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Itrsquos Hard to Put a Band-Aid on a Broken Spleen Pediatric
Trauma
Charles Eldridge MD Washington University in St Louis
St Louis Childrenrsquos Hospital Code 3 Conference October 22nd 2015
Disclosures
bull No Financial Disclosures
bull Special thanks to ndash Dr Martin Keller
bull Director of Trauma Division of Pediatric Surgery
Objectives bull Epidemiology of pediatric trauma bull Pediatric anatomic differences bull Challenges in prehospital care bull Initial evaluation and management
Pediatric Prehospital Care
bull gt110 millions ED visitsyear ndash ~frac14 ED visits are pediatric patients ndash ~10 of EMS transports are pediatric ndash EMS arrivals have higher admission rate
bull Trauma comprises ~13 of all PED visits
Mechanism
bull Falls- most common bull Low mortality
Traumatic Pain Management
bull Pain ndash Under-assessed ndash Undertreated
Pediatric Trauma bull Leading cause of death and disability bull Trauma gt 11000 pediatric deathsyear bull Trauma causes more pediatric death than
all other causes combined Causes of
death Ages 1-14 years
Deaths by Mechanism of Injury
NTDB Pediatric report 2007
Pediatric Trauma bull Kids ne Adults bull Smaller body mass
ndash Crowded trauma bed ndash Less muscle and fat for protection ndash Bones are less calcified and more pliable
bull Underlying injuries occur without fractures ndash Greater force per region
bull More systems often affected bull Waddel and Druckerrsquos Triad
ndash Lower extremity ndash Abdomenchest ndash Head
Pediatric Trauma
bull Larger heads alter airway alignment bull Weaker necks increase c-spine injury risk
wwwebmedicinenet
Airway Differences
bull Smaller airway ndash Smaller oral opening ndash Larger tongue in proportion
bull Larynx ndash More cephalad and anterior ndash More acute angle to access the cords
bull Limited functional residual capacity bull Faster to desaturation
Pediatric-Adult Differences
bull Greater BSA more prone to hypothermia bull Higher risk with radiation exposure bull Weight-based interventions bull Greater success with conservative care
Pediatric Challenges
bull Parents bull Non-accidental trauma bull Neglect bull Medically complex kids bull Pediatric patient exposure bull Pediatric intervention experience
Prehospital Pediatric Challenges
bull Less pediatric exposure ndash Experience
bull Critical procedures ~1 of transports bull CPR BMV or advanced airway in 04 of patients bull ALS specific transports BMV 5 ETI 3
bull Less success in pediatric patients ndash IV access success- 86 adult vs 66 kids ndash Intubating problems- 69 peds vs 21 adults
Pediatric and Adult Trauma
bull Trimodal death distribution ndash 1st peak- seconds to minutes after
bull Impacted by prevention ndash 2nd peak- minutes to hours after
bull ldquoGolden Hourrdquo bull Rapid assessment and treatment
ndash 3rd peak- days to weeks bull Quality pediatric care limits morbidity and mortality bull Infection and multi-organ failure
Scene Response
bull 8 year old male in a rollover atv accident
bull Pt is unresponsive localizes pain wonrsquot open his eyes
bull HR 130 BP 10060 bull RR 10 O2 sat 93 bull What do you want to do
Prehospital Intervention
bull Pre-hospital interventions did not significantly worsen care ndash Similar transport times ndash Similar mortality length of stay
bull ETI vs BMV ndash No difference in survival ndash No difference in neurological outcome
Where do you take the patient
bull Pediatric trauma centers ndash Less surgery on solid organ injuries ndash Less radiation- of scans and dosage ndash Less comorbidities
bull Lower costs bull Shorter length of stay bull Lower infections bull Less multi-organ failure
Patient arrives at the EDhellip
bull Where do you start ndash Primary Survey
Primary Survey bull Your ABCrsquoshellip
bull Airway bull Breathing bull Circulation bull Disability (Neuro- GCS) bull Exposure
Order is critical
bull A before B or C bull Morbiditymortality will
occur much faster from airway compromise than from breathing or circulatory problems
bull Systematic approach is the cornerstone of ATLS success
httpwwwuptodatecomcontentsimageimageKey=EM2F64241amptopicKey=EM2F6571amprank=17E150ampsource=see_linkampsearch=traumaamputdPopup=true
httpwwwuptodatecomcontentsimageimageKey=EM2F64241amptopicKey=EM2F6571amprank=17E150ampsource=see_linkampsearch=traumaamputdPopup=true
Airway bull What are you assessing
ndash Airway patency bull What makes the airway not patent
ndash Foreign bodies ndash Vomitbloodsecretions ndash Edemahematoma ndash Impending obstruction
bull Interventions ndash Clearing foreign bodies ndash Suction secretionsvomit with yankauer ndash Repositioning- jaw thrust ndash Nasal trumpetoral airway ndash Intubation ndash Cricothyrotomy jet ventilation
Indications for Intubation
bull Respiratory arrest bull Impending respiratory failure bull Impending airway obstruction bull Inability to protect the airway bull GCS lt8 bull Declining GCS
Breathing bull What are you assessing
ndash ldquoGoodrdquo symmetric chest rise ndash Lung sounds ndash Aeration ndash Basic RR assessment (fast or minimalnone)
bull Interventions ndash Oxygen ndash Albuterolatrovent racemic epi ndash Positive pressure (CPAP BIPAP BMV) ndash Needle decompression ndash Chest tube thoracostomy ndash Intubation ndash Jet ventilation
ETT Intubation Basics bull Size
ndash Age4 + 4 or (Age +16)4 bull Depth
ndash ~ 3 x ETT size when over 1 year of age bull Blade size mac vs miller
ndash 0~ newborn ndash 1~ up to 2 years of life ndash 2~ 2-10 years ndash 3~ 10+ years
bull RSI medications ndash +-Sedation (Always before paralytic) ndash +-Paralytic (May not need it and never wo sedation)
Circulation
bull What do you assess ndash Central and peripheral pulses ndash Heart rate ndash Blood pressure systolic (age x2) +70 ndash Capillary refill ndash Cardiac activity on FAST ndash End organ perfusion
bull Mental status bull Urine output
Circulation Hemodynamic Changes
Percent Blood Volume Loss 0 15 25 35 45
Heart Rate
Blood Pressure
Cardiac Output
Circulation
ndash Access 2 large bore IVrsquos ndash IVFrsquos ndash pRBCrsquos
bull Hgb lt7gdl or ongoing blood losses
ndash Massive Transfusion Protocol
bull (111 ratio of PRBCS FFP Platelets)
ndash Vasopressors (epi norepi dopamine)
ndash Control of Hemorrhage bull Pelvic binders bull Direct pressure bull Indirectproximal pressure bull Tourniquet (only when
absolutely necessary)
ndash Chest Compressions ndash Pericardiocentesis ndash Delayed resuscitation
controlled hypotension (MAP 50 vs 65)
ndash Tranexamic acid in the near future
bull Interventions
Fluid Resuscitation Algorithm 20 mLkg isotonic crystalloid
Reassess
20 mLkg isotonic crystalloid
Reassess
20 mLkg isotonic crystalloid (31 rule)
or consider 10 to 20 mLkg packed red cells
Reconsidering Crystalloid Resuscitation
bull Less fluid ndash Permissive hypotension to
prevent clot rupture (select cases)
bull Too much fluid ndash Excessive Third Spacing ndash Secondary Compartment
Syndrome ndash Greater risk of ARDS ndash Dilutional Coagulopathy
When to start MTP
bull As soon as you believe you will need it ndash Institution specific guidelines
bull gt4 units or 40mlkg of PRBCrsquos expected bull Earlier use of Massive Transfusion Protocol
(pRBC FFP PLT) in ldquoDamage Controlrdquo resuscitations may improve outcome
bull 111 unit ratio bull Risk of TRALI ARDS etc
Disability bull GCS
ndash Range 3-15 ndash We should be 15 ndash Dead are still 3 ndash Less than 8 intubate ndash Eyes- 4 eyes ndash Verbal- most difficult ndash Motor- V6 engine ndash Intubated T
