Wilderness Pediatric Medicine: Treating Children in Remote Environments

Children in wilderness settings face unique medical challenges. Their smaller size, developing physiology, and different injury patterns require specialized knowledge and adapted techniques. Understanding pediatric wilderness medicine can mean the difference between life and death when children are injured far from medical care.

Anatomical and Physiological Differences

Size and Surface Area
Children have a much higher surface area to body weight ratio, making them more susceptible to:

• Hypothermia and hyperthermia
• Dehydration
• Medication overdoses

Respiratory System

• Smaller airways obstruct more easily
• Higher oxygen consumption per body weight
• Faster respiratory rates (normal: 12-40 breaths/min depending on age)
• More prone to respiratory failure

Cardiovascular System

• Higher heart rates (normal: 80-180 bpm depending on age)
• Smaller blood volume (losing 1 cup of blood is significant)
• Better compensation until sudden decompensation

Head and Brain

• Larger head-to-body ratio
• Higher risk of head injuries from falls
• Brain more susceptible to swelling
• Soft spots (fontanelles) in infants under 18 months

Age-Specific Vital Signs

Infants (0-1 year)

• Heart Rate: 100-180 bpm
• Respiratory Rate: 30-40 per minute
• Blood Pressure: 60-90/30-60 mmHg

Toddlers (1-3 years)

• Heart Rate: 90-150 bpm
• Respiratory Rate: 20-30 per minute
• Blood Pressure: 80-110/40-70 mmHg

Preschool (3-6 years)

• Heart Rate: 80-140 bpm
• Respiratory Rate: 20-25 per minute
• Blood Pressure: 90-120/50-80 mmHg

School Age (6-12 years)

• Heart Rate: 70-120 bpm
• Respiratory Rate: 15-20 per minute
• Blood Pressure: 100-130/60-85 mmHg

Pediatric Assessment Challenges

Communication

• Use simple, age-appropriate language
• Explain procedures before performing them
• Allow parent/guardian presence when possible
• Use toys or games to distract during assessment

Fear and Anxiety

• Children may not cooperate when scared
• Parent separation increases distress
• Pain assessment requires modified scales
• Consider child’s developmental stage

Physical Examination

• Start with least invasive procedures
• Warm hands and equipment
• Use appropriately sized equipment
• Be gentle but thorough

Common Wilderness Pediatric Emergencies

Respiratory Emergencies

Croup
Cold air can trigger croup attacks in young children:

• Symptoms: Barking cough, stridor, respiratory distress
• Treatment: Humidified air, keep child calm, position of comfort
• Evacuation: If severe stridor or significant distress

Asthma
Exercise and cold air are common triggers:

• Treatment: Rescue inhaler with spacer, calm environment
• Evacuation: If poor response to medication or severe distress

Foreign Body Aspiration
Children commonly put objects in their mouths:

• Back blows for infants, Heimlich for older children
• Never finger sweep blindly
• Evacuate after successful removal

Trauma

Head Injuries
Children’s large heads make them prone to head trauma:

• Signs: Altered consciousness, vomiting, seizures
• Treatment: Maintain airway, cervical spine precautions
• Monitor: Any loss of consciousness requires evacuation

Abdominal Trauma
Children’s organs are less protected:

• Often no external signs of internal bleeding
• Watch for: Abdominal pain, distension, shock signs
• Evacuate: Any significant abdominal trauma

Fractures
Children’s bones are more flexible but heal faster:

• Growth plate injuries require orthopedic care
• Splint above and below injury
• Children tolerate pain differently than adults

Environmental Emergencies

Hypothermia
Children become hypothermic much faster:

• Prevention: Extra layers, frequent warm-up breaks
• Treatment: Gradual rewarming, warm environment
• Signs: Shivering, lethargy, confusion

Heat Illness
Children are at higher risk due to:

• Less efficient sweating
• Higher metabolic rate
• May not recognize thirst
• Treatment: Cooling, oral fluids if alert
• Prevention: Frequent fluid breaks, shade

Dehydration
More common and dangerous in children:

• Signs: Dry mouth, decreased urination, lethargy
• Severe: Sunken eyes, no tears, skin tenting
• Treatment: Small, frequent sips of fluids
• Evacuation: If unable to keep fluids down

