pediatric Surgery and Medicine for Hostile Environments 

Endotracheal tubes

determining size by age, 37

estimating depth of, 17

estimating size, 17

newborn infant sizes, 85

rapid estimation of size, 8

Energy expenditure, 579, 580

Energy requirements

effects of activity and stress factors on requirements in children, 580

ENT. See Ear, nose, and throat disorders

Enteral feeding

guidelines for initiating and advancing continuous feeding, 585

Enterocolitis, necrotizing, 332–335

Enucleation, 203

Epididymitis, 400

Epidural blocks

dosing for, 24

Epigastric hernias, 294

Epiglottitis

acute, 224–225

causes of, 427

evaluation of, 427–428

treatment of, 428

Epilepsy

antiepileptic medications, 515–517

childhood, 514

focal, 514–515

generalized epilepsy, 515

Epinephrine

cardiopulmonary resuscitation and, 635

extubation failure prevention, 44

hypotension treatment, 16

shock treatment, 63, 64

Epispadias, 391

Epistaxis, 243–244

Equipment sizing

arterial venous lines, 33

Broselow Pediatric Measuring Tape, 18

central venous catheters, 32–33

comprehensive guidelines, 714–715

disaster planning, 679, 682

endotracheal tube size, 8, 17, 37, 85

mechanical ventilation bag-valve sizes, 37

tracheostomy tube size, 37

urethral catheter size estimation, 384

vascular access catheter size, 27

Eruption hematoma, 211

Erythema migrans. See Lyme disease

Erythema multiforme, 566–567
lv

Index

Erythromycin

gastroesophageal reflux disease treatment, 451

neonatal conjunctivitis treatment, 455

Erythromycin ophthalmic ointment

newborn prophylaxis, 90

Escharotomy

burn care, 144–145, 147

Esophageal atresia, 313–315

Esophageal conditions

corrosive injuries, 315–317

esophageal atresia, 313–315

esophageal perforation, 317–318

gastroesophageal reflux, 318–320

strictures, 320

tracheoesophageal fistulas, 313–315

Esophageal hernia, 306

Esophageal injuries, penetrating, 274

Esophageal perforation, 317–318

Esotropia, 190

Established status epilepticus, 71, 73

Estimated blood volume, 47–48

Estimated glomerular filtration rate, 543–544

Ethambutol

tuberculosis treatment, 465–466

Ethical standards, 689

Ethylenediaminetetraacetic acid

radiological contamination treatment, 670

Etomidate

head injuries and, 163

for rapid sequence intubation, 9, 60, 62

European viper, 644

Evacuation. See Aeromedical evacuation; Patient evacuation

Exposure

assessment of, 13

External genital injuries, 388

External jugular vein cannulation, 28–29

Extracranial arteries, 285

Extraocular motility, 178–179

Extubation. See also Intubation

mechanical ventilation issues, 44

predictors for extubation failure, 44–45

Eye diseases

anterior uveitis, 186

blepharitis, 181

cataracts, 186–187

conjunctivitis, 184

eye injuries, 192–203

leukocoria, 186

nasolacrimal duct obstruction, 181–183
lvi

Pediatric Surgery and Medicine for Hostile Environments 

neonatal conjunctivitis, 455–456

nonaccidental trauma, 188–189

nonstrabismic conditions, 180–188

ocular manifestations of systemic disease, 192

ophthalmia neonatorum, 184–185

optic nerve abnormalities, 189

orbital cellulitis, 457

orbital dermoid cysts, 180

periorbital cellulitis, 185, 456

ptosis, 180–181

refractive error, 189–191

retinal disorders, 188–189

retinopathy of prematurity, 188

toxocara granuloma, 188

trachoma, 456

unilateral aphakia, 187–188

Eye examinations

binocularity, 178

birth history, 175–176

external examination, 179–180

extraocular motility, 178–179

intraocular pressure, 177

medical history, 176

physical examination, 176–177

stereo vision testing, 178

visual acuity by age, 176–177

Eye infections. See Eye diseases

Eye injuries

bacterial keratitis, 196

chemical injuries of the cornea, 194–195

corneal abrasions, 195–196

corneal ulcers, 196

enucleation, 203

foreign bodies, conjunctival and corneal, 197

hyphema, 197–199

lacerations (open globe), 193–194

lid lacerations, 201–203

open globe injuries, 193–194

orbital floor (blowout) fractures, 200–201

physical symptoms, 192

retrobulbar (orbital) hemorrhage, 199–200

ruptures, 193–194

subconjunctival hemorrhage, 194

vision examination, 192

Eyelid lacerations, 201–203

F

Face and neck disorders. See also Head injuries

acquired airway obstructions, 224–228
lvii

Index

acute otitis externa, 242

bacterial tracheitis, 429

buccal cellulitis, 457

cysts and tumors, 223

epiglottitis, 224–225, 427–428

establishing an airway, 230

general principles in hostile environments, 217

hearing evaluations, 242–243

hearing loss, 243–244

lymphatic malformations, 240–242

masses, 238–240

mumps, 458

otorrhea, 242

parapharyngeal abscesses, 458

parotitis, 458

sialadenitis, 458

surgical procedures for procuring emergency airway, 228–230

trauma, 230–237

upper airway disorders, 217–222

Facial injuries

bone fractures, 230–234

Factor IX levels, 540

Factor VIII levels, 540

Fasciotomy

burn care, 144, 146

FAST. See Focused assessment with sonography for trauma

FDA. See Food and Drug Administration

FDR. See Foreign disaster response

Febrile child with rash, 552–559

Febrile seizures, 513

Fecaliths, 340

Feeding issues. See Nutrition

Feeding tubes

gastrointestinal disorders and, 584

nursing assessment, 603–604

Femur fractures, 261–262

Fentanyl

dosing for caudal or epidural blocks, 24

intravenous dosage, 22

for mechanical ventilation sedation, 44

patient-controlled analgesia dosage, 23

postoperative pain management, 22–23

for rapid sequence intubation, 9

Ferric ferrocyanide

radiological contamination treatment, 670

FFP. See Fresh frozen plasma

Field Operations Guide for Disaster Assessment and Response, 683

Filoviridae, 662–663

Filoviruses, 484–485
lviii

Pediatric Surgery and Medicine for Hostile Environments 

First degree burns, 134, 135

Fistulas-in-ano, 352

Flail chest, 269–270

Flash blindness, 665

Flaviviridae, 662–663

Flesh-eating bacteria, 573–574

Fluid refractory shock, 61

Fluid resuscitation

anesthesia and, 19–20

burns and, 21, 132, 141–143

Fluids and electrolytes

administering maintenance fluid, 408, 410

anesthesia and, 19–20

burn care, 132

calculating fluid deficit replacement, 410

cerebral salt wasting, 409

changes in fluid composition and distribution during critical illness, 407–408

daily electrolyte requirements, 409

daily maintenance fluid requirements, 408

diabetic ketoacidosis and, 496

differentiating sources of sodium disturbances, 409

electrolyte management, 411–414

fluid resuscitation, 19–20

hyperkalemia and, 411–412

hypernatremia and, 409, 413–414

hypokalemia and, 411

hyponatremia, 409, 412–413

intravenous fluid rate by body weight, 19

parenteral electrolyte requirements, 585

pediatric considerations, 4

syndrome of inappropriate antidiuretic hormone and, 409, 412–413

total body water variation with age, 407

Focal epilepsy, 514–515

Focused assessment with sonography for trauma

examination windows, 97–98

hemothorax, 107–109

negative examinations, 97

online tutorials, 105–106

parasternal long-axis cardiac, 100, 104–106

pelvic, 100, 103

perihepatic, 100, 101

perisplenic, 100, 102

pleural effusion, 107–109

positive examinations, 97

sensitivity of, 97

subcostal long-axis cardiac, 98–100

Foley catheters, 603

Folic acid deficiency, 528–529

Food and Drug Administration, 629, 644, 654
lix

Index

Forearm fractures, 259

Foreign bodies

conjunctival, 197

corneal, 197

laryngeal, 221–222, 225–228

Foreign disaster response, 676–677

Foreskin retractility, 390

Fosphenytoin

status epilepticus treatment, 73

Fraction of inspired oxygen, 35

Fractures. See Bone fractures

Francisella tularensis, 660–661

Fresh frozen plasma

hemophilia treatment, 541

hypocalcemia prevention, 20

transfusion of, 49

Frostbite, 649

Furosemide

blood transfusion volume overload prevention, 54

G

Gait

neurological examination and, 508

Gallbladder disease, 360

Gastric antral webs, 323

Gastric perforation, 323–324

Gastroenteritis

acute, 346–347, 445

bacterial, 445

protozoal, 446

viral, 445

Gastroenterology. See also Gastrointestinal tract disorders

acute abdominal pain, 454

allergic colitis, 446–447

chronic abdominal pain, 453

constipation, 448–450

enteral feeding, 585

gastroesophageal reflux disease, 450–451

gastrointestinal bleeding, 452

intestinal infection, 445–446

malabsorption disorders, 447–448

osmotic diarrhea, 446

tube feeding, 584

vomiting, 450–451

Gastroesophageal reflux disease, 318–320, 450–451

Gastrointestinal bleeding, 452

Gastrointestinal tract disorders. See also Gastroenterology

anus, 351–353

duodenum, 320–326
lx

Pediatric Surgery and Medicine for Hostile Environments 

esophagus, 313–320

large intestine, 340–351

nursing assessment, 603

rectum, 351–353

small intestine, 326–340

stomach, 320–326

Gastroschisis

associated conditions, 300

complications of, 298

location of, 298–299

newborn infant care, 87

treatment, 300–302

GCS. See Glasgow Coma Scale

Generalized convulsive status epilepticus, 71

Generalized epilepsy, 515

Genital injuries, external, 388

Genitourinary tract

bladder injury, 382

bladder neck injuries, 382–385

conditions of, 388–404

external genital injuries, 388

nursing assessment, 603

penile conditions, 390–394

renal injuries, 377–380

scrotal conditions, 397–403

testicular conditions, 394–397

trauma, 377–388

ureteral injuries, 381–382

ureteropelvic junction disruption, 380–381

urethral injuries, 384, 385–387

urinary tract infections, 388–390

vaginal conditions, 403–404

Gentamicin

biological agent treatment, 659

dosages, 476

sepsis and meningitis treatment, 471

Gestational age

expected newborn weight, 86

large or small infants, 89–90

GFR. See Glomerular filtration rate

Giardiasis, 470

Glargine, 498

Glasgow Coma Scale

disability assessment, 12

head injuries and, 154–156

ICP monitoring and, 66, 68

as intubation indicator, 7

as mortality predictor, 3

Glaucoma
lxi

Index

cataracts and, 186

optic nerve abnormalities and, 189

Global health issues, 690–692

Glomerular filtration rate, 543–544

Glucose

cardiopulmonary resuscitation and, 636

diabetic ketoacidosis and, 496

Glucose-6-phosphate dehydrogenase deficiency, 531

Glycopyrrolate

preoperative sedation, 22

Grafts

burn care, 146

Granulomas, 291

Grief, 624

Grunting

respiratory emergencies and, 416

H

The Harriet Lane Handbook, 89, 431

HCA. See Humanitarian Civic Assistance

Head injuries. See also Face and neck disorders; Neurological problems; 