bull AVPU
Finishing Up the Evaluation
bull Airway bull Breathing bull Circulation bull Disability bull Exposure
ndash Expose and examine all parts ndash Cover quickly and keep warm
bull Secondary Survey
Bad Scene Responses
bull What are the outcomes of out-of-hospital cardiac arrest from blunt trauma
bull What are the outcomes of pediatric drowning patients
OHCA from Trauma
bull 2000-2003 bull 123 pts bull Mean age 73 yrs bull Most common
rhythms ndash Asystole 59 ndash PEA 29 ndash V-fib 35
bull 195 rosc in field ndash 98 survived for 24
hrs ndash 57 survived to
discharge ndash Drowning- 19
survival to discharge ndash Bystander CPR tripled
the survivor rate
Blunt Trauma- No Signs of Life
bull Review from 2002-2010 bull No signs of life- 025 of blunt trauma
ndash 25 resuscitated prior to hospital arrival bull 138 of these patients survived to discharge
bull 44 overall survived to hospital discharge
OHCA with CPR on Arrival
bull 169 children bull 141 deaths bull 69 required cpr on arrival- none survived bull 87 of patients requiring CPR on arrival
expired in the ED bull Of the 28 survivors
ndash 55 of survivors had full neurologic recovery
Pediatric Trauma
bull Fortunately these cases represent only a small fraction of EMS transports
bull Despite a few key differences pediatric trauma care overall is very similar to adult trauma care
Questions
References 1 bull NTDB 2013 pediatric Report bull Monkey bars httpsplaygroundchroniclesfileswordpresscom201307soccerjpg bull Screaming child httpblogsbabycentercomwp-contentuploads201409screaming-child-tantrum-fitjpg bull Pediatric airway image httpwwwcelebritydiagnosiscomwp-contentuploads201003pediatric-airwayjpg bull Child on backboard httpsencrypted-tbn2gstaticcomimagesq=tbnANd9GcQscrDVc8IH4MwkNGF6F1A9p7mSVzik5zrWyNvI-
qSwQT5S3GNyVg bull Elbow fracture httpwwwimageinterpretationcoukimageselbowSUPRACONDYLAR20LAT3jpg bull Bike riding httpsmile-per-daycomwp-contentuploads201412klr03jpg bull Dad and child pic httplaughingsquidcomwp-contentuploads471160jpg bull Weigth estimation inner city Am J Emerg Med 2015 Oct33(10)1364-7 doi 101016jajem201507040 Epub 2015 Jul 29 Weight
estimation in an inner-city pediatric ED the effect of obesity Chavez H1 Peterson RE2 Lo K3 Arel M4
bull Guess weight sign httpmedialiveauctiongroupneti963110572971_1jpgv=8CDDAAF8A5B9E20 bull Broselow tape httpsuploadwikimediaorgwikipediacommons994BTape1jpg bull Parent screaming httpmommyofamonstercomwp-contentuploads201301yellingjpg bull Prehospital pain management Am J Emerg Med 2015 Mar33(3)451-4 doi 101016jajem201412012 Epub 2014 Dec 18
Prehospital pain management of injured children a systematic review of current evidence Samuel N1 Steiner IP2 Shavit I3 bull Prehospital pain ped pain assessment Prehosp Emerg Care 2008 Apr-Jun12(2)182-6 doi 10108010903120801907471 Prehospital
pain assessment in pediatric trauma Izsak E1 Moore JL Stringfellow K Oswanski MF Lindstrom DA Stombaugh HA bull Ped pain management Prehosp Emerg Care 2005 Jan-Mar9(1)40-3 Prehospital pain management in children suffering traumatic
injury Swor R1 McEachin CM Seguin D Grall KH bull Prehospital intervention Allen CJ Teisch LF et al Prehospital care and transportation of pediatric trauma patients J Surg Res 2015
Aug197(2)240-6 JAMA 2000 Feb 9283(6)783-90 bull Effect of out-of-hospital pediatric endotracheal intubation on survival and neurological outcome a controlled clinical trial
Gausche M1 Lewis RJ Stratton SJ Haynes BE Gunter CS Goodrich SM Poore PD McCollough MD Henderson DP Pratt FD Seidel JS
bull Pediatric pain management survey Pediatr Emerg Care 2015 Sep 23 [Epub ahead of print] An Assessment of Newly Identified Barriers to and Enablers for Prehospital Pediatric Pain Management Whitley DE1 Li T Jones CM Cushman JT Williams DM Shah MN
References 2 bull httpwwwuptodatecomcontentsprehospital-pediatrics-and-emergency-medical-services-emsabstract6 bull httpwwwuptodatecomcontentsprehospital-pediatrics-and-emergency-medical-services-emsabstract7 bull Pediatr Crit Care Med 2011 Jul12(4)e166-70 doi 101097PCC0b013e3181f36f6e First responder
performance in pediatric trauma a comparison with an adult cohortBankole S1 Asuncion A Ross S Aghai Z Nollah L Echols H Da-Silva S
bull Drayna pc Browne LR et al Prehospital pediatric care Oppportunities for training treatment and research Prehosp Emerg Care 2015 Jul-Sep 19(3) Epub 2015 Feb 6
bull Pediatr Emerg Care 2001 Feb17(1) 5-9Pediatric pre-hospital advanced life support care in an urban setting Babl FE1 Vinci RJ Bauchner H Mottley L
bull Pediatr Crit Care Med 2015 Oct16(8)e260-7 doi 101097PCC0000000000000505Pediatric Out-of-Hospital Critical Procedures in the United States Carlson JN1 Gannon E Mann NC Jacobson KE Dai M Colleran C Wang HE
bull Pediatr Emerg Care 2009 Aug25(8)508-12 doi 101097PEC0b013e3181b0a0da The efficacy of pediatric advanced life support training in emergency medical service providers Baker TW1 King W Soto W Asher C Stolfi A Rowin ME
bull Sutton RM Case E et al ROC investigators A quantitative analysis of out-of-hospital pediatric and adolescent resuscitation quality A report from the ROC Epistry- Cardiac Arrest Resusciation 201593150-157
bull Resuscitation 2014 Aug85(8)1059-64 doi 101016jresuscitation201403307 Epub 2014 Apr 4 Neurocognitive long term follow-up study on drowned children Suominen PK1 Sutinen N2 Valle S3 Olkkola KT4 Loumlnnqvist T3
bull J Pediatr Surg 2010 Jul45(7)1413-9 doi 101016jjpedsurg200912020 Prehospital cardiopulmonary resuscitation in the pediatric trauma patient Murphy JT1 Jaiswal K Sabella J Vinson L Megison S Maxson RT
References 3 bull Pre atv accident
httpwwwctvnewscapolopoly_fs119871591409741949httpImageimagejpg_genderivativeslandscape_960imagejpg bull atv pic httpswwwutahadvocatescomwp-contentuploads201402atvAccidentLawyerjpg bull Blunt abdominal solid organ injury adult vs pediatric trauma center J Pediatr Surg 2015 Aug 28 pii S0022-3468(15)00526-6 doi
101016jjpedsurg201508012 [Epub ahead of print] Trauma center variation in the management of pediatric patients with blunt abdominal solid organ injury a national trauma data bank analysis Safavi A1 Skarsgard ED2 Rhee P1 Zangbar B1 Kulvatunyou N1 Tang A1 OKeeffe T1 Friese RS1 Joseph B3
bull Pediatric blunt abdominal injury Curr Opin Crit Care 2015 Sep 28 [Epub ahead of print] Pediatric blunt abdominal trauma current management Notrica DM1
bull Pediatric splenic injury management Am J Surg 2015 Jul 31 pii S0002-9610(15)00417-1 doi 101016jamjsurg201506009 [Epub ahead of print] Comparative effectiveness of treatment strategies for severe splenic trauma in the pediatric population Rialon KL1 Englum BR1 Gulack BC1 Guevara CJ2 Bhattacharya SD3 Shapiro ML4 Rice HE5 Scarborough JE4 Adibe OO6
bull Liver pic httpss-media-cache-ak0pinimgcom736x7da50e7da50eb2bb603c99ef6649ff897e26b5jpg bull Solid organ injury non op in peds J Trauma Acute Care Surg 2015 Oct79(4)683-93 doi 101097TA0000000000000808
Nonoperative management of blunt liver and spleen injury in children Evaluation of the ATOMAC guideline using GRADE Notrica DM1 Eubanks JW 3rd Tuggle DW Maxson RT Letton RW Garcia NM Alder AC Lawson KA St Peter SD Megison S Garcia Filion P
bull Pediaric vs nonped trauma ct use J Pediatr 2015 Oct167(4)897-904e3 doi 101016jjpeds201506052 Epub 2015 Jul 29 Variation in Computed Tomography Imaging for Pediatric Injury-Related Emergency Visits Marin JR1 Wang L2 Winger DG2 Mannix RC3