Modified Treatment Techniques

Airway Management

Positioning

• Infants: Flat position (large head causes neck flexion)
• Children: Small towel under shoulders
• Jaw thrust preferred over head-tilt/chin-lift

Rescue Breathing

• Infant: Cover mouth and nose with your mouth
• Child: Mouth-to-mouth, pinch nose
• Rate: 1 breath every 3-5 seconds
• Volume: Just enough to see chest rise

CPR Modifications

Compressions

• Infant: 2-finger technique, 1.5 inches deep
• Child: Heel of one hand, 2 inches deep
• Rate: 100-120 compressions per minute
• Ratio: 30:2 (15:2 if two rescuers)

Spinal Immobilization

Challenges:

• Proportionally larger head requires padding under body
• Shorter spine boards or improvisation needed
• Child may not cooperate with cervical collars

Solutions:

• Use towels under torso to align spine
• Parent can help maintain head position
• Consider spinal motion restriction vs. full immobilization

Medication Considerations

Dosing
Most medications are dosed by weight in children:

• Know child’s weight in kilograms
• Use pediatric dosing charts
• When in doubt, consult with medical control

Common Medications:

• Ibuprofen: 10mg/kg every 6 hours (age >6 months)
• Acetaminophen: 15mg/kg every 4 hours
• Epinephrine Auto-injector: Use pediatric dose (<30kg)

Special Considerations:

• Children dehydrate faster
• More sensitive to medication effects
• Avoid aspirin (Reye’s syndrome risk)

Psychological Considerations

Separation Anxiety

• Keep families together when possible
• Explain what happened to parents
• Allow comfort items (stuffed animals, blankets)

Developmental Understanding

• Infants/Toddlers: Respond to caregiver’s calm presence
• Preschoolers: Simple explanations, magical thinking
• School-age: More logical understanding, fear of procedures
• Adolescents: Adult-like understanding but may regress

Prevention Strategies

Supervision

• Maintain closer supervision than at home
• Assign adult to specific children
• Know each child’s abilities and limitations

Environmental Hazards

• Children explore without understanding danger
• Secure tent zippers, camp stoves, water containers
• Check for toxic plants at child’s eye level

Appropriate Activities

• Match activities to child’s developmental stage
• Plan shorter distances and frequent breaks
• Have contingency plans for weather changes

Equipment Modifications

First Aid Kit Additions:

• Pediatric medications (dosed by weight)
• Smaller bandages and gauze
• Thermometer
• Pediatric assessment cards
• Comfort items

Safety Equipment:

• Properly fitted helmets and life jackets
• Child harnesses for exposed areas
• Emergency whistle for each child
• Extra insulation layers

Evacuation Decisions

Evacuate Immediately:

• Any loss of consciousness
• Significant head trauma
• Respiratory distress
• Signs of internal bleeding
• Severe dehydration
• High fever with altered consciousness

Consider Evacuation:

• Persistent vomiting
• Inability to bear weight after injury
• Parent/caregiver has concerns
• Mechanism of injury suggests serious trauma

Communication with Children

During Assessment:

• Get down to child’s eye level
• Use simple words they understand
• Explain what you’re going to do
• Let them help when possible

Pain Assessment:

• Use faces pain scale
• Ask about "ouchies" or "boo-boos"
• Watch facial expressions and behavior
• Compare to normal behavior per parents

Special Wilderness Scenarios

Lost Child

• Children can survive longer than expected
• Look in sheltered areas where they might hide
• They often travel downhill or follow streams
• May not respond to calls if scared

Cold Weather

• Children lose heat much faster
• Watch for signs of hypothermia
• Extra attention to extremities
• Warm, sweet drinks if conscious

High Altitude

• Children may be more susceptible to altitude sickness
• Watch for headache, nausea, fatigue
• Descend if symptoms develop
• Maintain hydration

Treating children in wilderness settings requires patience, adaptability, and understanding of their unique physiology. The key is prevention through appropriate supervision and activity selection, but when injuries occur, quick assessment and age-appropriate treatment can save young lives.

Remember: Children are not small adults. Their anatomy, physiology, and psychology require specialized approaches. When in doubt, err on the side of caution and seek evacuation.