Neurosurgery

aeromedical evacuation, 172–173

Glasgow Coma Scale, 154–156

hypotension and, 157

hypoxia and, 157

Infant Face Scale and, 154–156

intracranial pressure and, 65, 68

intracranial pressure monitoring, 159–163

management goals, 69

medical adjuncts, 163–164

medical management, 157–163

pupillary reactivity, 156–157

seizure prophylaxis, 158–159

surgical management, 164–172

traumatic brain injuries, 518–519

Headaches

evaluation of, 510–511

types of, 511–512

Hearing evaluations, 242–243

Hearing loss, 243–244

Heart disease. See Cardiology

Heart injuries

aortic injuries, 272–273

myocardial contusions, 271

Heart murmurs, 431

Heart rate. See also Vital signs

newborn infants, 76, 86

normal, by age group, 4
lxii

Pediatric Surgery and Medicine for Hostile Environments 

Heat cramps, 650

Heat exhaustion, 650

Heat injuries

from nuclear detonations, 664–665

warm weather injuries, 650

Heatstroke, 650

Helicobacter pylori, 450, 451, 453

Heliox

extubation failure prevention, 44

Hemangiomas

of the airway, 224

classification of, 279–281

complications of, 281

diagnosis of, 281

treatment of, 281

Hemarthrosis, 540

Hematology

acute blood loss, 531

anemia, 521–524

bone marrow stress or failure, 529

chronic inflammation, 527

chronic lead poisoning, 525

chronic renal disease, 531–532

coagulopathies, 539–542

disseminated intravascular coagulation, 539

folic acid deficiency, 528–529

glucose-6-phosphate dehydrogenase deficiency, 531

hemolytic anemia, 530

hemolytic uremic syndrome, 348, 538–539

hemophilia, 539–541

hypothyroidism, 529

immune thrombocytopenic purpura, 537–538

iron deficiency, 524–525

liver disease, 529

macrocytic anemias, 527–529

microcytic anemias, 524–527

normocytic anemias, 530–537

renal disease, 531–532

sickle cell disease, 532–534

thalassemia, 526–527

thrombocytopenia, 534–537

thrombotic thrombocytopenic purpura, 538–539

transient erythroblastopenia of childhood, 531

vitamin B12 deficiency, 527–528

Von Willebrand’s disease, 541

Hematomas

eruption hematoma, 211

Hemobilia, 356

Hemodynamics. See Shock; Vital signs
lxiii

Index

Hemolytic anemia, 530

Hemolytic uremic syndrome, 348, 538

Hemopericardium

diagnosis of, 97

Hemoperitoneum

diagnosis of, 97

Hemophilia, 539–541

Hemoptysis, 278

Hemorrhage

gastrointestinal bleeding, 452

increased intracranial pressure and, 65

Hemorrhagic fevers

dengue, 486–487

viral, 484–485

Hemothorax

causes of, 167

symptoms, 268

treatment of, 268

ultrasonography of, 107–109

Henoch-Schönlein purpura, 347, 571–572

Hepatobiliary tract disorders

acalculous cholecystitis, 360–361

biliary ascites, 363

biliary atresia, 362

biliary hypoplasia, 363

biliary tract trauma, 359–360

choledochal cyst, 361–362

choledocholithiasis, 361

gallbladder disease, 360

hemobilia, 356

inspissated bile syndrome, 363

liver infections, 357–359

liver trauma, 355–356

Hereditary spherocytosis, 372

Hernias

congenital diaphragmatic, 306–311

epigastric, 294

inguinal, 295–296

Littré hernia, 331

ruptured diaphragmatic, 271–272

spigelian, 294

umbilical, 293–294

Herpes simplex virus

neonatal, 562–564

neonatal conjunctivitis and, 455–456

Herpetic gingivostomatitis, 213

Hirschsprung disease, 349–351, 449

Histoplasmosis

ocular manifestations, 192
lxiv

Pediatric Surgery and Medicine for Hostile Environments 

HIV. See Human immunodeficiency virus

Hospitals

disaster planning, 679, 683

HSV. See Herpes simplex virus

Human immunodeficiency virus, 478

Humanitarian assistance

activities during training and exercises, 698–699

activities in specific scenarios, 693–694

classification of operations, 692–696

diarrhea and, 467–470

ethical standards, 689

global health issues, 690–692

humanitarian transport requests, 126–127

infectious diseases and, 489–490

mass migration events, 696–698

military doctrine related to, 709–710

nonmilitary medical operations, 693

operations in support of counterinsurgency operations, 694–695

principles of US military medical humanitarian activities, 687–690

short-term medical civil action program clinics, 699–703

support for stability operations, 695–696

US military medical operations, 692–693

Humanitarian Assistance Disaster Relief, 692–693

Humanitarian Civic Assistance, 690, 692

Humanitarian Daily Rations, 582

Humeral fractures, 256–257

Hydatid cysts, 358–359

Hydroceles, 294–296

Hydrocephalus

increased intracranial pressure and, 65

Hydromorphone

intravenous dosage, 22

patient-controlled analgesia dosage, 23

postoperative pain management, 22–23

Hydrops, 360–361

Hydroxocobalamin

blood agent exposure treatment, 656–657

Hypercalcemia, 504

Hypercapnia

mechanical ventilation and, 41

Hyperglycemia, 583

Hyperkalemia

blood transfusions and, 53

etiologies, 411

glomerular filtration rate and, 544

symptoms, 411–412

treatment of, 412

Hypernatremia, 409, 413–414

Hyperosmolar therapy, 159–160
lxv

Index

Hyperparathyroidism

glomerular filtration rate and, 544

Hypersplenism, 374

Hyperthyroidism, 500–502

Hypertrophic pyloric stenosis, infantile, 320–323

Hyphema, 197–199

Hypocalcemia

blood transfusions and, 20, 53

neonate risk, 5

symptoms of, 503

treatment of, 503–504

Hypoglycemia

definition, 499

differential diagnosis, 499

fluid resuscitation and, 20

neonate risk, 5

newborn infant care, 89, 90

signs and symptoms, 499, 583

treatment of, 499–500

Hypokalemia, 411, 583

Hypomagnesemia

blood transfusions and, 53

symptoms, 583

treatment of, 504

Hyponatremia, 409, 412–413

Hypophosphatemia, 583

Hypoplasia, biliary, 363

Hypospadias, 390–391

Hypotension

assessment of, 11

head injuries and, 157

Hypothermia

aeromedical evacuation and, 123

blood transfusions and, 54

burns care, 132

Clinical Practice Guideline on Hypothermia Prevention, 123

mechanisms of heat loss, 647

pediatric considerations, 3

physiologic effects, 647–648

trauma resuscitation, 18–19

treatment of, 648

Hypothyroidism, 500, 529

Hypotonia, 510

Hypoventilation

anesthesia and, 16

Hypovolemia, 16

Hypovolemic shock

assessing the severity of, 59

causes of, 58
lxvi

Pediatric Surgery and Medicine for Hostile Environments 

signs and symptoms, 59

treatment of, 64

Hypoxemia

mechanical ventilation and, 41

shock and, 60

Hypoxia

aeromedical evacuation and, 122

bradycardia and, 433

head injuries and, 157

I

Ibuprofen, 511

ICP. See Intracranial pressure

Idiopathic thrombocytopenic purpura, 373–374, 537–538

Ileus, meconium, 338–339

Immune thrombocytopenic purpura, 537–538

Impending status epilepticus, 71, 73

Imperforate anus, 352–353

IMV. See Intermittent mandatory ventilation

Infant Face Scale

head injuries and, 154–156

Infant formula, 583

Infantile hypertrophic pyloric stenosis, 320–323

Infants. See also Trauma

airway and anesthesia considerations, 15

anesthesia considerations, 15

eye examinations, 176–177

Glasgow Coma Scale, 12

growth and development, 593–594

modified Lund and Bowder chart for estimating burn severity, 138–139

narcotics and, 22

ventilator respiratory rates, 17–18

vital signs, 4

Infections. See also Infectious diseases

cataracts and, 192

liver, 357–359

lung, 274–276

musculoskeletal, 246

pleural, 274–276

wound infections, 246–247

Infectious diseases. See also Infections

acquired immunodeficiency syndrome, 478

bones, 459–461

chikungunya virus, 487–488

dengue, 486–487

diarrhea in a humanitarian-assistance setting, 467–470

diphtheria, 477–478

face and neck, 457–458

human immunodeficiency virus, 478
lxvii

Index

humanitarian issues, 489–490

Japanese encephalitis, 478–479

joints, 459–461

leptospirosis, 479

Lyme disease, 479–480

malaria, 480–482

measles, 483

ocular, 455–457

polio, 483–484

pulmonary, 461–466

pyelonephritis, 466–467

skin, 459–461