bull Solid organ management in ped population J Trauma Acute Care Surg 2015 Aug79(2)206-14quiz 332 doi 101097TA0000000000000731 Management of children with solid organ injuries after blunt torso trauma Wisner DH1 Kuppermann N Cooper A Menaker J Ehrlich P Kooistra J Mahajan P Lee L Cook LJ Yen K Lillis K Holmes JF
bull Triad of death image httpimageslidesharecdncomdamage-control-resuscitation-1304253390-phpapp0195damage-control-resuscitation-14-728jpgcb=1304235553
bull Tranexamic acid study Eckert MJ Wertin TM Tyner SD et al 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 77852
bull Image care accident httpsuploadwikimediaorgwikipediacommonsthumbee1Car_crash_1jpg1280px-Car_crash_1jpg
References 4 bull httpwwwsurgeryvcuedudivisionsacutesurghtml bull Trauma management Approach to the unstable child
httpwwwuptodatecomcontentstrauma-management-approach-to-the-unstable-childsource=search_resultampsearch=pediatric+trauma+childrenampselectedTitle=17E150
bull Trauma management Unique pediatric considerations httpwwwuptodatecomcontentstrauma-management-unique-pediatric-considerationssource=search_resultampsearch=pediatric+trauma+childrenampselectedTitle=37E150
References 5 bull httpwwwetiquettehellcomsmfindexphptopic=8666360 bull httpwwwstlouischildrensorghealth-care-professionalsems-providers bull httpwwwuchicagokidshospitalorgspecialtiesemergency-medicinespecialhtml bull httpwwwsimsacademyinfoFXpatienthtm bull httptheemtspotcomwp-contentuploads200902another-burn-patient-by-annette-larsonjpg bull httplastangryfancomwp-contentuploads200910Clint-Malarchukjpg bull httpwwwtraumaorgarchiveresusmassivehtml bull httpwwwuptodatecomcontentsimageimageKey=PEDS68694amptopicKey=EM2F6389ampsourc
e=previewampsearch=pediatric+hemorrhagic+shockampselectedTitle=17E150amprank=undefined bull httptheemtspotcomwp-contentuploads200902gcsgif bull httpwwwuptodatecomcontentsimageimageKey=EM2F60409amptopicKey=EM2F6571amprank
=17E150ampsource=see_linkampsearch=traumaamputdPopup=true bull httpwwwuptodatecomcontentsimageimageKey=EM2F80874amptopicKey=EM2F6571amprank
=17E150ampsource=see_linkampsearch=traumaamputdPopup=true bull httpempracticenewswordpresscomcategorynexus-criteria bull httpswwwgooglecomsearchq=pediatric+glasgow+coma+scaleamptbm=ischamptbo=uampsource=uni
vampsa=Xampei=8TiOU7TNC5WuyATp5YG4BQampsqi=2ampved=0CDYQsAQampbiw=1426ampbih=883q=canadian+c-spine+rulesamptbm=ischampfacrc=_ampimgdii=_ampimgrc=WI94QMHgMLTQmM253A3BP5nbsFhNCXK0FM3Bhttp253A252F252Fwwwbmjcom252Fhighwire252Ffilestream252F436003252Ffield_highwire_fragment_image_l252F0jpg3Bhttp253A252F252Fwwwbmjcom252Fcontent252F339252Fbmjb41463B12803B1253
References 5 bull httpwwwuptodatecomcontentsimageimageKey=EM2F76777amptopicKey=EM2F6571amprank
=17E150ampsource=see_linkampsearch=traumaamputdPopup=true bull httpwwwdocumentingrealitycomforumattachmentsf14964898d1246625322-firework-injury-
m80injury1jpg bull httpwwwpediatriceducationorg20050620 bull httpwwwarmstrongmedicalcomindexcfmgoproductdetailsec3ssec19cat61fam515 bull httpwwwuptodatecomcontentsimageimageKey=PEDS61087amptopicKey=ID2F7661ampsource
=outline_linkampsearch=tetanus+prophylaxisamputdPopup=true bull httpwwwafsecafmilsharedmediaphotodbweb110609-F-MJ378-009jpg bull httpwwwuptodatecomcontentsimageimageKey=EM75765amptopicKey= bull EM2F6389ampsource=outline_linkampsearch=massive+transfusion+protocolamputdPopup=true bull httpwwwmotifakecomimagedemotivational-postersmall0910whats-the-question-ignorance-
calvin-and-hobbes-demotivational-poster-1255020127jpg
XXXXBoston study ems peds trauma procedures- limited pediatric procedural exposure (but more adult experience) bull Catchment area 590000
over 1 year bull 555 pediatric ALS
transport ndash 19 blunt trauma ndash 10 penetrating trauma
bull IV 33 bull BMV 5 bull Intubation 3 bull 50 ALS providers average
year ndash IV- 37 ndash Intubation- 03 ndash IO- 006
bull 7 ped ems ndash 13 trauma
bull Critical procedures ndash 101000 peds cases ndash Intubation 671000 ndash IO 51000 ndash 81 successful
Pediatr Emerg Care 2001 Feb17(1)5-9 Pediatric pre-hospital advanced life support care in an urban setting
Babl FE1 Vinci RJ Bauchner H Mottley L
Pediatr Crit Care Med 2015 Oct16(8)e260-7 doi 101097PCC0000000000000505 Pediatric Out-of-Hospital Critical Procedures in the United States
Carlson JN1 Gannon E Mann NC Jacobson KE Dai M Colleran C Wang HE
C-spine bull C-spine injuries rare bull Take pt to closest hospital if over injuries
call for it (ie resuscitation altered mental status) primary guide
bull Mechanism ndash Altered mental status focal neuro change
torticollis substantial torso injury diving high speed auto neck pain underlying predisposing condition Acad Emerg Med 2014 Jan21(1)55-64 doi 101111acem12288
Comparison of outcomes for children with cervical spine injury based on destination hospital from scene of injury Anders JF1 Adelgais K Hoyle JD Jr Olsen C Jaffe DM Leonard JC Pediatric Emergency Care Applied Research Network
(PECARN)
Ann Emerg Med 2011 Aug58(2)145-55 doi 101016jannemergmed201008038 Epub 2010 Oct 29 Factors associated with cervical spine injury in children after blunt trauma
Leonard JC Kuppermann N Olsen C Babcock-Cimpello L Brown K Mahajan P Adelgais KM Anders J Borgialli D Donoghue A Hoyle JD Jr Kim E Leonard JR Lillis KA Nigrovic LE Powell EC Rebella
G Reeves SD Rogers AJ Stankovic C Teshome G Jaffe DM Pediatric Emergency Care Applied Research Network
- Itrsquos Hard to Put a Band-Aid on a Broken Spleen Pediatric Trauma
- Disclosures
- Objectives
- Pediatric Prehospital Care
- Mechanism
- Traumatic Pain Management
- Pediatric Trauma
- Deaths by Mechanism of Injury
- Pediatric Trauma
- Pediatric Trauma
- Airway Differences
- Pediatric-Adult Differences
- Pediatric Challenges
- Prehospital Pediatric Challenges
- Pediatric and Adult Trauma
- Scene Response
- Prehospital Intervention
- Where do you take the patient
- Patient arrives at the EDhellip
- Primary Survey
- Order is critical
- Slide Number 22
- Slide Number 23
- Airway
- Indications for Intubation
- Breathing
- ETT Intubation Basics
- Circulation
- Slide Number 29
- CirculationHemodynamic Changes
- Circulation
- Fluid Resuscitation Algorithm
- Reconsidering Crystalloid Resuscitation
- When to start MTP
- Disability
- Finishing Up the Evaluation
- Bad Scene Responses
- OHCA from Trauma
- Blunt Trauma- No Signs of Life
- OHCA with CPR on Arrival
- Pediatric Trauma
- Questions
- References 1
- References 2
- References 3
- References 4
- References 5
- References 5
- XXXXBoston study ems peds trauma procedures- limited pediatric procedural exposure (but more adult experience)
- C-spine
Disclosures
bull No Financial Disclosures
bull Special thanks to ndash Dr Martin Keller
bull Director of Trauma Division of Pediatric Surgery
Objectives bull Epidemiology of pediatric trauma bull Pediatric anatomic differences bull Challenges in prehospital care bull Initial evaluation and management
Pediatric Prehospital Care
bull gt110 millions ED visitsyear ndash ~frac14 ED visits are pediatric patients ndash ~10 of EMS transports are pediatric ndash EMS arrivals have higher admission rate
bull Trauma comprises ~13 of all PED visits
Mechanism
bull Falls- most common bull Low mortality
Traumatic Pain Management
bull Pain ndash Under-assessed ndash Undertreated
Pediatric Trauma bull Leading cause of death and disability bull Trauma gt 11000 pediatric deathsyear bull Trauma causes more pediatric death than
all other causes combined Causes of
death Ages 1-14 years
Deaths by Mechanism of Injury
NTDB Pediatric report 2007
Pediatric Trauma bull Kids ne Adults bull Smaller body mass
ndash Crowded trauma bed ndash Less muscle and fat for protection ndash Bones are less calcified and more pliable
