EMS For Children Non-accidental Trauma

1. EMS For ChildrenNon-accidental Trauma Brianna Enriquez, MD Assistant Clinical Professor Department of Pediatrics Division of Emergency Medicine

2. Objectives • Review important pediatric differences in trauma • Review pediatric tools for assessment • Discuss upcoming state pediatric guidelines of care • Update on child abuse in our state

3. Epidemiology • 50% of all childhood deaths are due to injuries • 500,000 pediatric hospitalizations • 20-30 times more ED visits • 30,000 of injured have permanent disabilities

4. Causes • 50% Motor Vehicle Crashes • Large proportion are pedestrians • Falls • Submersion • Burns/Smoke inhalation • Homicide • Suicide

5. Causes • Pedestrian Injuries: • 20% of MVC fatalities • 3 S’s • Small, Slow, So certain they are invincible • Teen Driver’s • 3 U’s • Unrestrained (29%), Under the influence (29%), Uninsurable

6. Causes • Violence • Homicide 2nd leading cause of death 10-24yo • 85% of all homicides in children caused by guns • 54% of all suicides • 2002: 896,000 children were abuse victims 1,400 deaths

7. Where are the risks? • 80% of all trauma deaths occur at the scene or in the emergency department • 18% of hospital trauma deaths are avoidable Most common…. AIRWAY

8. Where are the risks? • More than 50% of major injuries have other major organ involvement • Most common single injury associated with death in pediatric patients… HEAD TRAUMA

9. They aren’t just small traumas…. BIG Head  more head trauma SOFT/THIN chest  more lung injury SMALL Airway  more risk of obstruction POOR Abd protection  more risk of abdominal inj. SMALL neck muscles, flatter/horizontal facets  more risk of injury VASOCONSTRICTION  init. normal BP Kidneys are mobile  more risk of injury Physes  Salter fractures

10. Pediatric Head Trauma • Open sutures + thin calvarium = more flexible skull  increased risk of bleed • Incomplete myelinization = greater plasticity, increased diffuse axonal injury • Big head vs body

11. Imaging: “while they are on the table…..”: C-spine • Cervical spine injuries in pediatric patients with multiple trauma…. 1-2% • 72% of pediatric spinal injuries (<8yo) are cervical injuries

12. Chest Trauma • Blunt trauma = 85% of thoracic injuries • Motor vehicle crashes • Falls • Bicycle accidents 50% Rib Fractures & Pulmonary Contusions 20% Pneumothorax 10% Hemothorax RARE: Cardiac Contusion ~5%

13. Chest Trauma • Penetrating Trauma = 15% • Gunshot Wounds • Hemothorax • Hemorrhagic shock • Stabbings • Tension Pneumothorax • Rare: • Cardiac injury  tamponade • Major vascular injuries

14. Pediatric Thoracic Trauma • Flexible ribs • Less overlying fat/muscle Large force  dissipates significant intrathoracic injury with few external signs of trauma

15. Pediatric Thoracic Trauma • Mediastinum is highly mobile • endures extreme excursion • rapid ventilatory/circulatory collapse Proportionally larger oxygen consumption Smaller functional residual capacity Hypoxia

16. Pediatric Thoracic Trauma • Greater dependence on diaphragmatic breathing  compromised with gastric distention • Place an NG Tube if prolonged BVM • Rapid sequence intubation

17. Pediatric Abdominal Injury • Abdominal injury = 10% of traumatic injuries in children…but most common unrecognized cause of fatal injuries • Physical Exam: only 65% accurate • Serial exams are more reliable

18. Pediatric patients are tough to eval • Different vital signs for age • Different differential diagnoses for age • Uncooperative…. • Patient • Parents

19. EMSC is born • Studies in the 1980’s identified the need for better services and skills devoted to the care of pediatric patients. • In 1984 the US congress authorizes the Emergency Medical Services for Children (EMSC) program.

20. EMS and Pediatrics • Gausche M, Hendersen DP, Seidel JS. 1990: (Annals of Emergency Medicine) Vital signs as part of the prehospital assessment of the pediatric patient: a survey of paramedics. • Significant differences in frequency of field vital sign assessment in pediatric versus adult patients.

21. The Pediatric Assessment Triangle(Background Continued) • Vital signs were more likely to be taken if base hospital contact was made • Vital signs were often not assessed in children <2 • Paramedics less confident in their ability to assess vital signs in children <2 yrs.

22. EMS and Pediatrics • Seidel JS, Henderson DP, et al. 1991 (Pediatrics) • Pediatric prehospital care in urban and rural areas • Young pediatric patients rarely received a full set of vitals and neurologic assessment • Advanced life support treatments and procedures were infrequently used.

23. EMS and Pediatrics • Origin of PEPP curriculum: • Began in 1990: California Pediatric Emergency and Critical Care Coalition and California EMSC project. • Steering committee composed of members from respected national organizations concerned with children and the emergency medical system. • 10 years of review

24. The Pediatric Assessment Triangle(Background Continued) • In 2000 the American Academy of Pediatrics published a new pediatric educational program for prehospital providers. Pediatric Education for Prehospital Professionals (PEPP)

25. The Pediatric Assessment Triangle(Background Continued) • Course is centered on the use of a new rapid assessment tool: The Pediatric Assessment Triangle (PAT)

26. The Pediatric Assessment Triangle(Background Continued) • ACEP and AAP Support the use of the PAT in the emergency department setting as part of their Advanced Pediatric Life Support (APLS): The Pediatric Emergency Medicine Course.