soft tissue, 459–461

systemic conditions, 470–476

urinary tract, 466–467

viral hemorrhagic fevers, 484–485

yellow fever, 488–489

Infective endocarditis

antibiotic prophylaxis, 440–441

Inferior vena cava

ultrasonography of, 112–114

Inflammation

anemia and, 527

splenic, 371–372

Inflammatory splenomegaly, acute, 371

Inguinal disorders

anatomy, 294

complications of, 296–298

hernias, 295–296

hydroceles, 295–296

incidence of, 295

symptoms, 295–96

treatment of, 296

Inhalant drug administration, 607–608

Inhalation injuries

burns and, 140–141

Inspissated bile syndrome, 363

Insulin

action times, 497

diabetes mellitus management, 497–498

diabetic ketoacidosis management, 495–496

dosing using neutral protamine hagedorn and regular insulin, 498

types of, 497

Integrated Management of Childhood Illness, 692

Intermittent exotropia, 190

Intermittent mandatory ventilation, 38–39

Internal jugular veins

ultrasonography of, 113, 115

Intestinal atresias, 303, 328–330
lxviii

Pediatric Surgery and Medicine for Hostile Environments 

Intestinal infections, 445–446

Intraarterial catheters, 33–34

Intracranial arteries, 285

Intracranial mass lesions

increased intracranial pressure and, 65

Intracranial pressure

causes of, 65

head injuries and, 157

initial evaluation of, 65–66

monitoring, 68

monitoring in head injuries, 159–160

neurologic intensive care monitoring, 68

nursing assessment, 599

signs of increased pressure, 66

traumatic brain injury management goals, 68–69

treatment of, 67–70

ventriculostomy catheters, 160–163

Intramuscular drug administration, 606–607

Intraocular pressure, 177

Intraoral neoplasms, 220, 222

Intraoral obstruction, 219–220

Intraosseous infusion, 607

Intraosseous needle placement

complications, 31–32

fluid resuscitation, 19

preferred sites (figure), 29–30

technique, 29, 31

Intravaginal deformity, 398

Intravenous access, 597–599

Intravenous drug administration

guidelines on, 606

postoperative pain management, 22–23

Intubation

anesthesia and, 16–18

burns and, 140

failure to intubate, 8

newborn infants, 79–80

postintubation subglottic tracheal stenosis and, 226–227

rapid sequence, 8–9

Intussusception, 335–338, 453

IO. See Intraosseous infusion

Ionizing radiation exposure, 665–666

IOP. See Intraocular pressure

Ipratropium bromide

pulmonary agent exposure treatment, 655

Iritis, traumatic, 186

Iron deficiency anemia, 524–525, 587–588

Irreversible shock, 58
lxix

Index

Isoniazid

tuberculosis treatment, 465–466

IVC. See Inferior vena cava

Ivemark syndrome, 370

J

Japanese encephalitis, 478–479

Joint infections, 459–461

Joint Theater Trauma System

Clinical Practice Guideline on Hypothermia Prevention, 123, 648

Jones Criteria

rheumatic heart disease diagnosis, 438

Jugular veins, internal

ultrasonography of, 113, 115

Juvenile hemangiomas, 280

K

Kasabach-Merritt syndrome, 280, 281

Kasai procedure, 362

Kawasaki disease, 284, 439–440, 557–558

Kayser-Fleisher corneal ring, 192

Kernig sign, 470

Ketamine

preoperative sedation, 22

for rapid sequence intubation, 9, 60

Ketorolac, 511

postoperative pain management, 23

Kidney disease. See Renal disease

Kidney injuries, 377–380, 544–546

Knobology, 97

Kwashiorkor, 581

L

Labial adhesions, 403

Labial fusion, 403

Lacerations

eyelids, 201–203

eyes, 193–194

Lactated Ringer’s solution

fluid resuscitation, 19, 21

shock treatment, 11

LactMed, 90

Large intestine disorders

acute appendicitis, 340–346

acute gastroenteritis, 346–347

constipation, 348

hemolytic uremic syndrome, 348

Henoch-Schönlein purpura, 347

Hirschsprung disease, 349–351
lxx

Pediatric Surgery and Medicine for Hostile Environments 

pneumonia and, 348

primary peritonitis, 347

typhlitis, 348–349

Laryngeal clefts, 221

Laryngeal obstructions

clefts, 221

foreign bodies, 221–222

malformations, 220–221

webs, 221

Laryngeal trauma, 235–237

Laryngoceles, 223

Laryngomalacia, 220–221

Laryngoscopy

procuring an emergency airway and, 229

rapid sequence intubation and, 8

video, 17

Laryngotracheal abnormalities, 220–222

Laryngotracheobronchitis, acute, 225

Larynx

pediatric considerations, 4

Lateral condyle fractures, 257–258

Lead poisoning, 525

Leptospirosis, 479

Leukemia

splenomegaly and, 373

Leukocoria

retinoblastoma and, 186, 192

Leukocyte-reduced blood products, 50

Levetiracetam

epilepsy treatment, 515–516

status epilepticus treatment, 73

Levothyroxine, 500, 659

Lewisite, 653–654

Lidocaine

cardiopulmonary resuscitation and, 638

dosing limits, 166

for rapid sequence intubation, 9

toothache pain treatment, 206

Linear array transducers, 93–95

Lispro, 498

Littré hernia, 331

Liver

infections, 357–359

Liver disease

anemia and, 529

Long-bone fractures, 255–256

Lorazepam

for mechanical ventilation sedation, 43–44

status epilepticus treatment, 73
lxxi

Index

Lower extremities

fractures, 260–263

Lumbar puncture

meningitis and, 471

status epilepticus contraindication, 72

Lund and Browder chart, modified, 138–139

Lung abscesses, 275

Lung infections, 274–276, 461–466

Lung injuries

flail chest and, 269–270

hemothorax, 267–268

lung laceration, 269

pneumothorax, 266–267

pulmonary contusion, 268–269

rib fractures and, 269–270

Lyme disease, 479–480, 559, 560

Lymphadenitis, 459–460

Lymphangiomas

of the airway, 223

diagnosis of, 282

treatment of, 282

types of, 282

Lymphangitis, 459

Lymphatic malformations, 240–241

Lymphedema, 282

Lymphocytes

blood product irradiation, 50

Lymphoma

head and neck, 239

M

M-mode ultrasound, 95–96

Mace, 657

Macrocytic anemias, 527–529

Macroglossia, 219–220

Mafenide cream

burn treatment, 143

Magnesium sulfate, 637

Malabsorption disorders, 447–448

Malaria, 480–482

Malignancies. See Oncology; specific type of malignancy

Malnutrition

deficiency symptoms, 589–590

enteral feeding, 585

iron deficiency, 587–588

mid-upper arm circumference screening for, 578

rates of, 579–580

refeeding syndrome, 582–583

severe acute malnutrition, 581–582
lxxii

Pediatric Surgery and Medicine for Hostile Environments 

total parenteral nutrition, 584–586

tube feeding, 584

vitamin A deficiency, 586–587

zinc deficiency, 588

Malrotation with or without volvulus, 326–328

Mandibular fractures, 230–232

Mandibular hypoplasia, 219

MAP. See Mean arterial pressure

Marasmus, 581

Marfan syndrome, 284

Mask ventilation, 36–37

Mass casualty events. See also Disasters

psychological effects, 625–626

Mass migration events, 696–698

Maxillary-mandibular fixation, 232

Maxillofacial fractures, 232–233

Mean arterial pressure

intracranial pressure and, 66, 163

Measles, 483, 553–555, 556

Mechanical ventilation

artificial airways, 37

bag-valve mask sizes, 37

bag-valve mask ventilation, 36–37

extubation considerations, 44

extubation failure predictors, 44–45

high peak pressures and, 42

hypercapnia and, 41

hypoxemia and, 41

initial settings, 17–18, 39–40

newborn infants, 78

noninvasive oxygen delivery, 35–37

oxygen tank requirements, 36

oxygen therapy device requirements, 35

peek inspiratory pressure, 17

positive end-expiratory pressure, 17

preparation for, 37–38

problem solving, 42

safety considerations, 38

sedation strategies, 43

simplified ventilation modes, 38–39

titration, 40

Meckel’s diverticulum, 330–332

Meconium ileus, 338–339

Meconium peritonitis, 304–305

Meconium plug syndrome, 340

Meconium-stained amniotic fluid, 83–84

MEDCAPs. See Medical Civil Action Patrols

Mediastinal masses, 277

Medical Civil Action Patrols, 693, 699–673
lxxiii

Index

Medical civil action program clinics, 699–703

Medical evacuation. See Patient evacuation

Medical intelligence, 688

Medical treatment facilities

aeromedical evacuation between, 121