bull Underlying injuries occur without fractures ndash Greater force per region
bull More systems often affected bull Waddel and Druckerrsquos Triad
ndash Lower extremity ndash Abdomenchest ndash Head
Pediatric Trauma
bull Larger heads alter airway alignment bull Weaker necks increase c-spine injury risk
wwwebmedicinenet
Airway Differences
bull Smaller airway ndash Smaller oral opening ndash Larger tongue in proportion
bull Larynx ndash More cephalad and anterior ndash More acute angle to access the cords
bull Limited functional residual capacity bull Faster to desaturation
Pediatric-Adult Differences
bull Greater BSA more prone to hypothermia bull Higher risk with radiation exposure bull Weight-based interventions bull Greater success with conservative care
Pediatric Challenges
bull Parents bull Non-accidental trauma bull Neglect bull Medically complex kids bull Pediatric patient exposure bull Pediatric intervention experience
Prehospital Pediatric Challenges
bull Less pediatric exposure ndash Experience
bull Critical procedures ~1 of transports bull CPR BMV or advanced airway in 04 of patients bull ALS specific transports BMV 5 ETI 3
bull Less success in pediatric patients ndash IV access success- 86 adult vs 66 kids ndash Intubating problems- 69 peds vs 21 adults
Pediatric and Adult Trauma
bull Trimodal death distribution ndash 1st peak- seconds to minutes after
bull Impacted by prevention ndash 2nd peak- minutes to hours after
bull ldquoGolden Hourrdquo bull Rapid assessment and treatment
ndash 3rd peak- days to weeks bull Quality pediatric care limits morbidity and mortality bull Infection and multi-organ failure
Scene Response
bull 8 year old male in a rollover atv accident
bull Pt is unresponsive localizes pain wonrsquot open his eyes
bull HR 130 BP 10060 bull RR 10 O2 sat 93 bull What do you want to do
Prehospital Intervention
bull Pre-hospital interventions did not significantly worsen care ndash Similar transport times ndash Similar mortality length of stay
bull ETI vs BMV ndash No difference in survival ndash No difference in neurological outcome
Where do you take the patient
bull Pediatric trauma centers ndash Less surgery on solid organ injuries ndash Less radiation- of scans and dosage ndash Less comorbidities
bull Lower costs bull Shorter length of stay bull Lower infections bull Less multi-organ failure
Patient arrives at the EDhellip
bull Where do you start ndash Primary Survey
Primary Survey bull Your ABCrsquoshellip
bull Airway bull Breathing bull Circulation bull Disability (Neuro- GCS) bull Exposure
Order is critical
bull A before B or C bull Morbiditymortality will
occur much faster from airway compromise than from breathing or circulatory problems
bull Systematic approach is the cornerstone of ATLS success
httpwwwuptodatecomcontentsimageimageKey=EM2F64241amptopicKey=EM2F6571amprank=17E150ampsource=see_linkampsearch=traumaamputdPopup=true
httpwwwuptodatecomcontentsimageimageKey=EM2F64241amptopicKey=EM2F6571amprank=17E150ampsource=see_linkampsearch=traumaamputdPopup=true
Airway bull What are you assessing
ndash Airway patency bull What makes the airway not patent
ndash Foreign bodies ndash Vomitbloodsecretions ndash Edemahematoma ndash Impending obstruction
bull Interventions ndash Clearing foreign bodies ndash Suction secretionsvomit with yankauer ndash Repositioning- jaw thrust ndash Nasal trumpetoral airway ndash Intubation ndash Cricothyrotomy jet ventilation
Indications for Intubation
bull Respiratory arrest bull Impending respiratory failure bull Impending airway obstruction bull Inability to protect the airway bull GCS lt8 bull Declining GCS
Breathing bull What are you assessing
ndash ldquoGoodrdquo symmetric chest rise ndash Lung sounds ndash Aeration ndash Basic RR assessment (fast or minimalnone)
bull Interventions ndash Oxygen ndash Albuterolatrovent racemic epi ndash Positive pressure (CPAP BIPAP BMV) ndash Needle decompression ndash Chest tube thoracostomy ndash Intubation ndash Jet ventilation
ETT Intubation Basics bull Size
ndash Age4 + 4 or (Age +16)4 bull Depth
ndash ~ 3 x ETT size when over 1 year of age bull Blade size mac vs miller
ndash 0~ newborn ndash 1~ up to 2 years of life ndash 2~ 2-10 years ndash 3~ 10+ years
bull RSI medications ndash +-Sedation (Always before paralytic) ndash +-Paralytic (May not need it and never wo sedation)
Circulation
bull What do you assess ndash Central and peripheral pulses ndash Heart rate ndash Blood pressure systolic (age x2) +70 ndash Capillary refill ndash Cardiac activity on FAST ndash End organ perfusion
bull Mental status bull Urine output
Circulation Hemodynamic Changes
Percent Blood Volume Loss 0 15 25 35 45
Heart Rate
Blood Pressure
Cardiac Output
Circulation
ndash Access 2 large bore IVrsquos ndash IVFrsquos ndash pRBCrsquos
bull Hgb lt7gdl or ongoing blood losses
ndash Massive Transfusion Protocol
bull (111 ratio of PRBCS FFP Platelets)
ndash Vasopressors (epi norepi dopamine)
ndash Control of Hemorrhage bull Pelvic binders bull Direct pressure bull Indirectproximal pressure bull Tourniquet (only when
absolutely necessary)
ndash Chest Compressions ndash Pericardiocentesis ndash Delayed resuscitation
controlled hypotension (MAP 50 vs 65)
ndash Tranexamic acid in the near future
bull Interventions
Fluid Resuscitation Algorithm 20 mLkg isotonic crystalloid
Reassess
20 mLkg isotonic crystalloid
Reassess
20 mLkg isotonic crystalloid (31 rule)
or consider 10 to 20 mLkg packed red cells
Reconsidering Crystalloid Resuscitation
bull Less fluid ndash Permissive hypotension to
prevent clot rupture (select cases)
bull Too much fluid ndash Excessive Third Spacing ndash Secondary Compartment
Syndrome ndash Greater risk of ARDS ndash Dilutional Coagulopathy
When to start MTP
bull As soon as you believe you will need it ndash Institution specific guidelines
bull gt4 units or 40mlkg of PRBCrsquos expected bull Earlier use of Massive Transfusion Protocol
(pRBC FFP PLT) in ldquoDamage Controlrdquo resuscitations may improve outcome
bull 111 unit ratio bull Risk of TRALI ARDS etc
Disability bull GCS
ndash Range 3-15 ndash We should be 15 ndash Dead are still 3 ndash Less than 8 intubate ndash Eyes- 4 eyes ndash Verbal- most difficult ndash Motor- V6 engine ndash Intubated T
bull AVPU
Finishing Up the Evaluation
bull Airway bull Breathing bull Circulation bull Disability bull Exposure
ndash Expose and examine all parts ndash Cover quickly and keep warm
bull Secondary Survey
Bad Scene Responses
bull What are the outcomes of out-of-hospital cardiac arrest from blunt trauma
bull What are the outcomes of pediatric drowning patients
OHCA from Trauma
bull 2000-2003 bull 123 pts bull Mean age 73 yrs bull Most common
rhythms ndash Asystole 59 ndash PEA 29 ndash V-fib 35
bull 195 rosc in field ndash 98 survived for 24
hrs ndash 57 survived to
discharge ndash Drowning- 19
survival to discharge ndash Bystander CPR tripled
the survivor rate
Blunt Trauma- No Signs of Life
bull Review from 2002-2010 bull No signs of life- 025 of blunt trauma
ndash 25 resuscitated prior to hospital arrival bull 138 of these patients survived to discharge
bull 44 overall survived to hospital discharge
OHCA with CPR on Arrival
bull 169 children bull 141 deaths bull 69 required cpr on arrival- none survived bull 87 of patients requiring CPR on arrival
expired in the ED bull Of the 28 survivors
ndash 55 of survivors had full neurologic recovery
Pediatric Trauma
bull Fortunately these cases represent only a small fraction of EMS transports
bull Despite a few key differences pediatric trauma care overall is very similar to adult trauma care