27. The Pediatric Assessment Triangle(Background Continued) What is the PAT? • “Rapid Assessment Tool” – across the room • Uses only visual and auditory clues • Requires no equipment • Only 30-60 seconds to utilize

28. The Pediatric Assessment Triangle(Background Continued) • Allows the emergency provider to: • Formally articulate their general impression of the child • Establish the child’s severity • Recognize the general category of pathophysiology • Determine the urgency of interventions

29. Appearance • Tone • Interactiveness • Consolability • Look/Gaze • Speech/Cry

30. Work of Breathing • Abnormal airway sounds • Stridor • Wheezing • Grunting • Abnormal positioning • Retractions • Flaring

31. Circulation to the Skin • Pallor • Mottling • Cyanosis

32. The Pediatric Assessment Triangle APPEARANCE Abnormal Tone Interactiveness Consolability Abnl. Look/Gaze Abnl. Speech/Cry BREATHING Abnormal Sounds Abnormal Position Retractions Flaring CIRCULATION Pallor Mottling Cyanosis

33. The Pediatric Assessment Triangle = STABLE = SHOCK = RESPIRATORY DISTRESS = CNS/METABOLIC = CARDIOPULMONARY FAILURE = RESPIRATORY FAILURE

34. Case: 4 month-old infant • Paramedics are dispatched to the home of a 4-month-old girl with trouble breathing • Baby had history of fever and cough and was just started on an antibiotic for pneumonia

35. The Pediatric Assessment Triangle4 Month-old infant APPEARANCE Abnormal Tone Interactiveness Consolability Abnl. Look/Gaze Abnl. Speech/Cry BREATHING Abnormal Sounds Abnormal Position Retractions Flaring CIRCULATION Pallor Mottling Cyanosis “Rapid, shallow, with retractions ” “Lethargic, poor tone, does not respond to parent” “Color is pale”

36. The Pediatric Assessment Triangle = STABLE = SHOCK = RESPIRATORY DISTRESS = CNS/METABOLIC = CARDIOPULMONARY FAILURE = RESPIRATORY FAILURE

37. The Pediatric Assessment Triangle • The PAT attempts to formalize the thought processes which occur when an experienced pediatrician assesses a patient.

38. Hello Dr. Broselow (and Luten) • 1998 first Broselow-Luten length based resuscitation tape.

39. Length Based Resuscitation • Initially, multiple studies showed it was useful • Recent studies suggest it underestimates weight due to rising obesity • Nieman CT et al. Acad Emerg. Med. 2006 Oct;13(10) • DuBois D et al. Pediatr Emerg Care. 2007 Apr; 23(4) • Ped Emerg Care 2007 Dec; 23(12) • Emerg Med J. 2009 Jan;26(1):43-7…did a GOOD job

40. Length Based Resuscitation • Bottom line… • It is better than formulas • Keeps you from doing math while a patient is coding • Decreases errors • Decreases time to medications

41. Length-based resuscitation • AAP Policy Statement : Patient Safety in the Pediatric Emergency Care Setting • 8. Encourage the use of clinical tools to aid in medication dosing and administration • a. Educate ED staff on the correct use of length-based tape Pediatrics Volume 120 (6) Dec 2007 PEPP, APLS, PALS, ACEP……….

42. What is NEXT? • Pediatric Technical Advisory Committee (TAC) Charter • Mission: Advise and make recommendations to the Governor’s Steering Committee on pre-hospital and hospital pediatric issues in the statewide emergency medical services and trauma care system.

43. Pediatric TAC Charter • Purpose: Support the EMS and trauma care system as outlined in the State Strategic Plan by acting as a source of pediatric professional and technical information to the Steering Committee and other TACs.

44. Pediatric TAC Charter • Membership: (Includes but not limited to the following) Physician with pediatric training Emergency physician Nurse with emergency pediatric experience Emergency medical technician

45. Current ACTIVE Members Harborview Medical Center Mary Bridge Children’s Hospital Sacred Heart Children’s Hospital Seattle Children’s Airlift Northwest

46. Pediatric Guidelines of Care: • Evidenced based guidelines (with references) • Outline current standards of care • Presented in a user friendly format • Periodically updated by pediatric TAC Intended to be used as a reference or tool to aid you in the formation of county specific protocols

47. Pediatric Guidelines • Important Features: • Stream-lined, easy to follow • Standard format with distinctive decision points and interventions • Generic medication names • Include pediatric pearls, things to think about • References

48. Why develop guidelines? • 1999 Institute of Medicine Report: To err is human: building a safer health care system • 2000 Society for Academic Emergency Medicine held a meeting on errors in the ED. • Evidence based guidelines of care developed • reduce errors • improve quality of care • formalize the process of reviewing the evidence and stay current