Medication. See also Pharmacotherapeutics; specific drugs

administration, 604–608

Broselow Pediatric Measuring Tape, 6

inhalant administration, 607–608

intramuscular administration, 606–607

intraosseous infusion, 607

IV infusion, 606

nasogastric administration, 605

neonate risk, 5

online weight-based emergency medication calculators, 596

oral administration, 604–605

rectal administration, 605–606

subcutaneous injection, 607

Melioidosis, 652

Meningitis

diagnosis of, 471

etiology, 471

increased intracranial pressure and, 65

symptoms, 470

treatment of, 471–472

Meningococcemia, 552–553

Mental health care

aggression, 624–625

antisocial behaviors, 624–625

anxiety disorders, 620–623

communication and, 612, 614–615

cultural issues, 611

depression, 624

discharge planning, 615–616

effects of mass casualty events, 5–6, 625–626, 685

grief, 624

online resources, 627–628

oppositionality, 624–625

principles of care, 609–616

providers’ well-being, 626

psychiatric conditions, 619–620

sleep disorders, 623–624

status of, 508–509

therapeutic modalities, 617–619

treatment phases, 616

Mental status, 508–509

Mesenteric cysts, 305

Methimazole

radiological contamination treatment, 669
lxxiv

Pediatric Surgery and Medicine for Hostile Environments 

Methohexital

preoperative sedation, 22

Methylprednisolone

idiopathic thrombocytopenic purpura treatment, 537

Metoclopramide

gastroesophageal reflux disease treatment, 451

Metronidazole

gastroesophageal reflux disease and, 451

Microcytic anemias, 524–527

Micrognathia, 219

Micronutrients, 586–588

Mid-upper arm circumference

screening for malnutrition, 578

Midazolam

for mechanical ventilation sedation, 43

preoperative sedation, 22

for rapid sequence intubation, 9

status epilepticus treatment, 73, 74

Midgut volvulus, 327–328

Midshaft humerus fracture, 256

Migraine headaches, 511

Military medicine, 707

Milrinone

shock treatment, 63

Milroy’s disease, 282

Ministry of health system, 688, 690–691

MMF. See Maxillary-mandibular fixation

MoH. See Ministry of health system

Monocular elevation deficiency, 191

Morgagni’s hernia, 306

Morphine

intravenous dosage, 22

for mechanical ventilation sedation, 44

patient-controlled analgesia dosage, 23

postoperative pain management, 22–23

Mortality predictors, 3

MTF. See Medical Treatment Facilities

Mucocutaneous lymph node syndrome. See Kawasaki disease

Mumps, 458

Musculoskeletal infections, 246

Mustard gas, 653–654

Myelodysplastic syndromes, 529

Myocardial contusions, 271

Myocardial infarction, 442–443

Myoglobinuria

electrical burns and, 148, 149
lxxv

Index

N

Naloxone, 637

Naproxen, 511

Narcotics. See Pharmacotherapeutics

Nasal disorders. See Ear, nose, and throat disorders

Nasal fractures, 233–235

Nasogastric tubes, 603, 605

Nasolacrimal duct obstruction, 181–183

Natural disasters, 676

Neck disorders. See Face and neck disorders

Neck injuries, penetrating, 235–237

Necks

pediatric considerations, 5

Necrotizing enterocolitis, 332–335

Necrotizing fasciitis, 573–574

Needle cricothyroidotomy, 8

Neisseria gonohorrhoeae

neonatal conjunctivitis and, 455–456

ophthalmia neonatorum and, 184–185

Neisseria meningitidis, 470, 552, 554

Neonatal conjunctivitis, 455–456

Neonatal herpes simplex virus, 562–564

Neonatal staining, 279

Neonates. See also Newborn care

eye examinations, 176

gastric perforation, 323–324

neonatal conjunctivitis, 455–456

special considerations, 5

teeth, 212

torsion of the scrotum and, 397–398

vital signs, 4

Neoplasms. See Oncology; specific types of cancer and tumors

Nephrolithiasis, 454

Nephrology. See also Renal disease; Renal injuries

acute kidney injuries, 544–546

assessing kidney function in children, 543–544

glomerular filtration rate, 543–544

nephrotic syndrome, 546–547

renal stones, 547–548

Nephrotic syndrome, 546–547

Nerve agents, 653

Nerve blocks

caudal, dosing for, 24

epidural, dosing for, 24

peripheral, dosing for single injection, 25

Neural tube defects

newborn infant care, 87

Neurological assessment, 599
lxxvi

Pediatric Surgery and Medicine for Hostile Environments 

Neurological problems. See also Head injuries

altered mental status, 508–509

assessment of, 12

concussion, 518–519

examination of, 507–508

headaches, 510–512

hypotonia, 510

posttraumatic seizures, 519

seizures, 513–517

weakness, 509–5510

Neurosurgery. See also Head injuries

bone flap preservation, 167, 168

closed injuries, 170–171

craniotomy, 166–167

Glasgow Coma Scale, 154–155

Infant Face Scale, 155–156

low-velocity penetrating head injuries, 165–166

penetrating injuries, 172

scalp lacerations, 165–166

spinal injuries, 167–170

ventriculostomy catheters, 160–162, 172–173

Neutral protamine Hagedorn, 497–498

Neutropenia, 542

Newborn care. See also Neonates

abdominal wall defects, 87

advanced resuscitation requirements, 78–90

Apgar evaluation of newborn infants, 77

apneic infants, 78–79

bathing, 91

bowel assessment, 87

breast-feeding, 89

congenital heart disease assessment, 91–92

dressing issues, 90–91

emergency vascular access, 80–82

endotracheal tube sizes, 85

expected newborn weight by gestational age, 86

feeding recommendations, 90

hospital stay, 91

hue transition, 77

hypoglycemia, 89

infants who are large or small for gestational age, 89–90

infants who are not vigorous, 78

infants who do not appear normal, 85–88

infants who need to be intubated, 79–80

jaundice assessment, 91

meconium-stained amniotic fluid and, 83–84

neural tube defects, 87

normal infant vital signs, 86

preterm infants, 84–85
lxxvii

Index

prophylaxis, 90

routine care, 90–92

routine resuscitation, 75–78

tension pneumothorax and, 82–83

term infants who appear ill, 88–89

upper airway anomalies, 88

vigorous infants, 76

voiding issues, 91

NGOs. See Nongovernmental organizations

Nissen fundoplication, 319–320

Nitrofurantoin

dosages, 475

Nitroprusside

shock treatment, 63

Nonaccidental trauma

ocular manifestations, 188–189

Noncomitant strabismus, 191

Nonconvulsive status epilepticus, 71

Nongovernmental organizations, 688, 693

Nongreenstick body fractures, 232

Nonsteroidal antiinflammatory drugs, 511–512

Nonstrabismic eye conditions

amblyopia, 187

anterior uveitis, 186

blepharitis, 181

cataracts, 186–187

conjunctivitis, 184

leukocoria, 186

nasolacrimal duct obstruction, 181–183

ophthalmia neonatorum, 184–185

orbital dermoid cysts, 180

periorbital cellulitis, 185

ptosis, 180–181

toxocara granuloma, 188

unilateral aphakia, 187–188

Norepinephrine

shock treatment, 63, 64

Normal saline

fluid resuscitation, 19

Normocytic anemias, 530–537

Nortriptyline, 512

Nose disorders. See Ear, nose, and throat disorders

NPH. See Neutral protamine Hagedorn

Nuclear and radiological casualties

blast injuries, 664

ionizing radiation exposure, 665–666

medical effects of nuclear detonation, 664–666

pediatric risks, 663

radiological contamination, 666–670
lxxviii

Pediatric Surgery and Medicine for Hostile Environments 

thermal injuries, 664–665

treatment, 669–670

Nursing assessment

airway assessment, 597

cardiovascular access, 597–599

communicating with children, 595–596

gastrointestinal, 603

genitourinary tract, 603

growth and development, 593–595

IV access, 597–599

medications, 604–608

neurological, 599

nursing tips, 596

pain, 600–602

respiratory assessment, 597

tubes and drains, 603–604

vital signs, 596

Nutrition

assessment methods for height, weight, and nutrition status, 577–578

breast-feeding, 583–584

burns and, 150

calorie requirements, 578–579

deficiency symptoms, 589–590

diabetes mellitus management, 497

enteral feeding, 585

iron deficiency, 587–588

micronutrients, 586–588

mid-upper arm circumference screening for malnutrition, 578