Questions
References 1 bull NTDB 2013 pediatric Report bull Monkey bars httpsplaygroundchroniclesfileswordpresscom201307soccerjpg bull Screaming child httpblogsbabycentercomwp-contentuploads201409screaming-child-tantrum-fitjpg bull Pediatric airway image httpwwwcelebritydiagnosiscomwp-contentuploads201003pediatric-airwayjpg bull Child on backboard httpsencrypted-tbn2gstaticcomimagesq=tbnANd9GcQscrDVc8IH4MwkNGF6F1A9p7mSVzik5zrWyNvI-
qSwQT5S3GNyVg bull Elbow fracture httpwwwimageinterpretationcoukimageselbowSUPRACONDYLAR20LAT3jpg bull Bike riding httpsmile-per-daycomwp-contentuploads201412klr03jpg bull Dad and child pic httplaughingsquidcomwp-contentuploads471160jpg bull Weigth estimation inner city Am J Emerg Med 2015 Oct33(10)1364-7 doi 101016jajem201507040 Epub 2015 Jul 29 Weight
estimation in an inner-city pediatric ED the effect of obesity Chavez H1 Peterson RE2 Lo K3 Arel M4
bull Guess weight sign httpmedialiveauctiongroupneti963110572971_1jpgv=8CDDAAF8A5B9E20 bull Broselow tape httpsuploadwikimediaorgwikipediacommons994BTape1jpg bull Parent screaming httpmommyofamonstercomwp-contentuploads201301yellingjpg bull Prehospital pain management Am J Emerg Med 2015 Mar33(3)451-4 doi 101016jajem201412012 Epub 2014 Dec 18
Prehospital pain management of injured children a systematic review of current evidence Samuel N1 Steiner IP2 Shavit I3 bull Prehospital pain ped pain assessment Prehosp Emerg Care 2008 Apr-Jun12(2)182-6 doi 10108010903120801907471 Prehospital
pain assessment in pediatric trauma Izsak E1 Moore JL Stringfellow K Oswanski MF Lindstrom DA Stombaugh HA bull Ped pain management Prehosp Emerg Care 2005 Jan-Mar9(1)40-3 Prehospital pain management in children suffering traumatic
injury Swor R1 McEachin CM Seguin D Grall KH bull Prehospital intervention Allen CJ Teisch LF et al Prehospital care and transportation of pediatric trauma patients J Surg Res 2015
Aug197(2)240-6 JAMA 2000 Feb 9283(6)783-90 bull Effect of out-of-hospital pediatric endotracheal intubation on survival and neurological outcome a controlled clinical trial
Gausche M1 Lewis RJ Stratton SJ Haynes BE Gunter CS Goodrich SM Poore PD McCollough MD Henderson DP Pratt FD Seidel JS
bull Pediatric pain management survey Pediatr Emerg Care 2015 Sep 23 [Epub ahead of print] An Assessment of Newly Identified Barriers to and Enablers for Prehospital Pediatric Pain Management Whitley DE1 Li T Jones CM Cushman JT Williams DM Shah MN
References 2 bull httpwwwuptodatecomcontentsprehospital-pediatrics-and-emergency-medical-services-emsabstract6 bull httpwwwuptodatecomcontentsprehospital-pediatrics-and-emergency-medical-services-emsabstract7 bull Pediatr Crit Care Med 2011 Jul12(4)e166-70 doi 101097PCC0b013e3181f36f6e First responder
performance in pediatric trauma a comparison with an adult cohortBankole S1 Asuncion A Ross S Aghai Z Nollah L Echols H Da-Silva S
bull Drayna pc Browne LR et al Prehospital pediatric care Oppportunities for training treatment and research Prehosp Emerg Care 2015 Jul-Sep 19(3) Epub 2015 Feb 6
bull Pediatr Emerg Care 2001 Feb17(1) 5-9Pediatric pre-hospital advanced life support care in an urban setting Babl FE1 Vinci RJ Bauchner H Mottley L
bull Pediatr Crit Care Med 2015 Oct16(8)e260-7 doi 101097PCC0000000000000505Pediatric Out-of-Hospital Critical Procedures in the United States Carlson JN1 Gannon E Mann NC Jacobson KE Dai M Colleran C Wang HE
bull Pediatr Emerg Care 2009 Aug25(8)508-12 doi 101097PEC0b013e3181b0a0da The efficacy of pediatric advanced life support training in emergency medical service providers Baker TW1 King W Soto W Asher C Stolfi A Rowin ME
bull Sutton RM Case E et al ROC investigators A quantitative analysis of out-of-hospital pediatric and adolescent resuscitation quality A report from the ROC Epistry- Cardiac Arrest Resusciation 201593150-157
bull Resuscitation 2014 Aug85(8)1059-64 doi 101016jresuscitation201403307 Epub 2014 Apr 4 Neurocognitive long term follow-up study on drowned children Suominen PK1 Sutinen N2 Valle S3 Olkkola KT4 Loumlnnqvist T3
bull J Pediatr Surg 2010 Jul45(7)1413-9 doi 101016jjpedsurg200912020 Prehospital cardiopulmonary resuscitation in the pediatric trauma patient Murphy JT1 Jaiswal K Sabella J Vinson L Megison S Maxson RT
References 3 bull Pre atv accident
httpwwwctvnewscapolopoly_fs119871591409741949httpImageimagejpg_genderivativeslandscape_960imagejpg bull atv pic httpswwwutahadvocatescomwp-contentuploads201402atvAccidentLawyerjpg bull Blunt abdominal solid organ injury adult vs pediatric trauma center J Pediatr Surg 2015 Aug 28 pii S0022-3468(15)00526-6 doi
101016jjpedsurg201508012 [Epub ahead of print] Trauma center variation in the management of pediatric patients with blunt abdominal solid organ injury a national trauma data bank analysis Safavi A1 Skarsgard ED2 Rhee P1 Zangbar B1 Kulvatunyou N1 Tang A1 OKeeffe T1 Friese RS1 Joseph B3
bull Pediatric blunt abdominal injury Curr Opin Crit Care 2015 Sep 28 [Epub ahead of print] Pediatric blunt abdominal trauma current management Notrica DM1
bull Pediatric splenic injury management Am J Surg 2015 Jul 31 pii S0002-9610(15)00417-1 doi 101016jamjsurg201506009 [Epub ahead of print] Comparative effectiveness of treatment strategies for severe splenic trauma in the pediatric population Rialon KL1 Englum BR1 Gulack BC1 Guevara CJ2 Bhattacharya SD3 Shapiro ML4 Rice HE5 Scarborough JE4 Adibe OO6
bull Liver pic httpss-media-cache-ak0pinimgcom736x7da50e7da50eb2bb603c99ef6649ff897e26b5jpg bull Solid organ injury non op in peds J Trauma Acute Care Surg 2015 Oct79(4)683-93 doi 101097TA0000000000000808
Nonoperative management of blunt liver and spleen injury in children Evaluation of the ATOMAC guideline using GRADE Notrica DM1 Eubanks JW 3rd Tuggle DW Maxson RT Letton RW Garcia NM Alder AC Lawson KA St Peter SD Megison S Garcia Filion P
bull Pediaric vs nonped trauma ct use J Pediatr 2015 Oct167(4)897-904e3 doi 101016jjpeds201506052 Epub 2015 Jul 29 Variation in Computed Tomography Imaging for Pediatric Injury-Related Emergency Visits Marin JR1 Wang L2 Winger DG2 Mannix RC3
bull Solid organ management in ped population J Trauma Acute Care Surg 2015 Aug79(2)206-14quiz 332 doi 101097TA0000000000000731 Management of children with solid organ injuries after blunt torso trauma Wisner DH1 Kuppermann N Cooper A Menaker J Ehrlich P Kooistra J Mahajan P Lee L Cook LJ Yen K Lillis K Holmes JF
bull Triad of death image httpimageslidesharecdncomdamage-control-resuscitation-1304253390-phpapp0195damage-control-resuscitation-14-728jpgcb=1304235553
bull Tranexamic acid study Eckert MJ Wertin TM Tyner SD et al 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 77852
bull Image care accident httpsuploadwikimediaorgwikipediacommonsthumbee1Car_crash_1jpg1280px-Car_crash_1jpg
References 4 bull httpwwwsurgeryvcuedudivisionsacutesurghtml bull Trauma management Approach to the unstable child
httpwwwuptodatecomcontentstrauma-management-approach-to-the-unstable-childsource=search_resultampsearch=pediatric+trauma+childrenampselectedTitle=17E150
bull Trauma management Unique pediatric considerations httpwwwuptodatecomcontentstrauma-management-unique-pediatric-considerationssource=search_resultampsearch=pediatric+trauma+childrenampselectedTitle=37E150
References 5 bull httpwwwetiquettehellcomsmfindexphptopic=8666360 bull httpwwwstlouischildrensorghealth-care-professionalsems-providers bull httpwwwuchicagokidshospitalorgspecialtiesemergency-medicinespecialhtml bull httpwwwsimsacademyinfoFXpatienthtm bull httptheemtspotcomwp-contentuploads200902another-burn-patient-by-annette-larsonjpg bull httplastangryfancomwp-contentuploads200910Clint-Malarchukjpg bull httpwwwtraumaorgarchiveresusmassivehtml bull httpwwwuptodatecomcontentsimageimageKey=PEDS68694amptopicKey=EM2F6389ampsourc
e=previewampsearch=pediatric+hemorrhagic+shockampselectedTitle=17E150amprank=undefined bull httptheemtspotcomwp-contentuploads200902gcsgif bull httpwwwuptodatecomcontentsimageimageKey=EM2F60409amptopicKey=EM2F6571amprank
=17E150ampsource=see_linkampsearch=traumaamputdPopup=true bull httpwwwuptodatecomcontentsimageimageKey=EM2F80874amptopicKey=EM2F6571amprank
=17E150ampsource=see_linkampsearch=traumaamputdPopup=true bull httpempracticenewswordpresscomcategorynexus-criteria bull httpswwwgooglecomsearchq=pediatric+glasgow+coma+scaleamptbm=ischamptbo=uampsource=uni
vampsa=Xampei=8TiOU7TNC5WuyATp5YG4BQampsqi=2ampved=0CDYQsAQampbiw=1426ampbih=883q=canadian+c-spine+rulesamptbm=ischampfacrc=_ampimgdii=_ampimgrc=WI94QMHgMLTQmM253A3BP5nbsFhNCXK0FM3Bhttp253A252F252Fwwwbmjcom252Fhighwire252Ffilestream252F436003252Ffield_highwire_fragment_image_l252F0jpg3Bhttp253A252F252Fwwwbmjcom252Fcontent252F339252Fbmjb41463B12803B1253
References 5 bull httpwwwuptodatecomcontentsimageimageKey=EM2F76777amptopicKey=EM2F6571amprank
=17E150ampsource=see_linkampsearch=traumaamputdPopup=true bull httpwwwdocumentingrealitycomforumattachmentsf14964898d1246625322-firework-injury-
m80injury1jpg bull httpwwwpediatriceducationorg20050620 bull httpwwwarmstrongmedicalcomindexcfmgoproductdetailsec3ssec19cat61fam515 bull httpwwwuptodatecomcontentsimageimageKey=PEDS61087amptopicKey=ID2F7661ampsource
=outline_linkampsearch=tetanus+prophylaxisamputdPopup=true bull httpwwwafsecafmilsharedmediaphotodbweb110609-F-MJ378-009jpg bull httpwwwuptodatecomcontentsimageimageKey=EM75765amptopicKey= bull EM2F6389ampsource=outline_linkampsearch=massive+transfusion+protocolamputdPopup=true bull httpwwwmotifakecomimagedemotivational-postersmall0910whats-the-question-ignorance-
calvin-and-hobbes-demotivational-poster-1255020127jpg
XXXXBoston study ems peds trauma procedures- limited pediatric procedural exposure (but more adult experience) bull Catchment area 590000
over 1 year bull 555 pediatric ALS
transport ndash 19 blunt trauma ndash 10 penetrating trauma
bull IV 33 bull BMV 5 bull Intubation 3 bull 50 ALS providers average
year ndash IV- 37 ndash Intubation- 03 ndash IO- 006
bull 7 ped ems ndash 13 trauma
bull Critical procedures ndash 101000 peds cases ndash Intubation 671000 ndash IO 51000 ndash 81 successful
Pediatr Emerg Care 2001 Feb17(1)5-9 Pediatric pre-hospital advanced life support care in an urban setting
Babl FE1 Vinci RJ Bauchner H Mottley L
Pediatr Crit Care Med 2015 Oct16(8)e260-7 doi 101097PCC0000000000000505 Pediatric Out-of-Hospital Critical Procedures in the United States
Carlson JN1 Gannon E Mann NC Jacobson KE Dai M Colleran C Wang HE
C-spine bull C-spine injuries rare bull Take pt to closest hospital if over injuries
call for it (ie resuscitation altered mental status) primary guide
bull Mechanism ndash Altered mental status focal neuro change
torticollis substantial torso injury diving high speed auto neck pain underlying predisposing condition Acad Emerg Med 2014 Jan21(1)55-64 doi 101111acem12288
Comparison of outcomes for children with cervical spine injury based on destination hospital from scene of injury Anders JF1 Adelgais K Hoyle JD Jr Olsen C Jaffe DM Leonard JC Pediatric Emergency Care Applied Research Network
(PECARN)
Ann Emerg Med 2011 Aug58(2)145-55 doi 101016jannemergmed201008038 Epub 2010 Oct 29 Factors associated with cervical spine injury in children after blunt trauma
Leonard JC Kuppermann N Olsen C Babcock-Cimpello L Brown K Mahajan P Adelgais KM Anders J Borgialli D Donoghue A Hoyle JD Jr Kim E Leonard JR Lillis KA Nigrovic LE Powell EC Rebella
G Reeves SD Rogers AJ Stankovic C Teshome G Jaffe DM Pediatric Emergency Care Applied Research Network
- Itrsquos Hard to Put a Band-Aid on a Broken Spleen Pediatric Trauma
- Disclosures
- Objectives
- Pediatric Prehospital Care
- Mechanism
- Traumatic Pain Management
- Pediatric Trauma
- Deaths by Mechanism of Injury
- Pediatric Trauma
- Pediatric Trauma
- Airway Differences
- Pediatric-Adult Differences
- Pediatric Challenges
- Prehospital Pediatric Challenges
- Pediatric and Adult Trauma
- Scene Response
- Prehospital Intervention
- Where do you take the patient
- Patient arrives at the EDhellip
- Primary Survey
- Order is critical
- Slide Number 22
- Slide Number 23
- Airway
- Indications for Intubation
- Breathing
- ETT Intubation Basics
- Circulation
- Slide Number 29
- CirculationHemodynamic Changes
- Circulation
- Fluid Resuscitation Algorithm
- Reconsidering Crystalloid Resuscitation
- When to start MTP
- Disability
- Finishing Up the Evaluation
- Bad Scene Responses
- OHCA from Trauma
- Blunt Trauma- No Signs of Life
- OHCA with CPR on Arrival
- Pediatric Trauma
- Questions
- References 1
- References 2
- References 3
- References 4
- References 5
- References 5
- XXXXBoston study ems peds trauma procedures- limited pediatric procedural exposure (but more adult experience)
- C-spine
Objectives bull Epidemiology of pediatric trauma bull Pediatric anatomic differences bull Challenges in prehospital care bull Initial evaluation and management
Pediatric Prehospital Care
bull gt110 millions ED visitsyear ndash ~frac14 ED visits are pediatric patients ndash ~10 of EMS transports are pediatric ndash EMS arrivals have higher admission rate
bull Trauma comprises ~13 of all PED visits
Mechanism
bull Falls- most common bull Low mortality
Traumatic Pain Management
bull Pain ndash Under-assessed ndash Undertreated
Pediatric Trauma bull Leading cause of death and disability bull Trauma gt 11000 pediatric deathsyear bull Trauma causes more pediatric death than
all other causes combined Causes of
death Ages 1-14 years
Deaths by Mechanism of Injury
NTDB Pediatric report 2007
Pediatric Trauma bull Kids ne Adults bull Smaller body mass
ndash Crowded trauma bed ndash Less muscle and fat for protection ndash Bones are less calcified and more pliable
bull Underlying injuries occur without fractures ndash Greater force per region
bull More systems often affected bull Waddel and Druckerrsquos Triad
ndash Lower extremity ndash Abdomenchest ndash Head
Pediatric Trauma
bull Larger heads alter airway alignment bull Weaker necks increase c-spine injury risk
wwwebmedicinenet
Airway Differences
bull Smaller airway ndash Smaller oral opening ndash Larger tongue in proportion
bull Larynx ndash More cephalad and anterior ndash More acute angle to access the cords
bull Limited functional residual capacity bull Faster to desaturation
Pediatric-Adult Differences
bull Greater BSA more prone to hypothermia bull Higher risk with radiation exposure bull Weight-based interventions bull Greater success with conservative care
Pediatric Challenges
bull Parents bull Non-accidental trauma bull Neglect bull Medically complex kids bull Pediatric patient exposure bull Pediatric intervention experience
Prehospital Pediatric Challenges
bull Less pediatric exposure ndash Experience
bull Critical procedures ~1 of transports bull CPR BMV or advanced airway in 04 of patients bull ALS specific transports BMV 5 ETI 3
bull Less success in pediatric patients ndash IV access success- 86 adult vs 66 kids ndash Intubating problems- 69 peds vs 21 adults
Pediatric and Adult Trauma
bull Trimodal death distribution ndash 1st peak- seconds to minutes after
bull Impacted by prevention ndash 2nd peak- minutes to hours after
bull ldquoGolden Hourrdquo bull Rapid assessment and treatment