parenteral electrolyte requirements, 585

pediatric requirements, 585–586

protein requirements, 578–579

rates of malnutrition, 579–580

refeeding syndrome, 582–583

severe acute malnutrition, 581–582

total parenteral nutrition, 584–586

tube feeding, 584

vitamin A deficiency, 586–587

zinc deficiency, 588

O

Occlusive syndromes, 285

Ocular injuries. See Eye injuries

OFDA. See Office of Foreign Disaster Assistance

Office of Foreign Disaster Assistance, 676–677, 683

Omental cysts, 305, 454

Omeprazole

gastroesophageal reflux disease treatment, 451

Omphalitis, 291

Omphaloceles
lxxix

Index

associated anomalies, 300–301

incidence of, 299

newborn infant care, 87

ruptured, 299

treatment, 300–302

Oncology

fever management, 542

infection susceptibility and, 542

intraoral neoplasms, 220, 222

most common malignancies of childhood, 542

neutropenia management, 542

renal, 402–403

scrotal, 401–403

Wilms tumor, 192, 402

Open fractures, 255

Open globe injuries, 193–194

Ophthalmia neonatorum, 184–185

Ophthalmology

eye diseases, 180–188

eye examinations, 175–180

eye injuries, 192–203

newborn prophylaxis, 90

normal visual acuity by age, 176

optic nerve abnormalities, 189

refractive error, 189–192

retinal disorders, 188–189

Opioids. See also specific drugs

for mechanical ventilation sedation, 43

Oppositionality, 624–625

Optic nerve abnormalities, 189

Oral drug administration, 604–605

Oral pathology

aphthous ulcers, 212–213

dentoalveolar abscesses, 210–211

eruption hematoma, 211

herpetic gingivostomatitis, 213

natal and neonatal teeth, 212

pyogenic granuloma, 212

Riga-Fede disease, 213

Orbital cellulitis, 457

Orbital dermoid cysts, 180

Orbital floor fractures, 200–201

Orbital hemorrhage, 199–200

Orchidopexy, 396

Orchiectomy, 402

Orchitis, 401

Orotracheal intubation, 17

Orthopedics. See also Bone fractures

amputations, 247–253
lxxx

Pediatric Surgery and Medicine for Hostile Environments 

differences in levels of trauma, 247

epidemiology, 245–247

infections, 246–247

osteomyelitis, 247

types of care, 245–247

Orthopoxvirus, 661–662

Osmotic diarrhea, 446

Osteogenesis imperfecta

ocular manifestations, 192

Osteomyelitis, 247, 460–461

Otitis externa, acute, 242

Otorrhea, 242

Overseas Humanitarian Disaster Assistance and Civic Aid, 690

Oxycodone

postoperative pain management, 24

Oxygen therapy, noninvasive

bag-valve-mask ventilation, 36–37

device requirements, 35

oxygen tank capacities, 36

P

Packed red blood cells

anemia treatment, 48

estimating transfusion volume, 47

frozen, 48

indications, 47

risks of, 48

Pain management. See also specific drugs

burns and, 150

nursing assessment, 600–602

postoperative, 22–24

toothache and, 206–208

PALS. See Pediatric Advanced Life Support

Pancreatic disorders

congenital variations, 365–366

pancreatitis, 367–368

pseudocysts, 369

trauma, 366–367

Pancreatitis, 367–368

Papillomas

of the airway, 224

Parapharyngeal abscesses, 458

Paraphimosis, 393–394

Parasternal long-axis cardiac ultrasound, 100, 104–106

Parasymphysis fractures, 232

Parkland formula, 21

Parotitis, 458

Patent omphalomesenteric sinus, 293

Patient-controlled analgesia, 22–23
lxxxi

Index

Patient evacuation. See also Aeromedical evacuation

disaster planning, 685

mass migration events, 696–698

spinal injuries, 170–173

Patient isolation, 618–619

Patient Movement Requirements Center, 127–128

PCA. See Patient-controlled analgesia

Pediatric Advanced Life Support

pediatric assessment triangle, 6

Pediatric trauma. See Trauma; specific injuries

Peek inspiratory pressure, 17, 46

PEEP. See Positive end-expiratory pressure

Pelvic fractures, 260–261

Pelvic ultrasound, 100, 103

Penetrating injuries

esophageal, 274

head, 165–166

neck, 235–237

spinal, 172

Penicillamine

radiological contamination treatment, 670

Penicillin

biological agent treatment, 659

dosages, 475

rheumatic fever treatment, 473, 475

Penile conditions

circumcision, 394

epispadias, 391

foreskin retractility, 390

hypospadias, 390–391

paraphimosis, 393–394

phimosis, 391–393

Pepper spray, 657

Peptic ulcer disease, 454

Percutaneous central venous lines

pediatric line sizes, 32–33

preferred site, 32

risks of, 32

Perfluoroisobutylene, 654–655

Perianal abscesses, 352

Pericardial tamponade

diagnosis of, 11, 270

treatment, 270–271

Perihepatic ultrasound, 100, 101

Periorbital cellulitis, 185, 456

Peripheral intravenous catheter insertion

ultrasonography of, 117–118

Peripheral nerve block

dosing for single injection, 25
lxxxii

Pediatric Surgery and Medicine for Hostile Environments 

Peripheral venous cutdowns, 32–33

Perisplenic ultrasound, 100, 102

Peritoneal adhesions, 305

Peritoneal disorders

abdominal compartment syndrome, 304

ascites, 305

congenital diaphragmatic hernia, 306–311

meconium peritonitis, 304–305

mesenteric cysts, 305

omental cysts, 305

peritoneal adhesions, 305

Peritonitis, primary, 347

Pertussis, 463–464

Pharmacotherapeutics, 91. See also Medication; Sedation

absorption issues, 629–630

administering drugs to children, 633–634

Broselow Pediatric Measuring Tape, 6, 18

distribution issues, 630–631

drugs used during pediatric cardiopulmonary arrests, 635–638

emergency pediatric drug therapy, 634–638

excretion of drugs, 632

factors affecting, 629

mechanical ventilation and sedation, 43–44

metabolism of drugs, 631–632

preoperative sedation, 21–22

Phased array transducers, 94–95

Phenobarbital

epilepsy treatment, 516

posttraumatic seizure treatment, 519

status epilepticus treatment, 74

Phenylephrine

hypotension and, 16

shock treatment, 63

Phenytoin

epilepsy treatment, 517

prophylaxis for seizures, 158–159

Phimosis, 391–393

Phosgene, 654–655

Physicians

resources for, 705–710

Phytonadione

newborn prophylaxis, 90

Pierre Robin syndrome

mandibular hypoplasia and, 219

newborn infant care, 88

PIP. See Peek inspiratory pressure

Pit viper, 644

Plague, 658, 660

Plasmodium falciparum, 480–482
lxxxiii

Index

Platelets

coagulopathy minimization, 20–21

transfusion of, 49

Pleural effusion

thoracentesis site, 110

ultrasonography of, 107–109

Pleural infections, 274–276

Pneumatoceles, 271–275

Pneumatosis intestinalis, 332

Pneumonia, 348, 461–463

Pneumoperitoneum, 333

Pneumothorax

clinical presentation, 267

diagnosis of, 267

spontaneous, 277–278

treatment of, 267

types of, 266–267

ultrasonography of, 110–112

Pneumothorax, tension

newborn infants, 82–83

pediatric considerations, 5

treatment of, 10

Polio, 483–484

Polyps, 291–292

Polysplenia, 370

Positive end-expiratory pressure

extubation failure prevention, 44

hypoxemia prevention, 41

mechanical ventilation and, 17, 36–37, 40

Positive-pressure ventilation

newborn infants, 78–79

Postintubation subglottic tracheal stenosis, 226–227

Postoperative pain management

intravenous narcotics, 22

opioids, 22–24

patient-controlled analgesia, 22–23

Posttraumatic seizures, 519

Pralidoxime chloride

nerve agent exposure treatment, 653

Prednisone

idiopathic thrombocytopenic purpura treatment, 537

Pregnancy

appendicitis during, 344–345

Premature ventricular contraction, 436

Preoperative sedation, 21–22

Preschool children

eye examinations, 177

growth and development, 594–595

Preterm infants

advanced resuscitation, 84–85
lxxxiv

Pediatric Surgery and Medicine for Hostile Environments 

Primary peritonitis, 347

Prism test, 178

Processus vaginalis, 294

Procidentia, 351

Proguanil

malaria treatment, 482

Propofol

head injuries and, 163

for mechanical ventilation sedation, 43

for rapid sequence intubation, 9

Propranolol

hyperthyroidism treatment, 501

Propylthiouracil

hyperthyroidism treatment, 501

radiological contamination treatment, 669

Protein-losing enteropathy, 448

Protein requirements, 578–579

Proton pump inhibitors

gastroesophageal reflux disease treatment, 451

Proximal humerus fracture, 256

Pseudocysts, 369

Pseudomonas aeruginosa

wound infections, 246

Psychological care

aggression, 624–625

antisocial behaviors, 624–625

anxiety disorders, 620–623

communication and, 612, 614–615

cultural issues, 611

depression, 624

discharge planning, 615–616

effects of mass casualty events, 5–6, 625–626, 685

grief, 624

online resources, 627–628

oppositionality, 624–625

principles of, 609–616

providers’ well-being, 626

psychiatric conditions, 619–620

sleep disorders, 623–624

therapeutic modalities, 617–619

treatment phases, 616

Psychological impact, 5–6, 625–626, 685

Psychotropics, 617

PsySTART, 620, 625, 628

Ptosis, 180–181

Pulmonary agents, 654–655

Pulmonary contusion, 268–269

Pulmonary infections

bronchiolitis, 424–426
lxxxv

Index

croup, 225, 426–427

pneumonia, 461–463

tuberculosis, 464–466

whooping cough, 463–464

Pulse oximetry

congenital heart disease screening of newborn infants, 91–92

respiratory emergencies monitoring, 22, 416–417

Pulse pressure

assessment of, 11

Pupillary reactivity

head injuries and, 156–157

Purpura

Henoch-Schönlein purpura, 571–572

purpura fulminans, 571–573

Purpura fulminans, 571–573

PVC. See Premature ventricular contraction

Pyelonephritis, 466–467

Pyloric stenosis, infantile hypertrophic, 320–323

Pyogenic abscesses, 357–358

Pyogenic granuloma, 212

Pyrazinamide

tuberculosis treatment, 465–466

Pyridoxine

status epilepticus treatment, 73

Q

Quinidine gluconate

malaria treatment, 481

Quinine sulfate

malaria treatment, 482

R

Radial neck fractions, 259

Radiation dermatitis, 665

Radiation Emergency Assistance Center/Training Site, 669

Radiography

spinal injuries, 169–170

Radiological casualties. See Nuclear and radiological casualties

Radiological contamination

external, 666–667

internal, 667–670

treatment, 669–670

Rales, 416

Ramus fractures, 232

Randot test, 178

Ranitidine

gastroesophageal reflux disease treatment, 451

Rapid sequence intubation

drugs and doses, 8–9
lxxxvi

Pediatric Surgery and Medicine for Hostile Environments 

establishing an airway, 230

shock and, 60, 62

Rashes. See Dermatology

Raxibacumab

biological agent treatment, 659

Reactive Skin Decontamination Lotion Kit, 654

Recombinant factor VIIa

blood transfusions and, 53

Rectal disorders. See also Anal disorders

perirectal abscesses, 232

preoperative mechanical bowel preparation, 353

rectal prolapse, 351

Rectal drug administration, 605–606

Rectal prolapse, 351

Red blood cells

normal values, 522

packed, transfusion of, 47–48

Refeeding syndrome, 582–583

Reflexes

pediatric neurological examination for, 508

Refractive error, 189–191

Refractory status epilepticus, 71, 73–74

Regional anesthesia

caudal or epidural block dosing, 24

contraindications, 24

single injection peripheral nerve block dosing, 25

spinal dosing, 25

Regulating and Command and Control Evacuation System, 127

Rehabilitation

burns and, 150–151

Renal artery stenosis, 285

Renal cell carcinoma, 402–403

Renal disease

anemia and, 531–532

glomerular filtration rate and, 543–544

nephrotic syndrome, 546–547

renal stones, 547–548

Renal injuries, 377–380, 544–546

Renal stones, 547–548

Renal tumors, 402–403

Resource-limited settings

medical care in, 706–707

Respiratory acidosis

anesthesia and, 16

Respiratory distress

shock and, 60

Respiratory emergencies

anaphylaxis, 422–424

bacterial tracheitis, 429
lxxxvii

Index

breathing assessment, 10

bronchiolitis, 424–426

chronic asthma management, 417–422

croup, 426–427

epiglottitis, 427–428

narcotics infusions and, 22

newborn infant care, 89

respiratory distress assessment, 7–8

respiratory rates, 415

status asthmaticus, 417

work of breathing and, 415–417

Respiratory nursing assessment, 597

Respiratory rates

by age, 415

newborn infants, 86

normal, by age group, 4

ventilator settings, 17–18

Restraints, 618–619

Resuscitation

blood therapy, 20–21

burns, 21

fluid resuscitation, 19–20

hypothermia, 18–19

monitoring, 20

newborn care, 75–90

trauma, 18–21

Retinal burns, 665

Retinal disorders

nonaccidental trauma, 188–189

optic nerve abnormalities, 189

refractive error, 189–191

retinopathy of prematurity, 188

Retinoblastoma

leukocoria and, 186, 192

Retinopathy of prematurity, 188

Retractile testis, 394

Retrobulbar hemorrhage, 199–200

Retrograde urethrograms, 386–387

Rewarming patients, 648

Rheumatic fever, 473–476

Rheumatic heart disease, 438–439

Ribs

cervical spine, 5

fractures, 269–270

Rickets, 504–505

Rickettsial diseases, 552

Rifampin

meningitis treatment, 471

tuberculosis treatment, 465–466
lxxxviii

Pediatric Surgery and Medicine for Hostile Environments 

Riga-Fede disease, 213

Ringer’s solution, lactated

burn care, 142

Riot control agents, 657

Rizatriptan, 511

Rocky Mountain spotted fever, 552, 553

Rocuronium

for rapid sequence intubation, 9

ROP. See Retinopathy of prematurity

Ropivacaine

dosing for caudal or epidural blocks, 24

dosing for spinal anesthesia, 25

RSDL. See Reactive Skin Decontamination Lotion Kit

Rubeola, 483, 553–555

RUG. See Retrograde urethrograms

Rule of nines, 138

Ruptured diaphragmatic hernia, 271–272

S

Saline solution

fluid resuscitation, 19

Salmon patches, 280

Salmonella typhi infections, 246

SALT triage system, 679–680

Salter-Harris classification, 254

SAM. See Severe acute malnutrition

SAMPLE pneumonic, 13

Scalded skin syndrome. See Staphylococcal scalded skin syndrome

Scalp anatomy, 165

Scarlet fever, 555–557

Schwartz formula, 543, 633

Scorpion bites, 644–645

Scrotal conditions. See also Testicular conditions

epididymitis, 400

orchitis, 401

torsion, 397–399

torsion of the appendix testis or appendix epididymis, 399–400

tumors, 401–403

varicoceles, 401

Second degree burns, 134, 136

Secure Internet Protocol Router Network, 127

Sedation. See also specific drugs

mechanical ventilation and, 43–44

preoperative, 21–22

Seizures

antiepileptic medications, 515–517

childhood epilepsy, 514

febrile, 513

focal epilepsy, 514–515
lxxxix

Index

generalized epilepsy, 515

head injuries and, 158–159

posttraumatic, 519

prophylaxis for, 158–159

status epilepticus, 65, 71–74

Seldinger technique, 32

Sepsis

diagnosis, 471

etiology, 471

neonate risk, 5

newborn infant care, 88–89

symptoms, 470

treatment of, 471–472

Septic arthritis, 460

Septic shock

treatment of, 62–64

Severe acute malnutrition, 581–582

Shaken baby syndrome

eye trauma and, 188–189

Shock

assessing severity of hypovolemic shock, 59

assessment of, 11

cardiogenic, 58, 59

catecholamine-resistant shock, 61

causes of, 58

compensated shock, 57

decompensated shock, 57–58

distributive, 58, 59

features of clinical shock states, 59

fluid refractory shock, 61

hypovolemic, 58, 59, 64

increased intracranial pressure and, 65

initial resuscitation, 60, 61

irreversible shock, 58

septic, 62–64

signs and symptoms, 57–58, 61

treatment of, 60–64

types of, 58–60

vasoactive support, 63

SIADH. See Syndrome of inappropriate antidiuretic hormone

Sialadenitis, 458

Sickle cell disease, 372–373, 532–534

Silver nitrate eye drops

newborn prophylaxis, 90

Silver nitrate solution

burn treatment, 143

Silver sulfadiazine cream

burn treatment, 143

Sinus tachycardia, 434
xc

Pediatric Surgery and Medicine for Hostile Environments 

Sinusitis, acute bacterial, 244

SIPRNet. See Secure Internet Protocol Router Network

Skin disorders. See Dermatology

Skin infections, 459–461

Skull

pediatric considerations, 5

Skull base fractures, 234

Sleep disorders, 623–624

Small intestine disorders

intestinal atresias, 328–330