ndash 3rd peak- days to weeks bull Quality pediatric care limits morbidity and mortality bull Infection and multi-organ failure
Scene Response
bull 8 year old male in a rollover atv accident
bull Pt is unresponsive localizes pain wonrsquot open his eyes
bull HR 130 BP 10060 bull RR 10 O2 sat 93 bull What do you want to do
Prehospital Intervention
bull Pre-hospital interventions did not significantly worsen care ndash Similar transport times ndash Similar mortality length of stay
bull ETI vs BMV ndash No difference in survival ndash No difference in neurological outcome
Where do you take the patient
bull Pediatric trauma centers ndash Less surgery on solid organ injuries ndash Less radiation- of scans and dosage ndash Less comorbidities
bull Lower costs bull Shorter length of stay bull Lower infections bull Less multi-organ failure
Patient arrives at the EDhellip
bull Where do you start ndash Primary Survey
Primary Survey bull Your ABCrsquoshellip
bull Airway bull Breathing bull Circulation bull Disability (Neuro- GCS) bull Exposure
Order is critical
bull A before B or C bull Morbiditymortality will
occur much faster from airway compromise than from breathing or circulatory problems
bull Systematic approach is the cornerstone of ATLS success
httpwwwuptodatecomcontentsimageimageKey=EM2F64241amptopicKey=EM2F6571amprank=17E150ampsource=see_linkampsearch=traumaamputdPopup=true
httpwwwuptodatecomcontentsimageimageKey=EM2F64241amptopicKey=EM2F6571amprank=17E150ampsource=see_linkampsearch=traumaamputdPopup=true
Airway bull What are you assessing
ndash Airway patency bull What makes the airway not patent
ndash Foreign bodies ndash Vomitbloodsecretions ndash Edemahematoma ndash Impending obstruction
bull Interventions ndash Clearing foreign bodies ndash Suction secretionsvomit with yankauer ndash Repositioning- jaw thrust ndash Nasal trumpetoral airway ndash Intubation ndash Cricothyrotomy jet ventilation
Indications for Intubation
bull Respiratory arrest bull Impending respiratory failure bull Impending airway obstruction bull Inability to protect the airway bull GCS lt8 bull Declining GCS
Breathing bull What are you assessing
ndash ldquoGoodrdquo symmetric chest rise ndash Lung sounds ndash Aeration ndash Basic RR assessment (fast or minimalnone)
bull Interventions ndash Oxygen ndash Albuterolatrovent racemic epi ndash Positive pressure (CPAP BIPAP BMV) ndash Needle decompression ndash Chest tube thoracostomy ndash Intubation ndash Jet ventilation
ETT Intubation Basics bull Size
ndash Age4 + 4 or (Age +16)4 bull Depth
ndash ~ 3 x ETT size when over 1 year of age bull Blade size mac vs miller
ndash 0~ newborn ndash 1~ up to 2 years of life ndash 2~ 2-10 years ndash 3~ 10+ years
bull RSI medications ndash +-Sedation (Always before paralytic) ndash +-Paralytic (May not need it and never wo sedation)
Circulation
bull What do you assess ndash Central and peripheral pulses ndash Heart rate ndash Blood pressure systolic (age x2) +70 ndash Capillary refill ndash Cardiac activity on FAST ndash End organ perfusion
bull Mental status bull Urine output
Circulation Hemodynamic Changes
Percent Blood Volume Loss 0 15 25 35 45
Heart Rate
Blood Pressure
Cardiac Output
Circulation
ndash Access 2 large bore IVrsquos ndash IVFrsquos ndash pRBCrsquos
bull Hgb lt7gdl or ongoing blood losses
ndash Massive Transfusion Protocol
bull (111 ratio of PRBCS FFP Platelets)
ndash Vasopressors (epi norepi dopamine)
ndash Control of Hemorrhage bull Pelvic binders bull Direct pressure bull Indirectproximal pressure bull Tourniquet (only when
absolutely necessary)
ndash Chest Compressions ndash Pericardiocentesis ndash Delayed resuscitation
controlled hypotension (MAP 50 vs 65)
ndash Tranexamic acid in the near future
bull Interventions
Fluid Resuscitation Algorithm 20 mLkg isotonic crystalloid
Reassess
20 mLkg isotonic crystalloid
Reassess
20 mLkg isotonic crystalloid (31 rule)
or consider 10 to 20 mLkg packed red cells
Reconsidering Crystalloid Resuscitation
bull Less fluid ndash Permissive hypotension to
prevent clot rupture (select cases)
bull Too much fluid ndash Excessive Third Spacing ndash Secondary Compartment
Syndrome ndash Greater risk of ARDS ndash Dilutional Coagulopathy
When to start MTP
bull As soon as you believe you will need it ndash Institution specific guidelines
bull gt4 units or 40mlkg of PRBCrsquos expected bull Earlier use of Massive Transfusion Protocol
(pRBC FFP PLT) in ldquoDamage Controlrdquo resuscitations may improve outcome
bull 111 unit ratio bull Risk of TRALI ARDS etc
Disability bull GCS
ndash Range 3-15 ndash We should be 15 ndash Dead are still 3 ndash Less than 8 intubate ndash Eyes- 4 eyes ndash Verbal- most difficult ndash Motor- V6 engine ndash Intubated T
bull AVPU
Finishing Up the Evaluation
bull Airway bull Breathing bull Circulation bull Disability bull Exposure
ndash Expose and examine all parts ndash Cover quickly and keep warm
bull Secondary Survey
Bad Scene Responses
bull What are the outcomes of out-of-hospital cardiac arrest from blunt trauma
bull What are the outcomes of pediatric drowning patients
OHCA from Trauma
bull 2000-2003 bull 123 pts bull Mean age 73 yrs bull Most common
rhythms ndash Asystole 59 ndash PEA 29 ndash V-fib 35
bull 195 rosc in field ndash 98 survived for 24
hrs ndash 57 survived to
discharge ndash Drowning- 19
survival to discharge ndash Bystander CPR tripled
the survivor rate
Blunt Trauma- No Signs of Life
bull Review from 2002-2010 bull No signs of life- 025 of blunt trauma
ndash 25 resuscitated prior to hospital arrival bull 138 of these patients survived to discharge
bull 44 overall survived to hospital discharge
OHCA with CPR on Arrival
bull 169 children bull 141 deaths bull 69 required cpr on arrival- none survived bull 87 of patients requiring CPR on arrival
expired in the ED bull Of the 28 survivors
ndash 55 of survivors had full neurologic recovery
Pediatric Trauma
bull Fortunately these cases represent only a small fraction of EMS transports
bull Despite a few key differences pediatric trauma care overall is very similar to adult trauma care
Questions
References 1 bull NTDB 2013 pediatric Report bull Monkey bars httpsplaygroundchroniclesfileswordpresscom201307soccerjpg bull Screaming child httpblogsbabycentercomwp-contentuploads201409screaming-child-tantrum-fitjpg bull Pediatric airway image httpwwwcelebritydiagnosiscomwp-contentuploads201003pediatric-airwayjpg bull Child on backboard httpsencrypted-tbn2gstaticcomimagesq=tbnANd9GcQscrDVc8IH4MwkNGF6F1A9p7mSVzik5zrWyNvI-
qSwQT5S3GNyVg bull Elbow fracture httpwwwimageinterpretationcoukimageselbowSUPRACONDYLAR20LAT3jpg bull Bike riding httpsmile-per-daycomwp-contentuploads201412klr03jpg bull Dad and child pic httplaughingsquidcomwp-contentuploads471160jpg bull Weigth estimation inner city Am J Emerg Med 2015 Oct33(10)1364-7 doi 101016jajem201507040 Epub 2015 Jul 29 Weight
estimation in an inner-city pediatric ED the effect of obesity Chavez H1 Peterson RE2 Lo K3 Arel M4
bull Guess weight sign httpmedialiveauctiongroupneti963110572971_1jpgv=8CDDAAF8A5B9E20 bull Broselow tape httpsuploadwikimediaorgwikipediacommons994BTape1jpg bull Parent screaming httpmommyofamonstercomwp-contentuploads201301yellingjpg bull Prehospital pain management Am J Emerg Med 2015 Mar33(3)451-4 doi 101016jajem201412012 Epub 2014 Dec 18
Prehospital pain management of injured children a systematic review of current evidence Samuel N1 Steiner IP2 Shavit I3 bull Prehospital pain ped pain assessment Prehosp Emerg Care 2008 Apr-Jun12(2)182-6 doi 10108010903120801907471 Prehospital