intussusception, 335–338

malrotation with or without volvulus, 326–328

Meckel’s diverticulum, 330–332

meconium ileus, 338–339

meconium plug syndrome, 340

midgut volvulus, 327–328

necrotizing enterocolitis, 332–335

Smallpox, 569–571, 661–662

Snake bites, 642–644

Sodium bicarbonate, 636

Sodium disorders. See Fluids and electrolytes

Sodium nitrite

blood agent exposure treatment, 656

Sodium thiosulfate

blood agent exposure treatment, 656

Soft tissue infections, 459–461

Soft-tissue trauma, 237

Sphere Project, 693

Spider angiomas, 280

Spider bites, 645–646

Spigelian hernias, 294

Spinal anesthesia

dosing, 25

Spinal injuries

anatomical considerations, 167, 169

assessment of, 12

biomechanical considerations, 167, 169

closed, 170–171

pathophysiology of, 169

pediatric considerations, 5

penetrating, 172

radiographic considerations, 169–170

transport considerations, 170–172

Spleen

abscess, 371–372

accessory spleen, 370

acute inflammatory splenomegaly, 371

asplenia, 370

congenital anomalies, 370–371
xci

Index

cysts, 370–371

elliptocytosis, 372

function of, 369–370

hematologic disorders, 372–376

hereditary spherocytosis, 372

hypersplenism, 374

idiopathic thrombocytopenic purpura, 373–374

inflammation of, 371–372

leukemia and, 373

platelet disorders, 373–374

polysplenia, 370

red blood cell disorders, 372–373

sickle cell anemia, 372–373

splenectomy, 374–376

trauma to, 371

wandering (ectopic) spleen, 374

white blood cell disorders, 373–374

Splenectomy, 374–376

Splenomegaly, acute inflammatory, 371

Spontaneous pneumothorax, 277–278

Stability operations, 695–696

Staphylococcal scalded skin syndrome, 561, 562

Staphylococcal toxic shock syndrome, 558–559

Staphylococcus aureus

musculoskeletal infections, 246

START/JumpSTART algorithm, 679, 681

Status asthmaticus, 417

Status epilepticus

causes of, 71–72

complications, 72

emergency management, 73–74

established, 71, 73

generalized convulsive, 71

impending, 71, 73

increased intracranial pressure and, 65

nonconvulsive, 71

refractory, 71, 73–74

Stereo vision testing, 178

Stereopsis, 191

Steroids

extubation failure prevention, 44

Stevens-Johnson syndrome, 564–568

Stings. See Bites and stings

Stomach disorders

bezoars, 324

gastric antral webs, 323

gastric perforation, 323–324

infantile hypertrophic pyloric stenosis, 320–323

Stork’s bite, 279
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Pediatric Surgery and Medicine for Hostile Environments 

Strabismus, 190, 191

Strawberry hemangiomas, 280

Streptococcal toxic shock syndrome, 558–559

Stress, psychological

pediatric considerations, 5–6

Strictures, esophageal, 320

Stridor

causes of, 416

postextubation, 44

Strokes

increased intracranial pressure and, 65

Sturge-Weber syndrome, 280

Subcondylar fractures, 232

Subconjunctival hemorrhage, 194

Subcostal long-axis cardiac ultrasound, 98–100

Subcutaneous drug injection, 607

Succinylcholine

for rapid sequence intubation, 9

Sulfamethoxazole

dosages, 475

Sumatriptan, 511

Supracondylar humerus fracture, 256–257

Supraglottitis, 224–225

Supraventricular tachycardia, 434–435

Surgery. See also specific types of surgery

abdominal wall, 291–311

burns, 131–151

dental, 205–216

diaphragm, 291–311

face and neck, 217–244

gastrointestinal tract, 313–353

genitourinary tract, 377–404

hepatobiliary tract, 355–363

neurosurgery, 153–173

ophthalmologic, 175–203

orthopedics, 245–264

pancreas, 365–376

peritoneum, 291–311

spleen, 365–376

thoracic cavity, 265–278

vascular, 279–290

Surviving Sepsis Campaign 2010, 60

Syncope, cardiac, 441

Syndrome of inappropriate antidiuretic hormone, 409, 412–413

Syphilis

ocular manifestations, 192

Systemic diseases

acute rheumatic fever, 473–476

meningitis, 470–472
xciii

Index

ocular manifestations, 192

sepsis, 470–472

Systolic blood pressure

normal, by age group, 4

T

Tachycardia, 434–435

Tachypnea

assessment of, 10

Tamponade, pericardial

diagnosis of, 11

TBI. See Traumatic brain injuries

TBSA. See Total body surface area

TBW. See Total body water

Tear gas, 657

Teeth

avulsion of, 214–215

caries, 205–208

extraction, 208–210

fractures, 214

intrusion of, 215–216

luxation of, 216

natal and neonatal, 212

toothaches, 206–208

TEF. See Tracheoesophageal fistulas

Teledermatology consultation, 549–551

Temporal bone fractures, 234

Tensilon test, 643

Tension headaches, 511–512

Tension pneumothorax

newborn infants, 82–83

pediatric considerations, 5

treatment of, 10

Testicular conditions. See also Scrotal conditions

cryptorchidism, 394–397

retractile testis, 394

Tetracaine

dosing for spinal anesthesia, 25

Tetracycline

malaria treatment, 482

Thalassemia, 526–527

Thermal injuries, 664–665

Thiopental

head injuries and, 164

for rapid sequence intubation, 9

Third degree burns, 134–135, 137

Thoracentesis

ultrasonography of, 110
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Pediatric Surgery and Medicine for Hostile Environments 

Thoracic injuries

aortic injuries, 272–273

bronchial injuries, 273–274

clinical presentation, 265

empyema, 276

evaluation of, 265–266

general approach to, 265–266

heart injuries, 271

hemoptysis, 278

incidence of, 265

lung abscess, 275

lung injuries, 266–270

mediastinal masses, 277

pericardial injuries, 270–271

pneumatocele, 274–275

ruptured diaphragmatic hernia, 271–272

spontaneous pneumothorax, 277–278

tracheal injuries, 273–274

treatment of, 266

Throat disorders. See Ear, nose, and throat disorders

Thrombi, 285

Thrombocytopenia, 534–537

Thrombocytosis, 376

Thrombotic thrombocytopenic purpura, 538–539

Thyroglossal duct cysts, 239

Thyroid disorders

hyperthyroidism, 500–502

hypothyroidism, 500

Tibial shaft fractures, 262–263

Tick bites

paralysis from, 646

rickettsial diseases, 552

Tidal volume

mechanical ventilation and, 17, 42

respiratory emergencies and, 416

Titmus test, 178

Toddlers

growth and development, 594

vital signs, 4

Toothaches, 206–208

Topiramate, 512, 516

Torsion of the scrotum

bell clapper deformity, 398

differential diagnosis, 397

intravaginal, 398

laboratory tests, 398–399

neonatal, 397–398

prognosis, 399

symptoms, 398
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Index

treatment of, 399

types of, 397–398

Torticollis, 243

Total body surface area

burns and, 21, 138, 141–142

Total body water

variation with age, 407

Total energy expenditure, 579, 580

Total parenteral nutrition, 582, 584–586

Tourniquets

guidelines for, 249–250

Toxic epidermal necrolysis, 564–568

Toxic shock syndrome, 62, 558–559

Toxocara granuloma, 188

Toxoplasmosis

ocular manifestations, 192

TRAC2ES. See TRANSCOM Regulating and Command and Control Evacuation 

System

Tracheal injuries, 273

Tracheoesophageal fistulas, 313–315

Tracheostomy

as rescue airway option, 8, 221, 229

tube size, 37

use of, 17

Trachoma, 456

Training activities, 698–699

Tramadol

postoperative pain management, 23

Tranexamic acid

as blood transfusion adjunct, 51–52

TRANSCOM. See United States Transportation Command

TRANSCOM Regulating and Command and Control Evacuation System, 127

Transducers, ultrasound, 93–95

Transfusion medicine

blood volume by age, 48

cryoprecipitate, 49–50

estimated blood product unit volumes in theater, 47

fresh frozen plasma, 49

hyperkalemia and, 53

hypocalcemia and, 20k53

hypomagnesemia and, 53

hypothermia and, 54

massive transfusion adjuncts, 51–53

massive transfusions, 51–54

packed red blood cells, 47–48

platelets, 49

recombinant factor VIIa dosing, 53

risks of massive transfusion, 53–54

special blood product preparations, 50
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Pediatric Surgery and Medicine for Hostile Environments 

tranexamic acid dosing, 51–52

transfusing less than a unit dose, 47

transfusion-associated volume overload, 48, 54

whole blood transfusion, 48

Transfusions

shock treatment, 11

Transient erythroblastopenia of childhood, 531

Trauma. See also specific injuries

airway, 7–9

anatomic considerations, 3–6

assessment of, 6–7

biliary tract, 359–360

bladder injury, 382

bladder neck injuries, 382–385

breathing assessment, 10

circulation assessment, 10–11

dentoalveolar, 213–214

disability assessment, 11–12

exposure, 13

external genital injuries, 388

eyes, 193–194

facial bone fractures, 230–234

focused assessment with sonography for trauma, 97–109

genitourinary tract, 377–388

laryngeal trauma, 235–237

liver, 355–356

mortality predictors, 3

nasal fractures, 233–235

nonaccidental, 188–189

ocular manifestations, 188–189

orthopedic, 247

overview, 3

pancreatic, 366–367

physiological considerations, 3–6

psychological impact, 5–6

rapid sequence intubation, 8–9

renal injuries, 377–380

resuscitation, 18–21

secondary surveys, 13

soft-tissue, 237

splenic, 371

traumatic brain injuries, 518–519

triage for, 3

ureteral injuries, 381–382

ureteropelvic junction disruption, 380–381

urethral injuries, 384, 385–387

vascular injuries, 285–290

vital signs, 3–4

Traumatic brain injuries

second impact syndrome, 518
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Index

severity classification, 518

symptoms, 518–519

Travelers’ Health website, 489

Treacher Collins syndrome

mandibular hypoplasia and, 219

Triage

disaster response, 678–679, 680–681

pediatric trauma, 3

SALT triage system, 679–680

START/JumpSTART algorithm, 679, 681

Trifluridine

neonatal conjunctivitis treatment, 456

Triptans, 511

Tube feedings

gastrointestinal disorders and, 584

nursing assessment, 603–604

Tuberculosis

diagnosis of, 464–465

ocular manifestations, 192

symptoms, 464

treatment of, 465–466

Tularemia, 660–661

Typhlitis, 348–349

U

UDT. See Undescended testes

Ulcers

corneal, 196

Ultrasound

abdominal disorder diagnosis, 118

depth, 95

focused assessment with sonography for trauma, 97–106

fundamentals, 93–97

gain, 95

hemothorax, 107–109

musculoskeletal disorder diagnosis, 118

online tutorials, 97, 105–106, 110, 111, 116, 118

peripheral intravenous catheter insertion, 117–118

pleural effusion, 107–109

pneumonia diagnosis, 118

pneumothorax, 110–112

probe orientation, 95

procedural guidance, 118

scanning modes, 95–96

thoracentesis site, 110

transducer types, 93–95

tube thoracostomy placement, 110

vascular access, 113–117

volume status, 112–113
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Pediatric Surgery and Medicine for Hostile Environments 

Umbilical disorders

umbilical drainage, 291–292

Umbilical hernias, 293–294

Umbilical vein catheters, 80–82

Undescended testes, 395–397

Unilateral aphakia, 187–188

United Nations Children’s Fund, 579

United States Agency for International Development, 676–677, 683, 693

United States Transportation Command, 122, 127–128

Upper airway disorders

choanal atresia, 217–219

intraoral neoplasms, 220, 222

intraoral obstruction, 219–220

laryngotracheal abnormalities, 220–222

macroglossia, 219–220

mandibular hypoplasia, 219

micrognathia, 219

Upper extremities

fractures, 256–260

Urachal cysts, 292–293

Urachal sinus, 292

Ureteral injuries, 381–382

Ureteral stones

differentiating from appendicitis, 346

Ureteropelvic junction disruption, 380–381

Urethral catheter size estimation, 384

Urethral injuries, 384, 385–387

Urinary tract infections

diagnosis of, 388–390, 467

differentiating from appendicitis, 346

symptoms, 466

treatment of, 390, 467

Urolithiasis, 403–404

US Army consultation service, 549

US Department of Defense

disaster response, 676–677

US Department of State

disaster response, 676

US military medical operations, 692–693

USAID. See United States Agency for International Development

UVC. See Umbilical vein catheters

V

Vaginal conditions

labial fusion, 403

urolithiasis, 403–404

vaginitis, 403

Vaginitis, 403

Valproate
xcix

Index

epilepsy treatment, 516

status epilepticus treatment, 73

Vancomycin

orbital cellulitis treatment, 457

sepsis and meningitis treatment, 472

Vanishing testis, 395

Varicoceles, 401

Variola major, 569–571

Variola virus, 661–662

Vascular access

arterial venous line size, 33

catheter size, 27

central venous line size, 33

common pitfalls in pediatric IV placement, 27

complications, 28–29

external jugular vein cannulation, 28–29

intraarterial catheters, 33–34

intraosseous needle placement, 29–32

newborn infants, 80–82

percutaneous central venous catheters, 32

peripheral venous cutdowns, 32–33

routine access, 27

technique, 28

ultrasonography of, 113–117

Vascular surgery

arterial disorders, 284

arteries to ligate versus arteries to reconstruct, 286

connective tissue disorders, 284–285

hemangiomas, 279–281

lymphangiomas, 282

technical pitfalls, 290

traumatic vascular injuries, 285–290

veins to ligate versus veins to reconstruct, 287

venous disorders, 283

Vasoactive support

shock treatment, 63

Venezuelan equine encephalitis, 652

Venous disorders, 283

Venous malformations, 280

Ventilation. See Mechanical ventilation

Ventilators

age-appropriate respiratory rates, 17–18

Ventricular dysrhythmias, 436

Ventricular tachycardia, 436

Ventriculostomy catheters, 160–162, 172–173

Verapamil, 512

Vesicants, 653–654

Vidarabine

neonatal conjunctivitis treatment, 456
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Pediatric Surgery and Medicine for Hostile Environments 

Video laryngoscopy, 17

Vipera berus, 644

Viral conjunctivitis, 184

Viral hemorrhagic fevers, 484–485, 662–663

Visceral aneurysms, 284

Visceral hemangiomas, 281

Vision. See Ophthalmology

Visual acuity

normal visual acuity by age, 176–177

Vital signs

newborn infants, 86

normal signs by age group, 3–4

obtaining, 596

Vitamin A deficiency, 586–587

Vitamin B12

blood agent exposure treatment, 656–657

Vitamin B12 deficiency, 527–528

Vitamin D disorders

rickets, 504–505

Vitamin K

newborn prophylaxis, 90

Volvulus, intestinal, 326–328

Vomiting, 450–451

Von Willebrand’s disease, 541

W

Wandering (ectopic) spleen, 374

Warm weather injuries, 650

Wasp stings, 642

Weakness

pediatric neurological examination for, 509–510

Weil’s disease, 479

Wheezing, 416

White phosphorus burns, 148

White pupil, 186, 192

WHO. See World Health Organization

Whole blood, fresh

transfusion of, 48

Whooping cough, 463–464

Willy Peter. See White phosphorus burns

Wilms tumor

ocular manifestations, 192

Wilson disease

ocular manifestations, 192

World Bank, 579

World Health Organization

age-and length-based norms for weight, 577–578

emergency relief measures, 682, 684

equations for estimating resting energy expenditures, 580
ci

Index

humanitarian medical programs, 690–692

Integrated Management of Childhood Illness, 692

medical intelligence, 688

rates of malnutrition, 579

tuberculosis diagnosis kits, 464–465

venomous snake distribution and antivenom website, 644

Worth 4 Dot Test, 178

Wound infections, 246–247

Wounds. See specific injury type

Wrist fractures, 259–260

X

Xpert MTB/RIF, 465

Y

Yeast infections, 459

Yellow fever, 488–489

Yersinia pestis, 658, 660

Z

Zinc deficiency, 588
cii

Pediatric Surgery and Medicine for Hostile Environments 
ciii

Index
civ

Pediatric Surgery and Medicine for Hostile Environments