pain assessment in pediatric trauma Izsak E1 Moore JL Stringfellow K Oswanski MF Lindstrom DA Stombaugh HA bull Ped pain management Prehosp Emerg Care 2005 Jan-Mar9(1)40-3 Prehospital pain management in children suffering traumatic
injury Swor R1 McEachin CM Seguin D Grall KH bull Prehospital intervention Allen CJ Teisch LF et al Prehospital care and transportation of pediatric trauma patients J Surg Res 2015
Aug197(2)240-6 JAMA 2000 Feb 9283(6)783-90 bull Effect of out-of-hospital pediatric endotracheal intubation on survival and neurological outcome a controlled clinical trial
Gausche M1 Lewis RJ Stratton SJ Haynes BE Gunter CS Goodrich SM Poore PD McCollough MD Henderson DP Pratt FD Seidel JS
bull Pediatric pain management survey Pediatr Emerg Care 2015 Sep 23 [Epub ahead of print] An Assessment of Newly Identified Barriers to and Enablers for Prehospital Pediatric Pain Management Whitley DE1 Li T Jones CM Cushman JT Williams DM Shah MN
References 2 bull httpwwwuptodatecomcontentsprehospital-pediatrics-and-emergency-medical-services-emsabstract6 bull httpwwwuptodatecomcontentsprehospital-pediatrics-and-emergency-medical-services-emsabstract7 bull Pediatr Crit Care Med 2011 Jul12(4)e166-70 doi 101097PCC0b013e3181f36f6e First responder
performance in pediatric trauma a comparison with an adult cohortBankole S1 Asuncion A Ross S Aghai Z Nollah L Echols H Da-Silva S
bull Drayna pc Browne LR et al Prehospital pediatric care Oppportunities for training treatment and research Prehosp Emerg Care 2015 Jul-Sep 19(3) Epub 2015 Feb 6
bull Pediatr Emerg Care 2001 Feb17(1) 5-9Pediatric pre-hospital advanced life support care in an urban setting Babl FE1 Vinci RJ Bauchner H Mottley L
bull Pediatr Crit Care Med 2015 Oct16(8)e260-7 doi 101097PCC0000000000000505Pediatric Out-of-Hospital Critical Procedures in the United States Carlson JN1 Gannon E Mann NC Jacobson KE Dai M Colleran C Wang HE
bull Pediatr Emerg Care 2009 Aug25(8)508-12 doi 101097PEC0b013e3181b0a0da The efficacy of pediatric advanced life support training in emergency medical service providers Baker TW1 King W Soto W Asher C Stolfi A Rowin ME
bull Sutton RM Case E et al ROC investigators A quantitative analysis of out-of-hospital pediatric and adolescent resuscitation quality A report from the ROC Epistry- Cardiac Arrest Resusciation 201593150-157
bull Resuscitation 2014 Aug85(8)1059-64 doi 101016jresuscitation201403307 Epub 2014 Apr 4 Neurocognitive long term follow-up study on drowned children Suominen PK1 Sutinen N2 Valle S3 Olkkola KT4 Loumlnnqvist T3
bull J Pediatr Surg 2010 Jul45(7)1413-9 doi 101016jjpedsurg200912020 Prehospital cardiopulmonary resuscitation in the pediatric trauma patient Murphy JT1 Jaiswal K Sabella J Vinson L Megison S Maxson RT
References 3 bull Pre atv accident
httpwwwctvnewscapolopoly_fs119871591409741949httpImageimagejpg_genderivativeslandscape_960imagejpg bull atv pic httpswwwutahadvocatescomwp-contentuploads201402atvAccidentLawyerjpg bull Blunt abdominal solid organ injury adult vs pediatric trauma center J Pediatr Surg 2015 Aug 28 pii S0022-3468(15)00526-6 doi
101016jjpedsurg201508012 [Epub ahead of print] Trauma center variation in the management of pediatric patients with blunt abdominal solid organ injury a national trauma data bank analysis Safavi A1 Skarsgard ED2 Rhee P1 Zangbar B1 Kulvatunyou N1 Tang A1 OKeeffe T1 Friese RS1 Joseph B3
bull Pediatric blunt abdominal injury Curr Opin Crit Care 2015 Sep 28 [Epub ahead of print] Pediatric blunt abdominal trauma current management Notrica DM1
bull Pediatric splenic injury management Am J Surg 2015 Jul 31 pii S0002-9610(15)00417-1 doi 101016jamjsurg201506009 [Epub ahead of print] Comparative effectiveness of treatment strategies for severe splenic trauma in the pediatric population Rialon KL1 Englum BR1 Gulack BC1 Guevara CJ2 Bhattacharya SD3 Shapiro ML4 Rice HE5 Scarborough JE4 Adibe OO6
bull Liver pic httpss-media-cache-ak0pinimgcom736x7da50e7da50eb2bb603c99ef6649ff897e26b5jpg bull Solid organ injury non op in peds J Trauma Acute Care Surg 2015 Oct79(4)683-93 doi 101097TA0000000000000808
Nonoperative management of blunt liver and spleen injury in children Evaluation of the ATOMAC guideline using GRADE Notrica DM1 Eubanks JW 3rd Tuggle DW Maxson RT Letton RW Garcia NM Alder AC Lawson KA St Peter SD Megison S Garcia Filion P
bull Pediaric vs nonped trauma ct use J Pediatr 2015 Oct167(4)897-904e3 doi 101016jjpeds201506052 Epub 2015 Jul 29 Variation in Computed Tomography Imaging for Pediatric Injury-Related Emergency Visits Marin JR1 Wang L2 Winger DG2 Mannix RC3
bull Solid organ management in ped population J Trauma Acute Care Surg 2015 Aug79(2)206-14quiz 332 doi 101097TA0000000000000731 Management of children with solid organ injuries after blunt torso trauma Wisner DH1 Kuppermann N Cooper A Menaker J Ehrlich P Kooistra J Mahajan P Lee L Cook LJ Yen K Lillis K Holmes JF
bull Triad of death image httpimageslidesharecdncomdamage-control-resuscitation-1304253390-phpapp0195damage-control-resuscitation-14-728jpgcb=1304235553
bull Tranexamic acid study Eckert MJ Wertin TM Tyner SD et al 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 77852
bull Image care accident httpsuploadwikimediaorgwikipediacommonsthumbee1Car_crash_1jpg1280px-Car_crash_1jpg
References 4 bull httpwwwsurgeryvcuedudivisionsacutesurghtml bull Trauma management Approach to the unstable child
httpwwwuptodatecomcontentstrauma-management-approach-to-the-unstable-childsource=search_resultampsearch=pediatric+trauma+childrenampselectedTitle=17E150
bull Trauma management Unique pediatric considerations httpwwwuptodatecomcontentstrauma-management-unique-pediatric-considerationssource=search_resultampsearch=pediatric+trauma+childrenampselectedTitle=37E150
References 5 bull httpwwwetiquettehellcomsmfindexphptopic=8666360 bull httpwwwstlouischildrensorghealth-care-professionalsems-providers bull httpwwwuchicagokidshospitalorgspecialtiesemergency-medicinespecialhtml bull httpwwwsimsacademyinfoFXpatienthtm bull httptheemtspotcomwp-contentuploads200902another-burn-patient-by-annette-larsonjpg bull httplastangryfancomwp-contentuploads200910Clint-Malarchukjpg bull httpwwwtraumaorgarchiveresusmassivehtml bull httpwwwuptodatecomcontentsimageimageKey=PEDS68694amptopicKey=EM2F6389ampsourc
e=previewampsearch=pediatric+hemorrhagic+shockampselectedTitle=17E150amprank=undefined bull httptheemtspotcomwp-contentuploads200902gcsgif bull httpwwwuptodatecomcontentsimageimageKey=EM2F60409amptopicKey=EM2F6571amprank
=17E150ampsource=see_linkampsearch=traumaamputdPopup=true bull httpwwwuptodatecomcontentsimageimageKey=EM2F80874amptopicKey=EM2F6571amprank
=17E150ampsource=see_linkampsearch=traumaamputdPopup=true bull httpempracticenewswordpresscomcategorynexus-criteria bull httpswwwgooglecomsearchq=pediatric+glasgow+coma+scaleamptbm=ischamptbo=uampsource=uni
vampsa=Xampei=8TiOU7TNC5WuyATp5YG4BQampsqi=2ampved=0CDYQsAQampbiw=1426ampbih=883q=canadian+c-spine+rulesamptbm=ischampfacrc=_ampimgdii=_ampimgrc=WI94QMHgMLTQmM253A3BP5nbsFhNCXK0FM3Bhttp253A252F252Fwwwbmjcom252Fhighwire252Ffilestream252F436003252Ffield_highwire_fragment_image_l252F0jpg3Bhttp253A252F252Fwwwbmjcom252Fcontent252F339252Fbmjb41463B12803B1253
References 5 bull httpwwwuptodatecomcontentsimageimageKey=EM2F76777amptopicKey=EM2F6571amprank
=17E150ampsource=see_linkampsearch=traumaamputdPopup=true bull httpwwwdocumentingrealitycomforumattachmentsf14964898d1246625322-firework-injury-
m80injury1jpg bull httpwwwpediatriceducationorg20050620 bull httpwwwarmstrongmedicalcomindexcfmgoproductdetailsec3ssec19cat61fam515 bull httpwwwuptodatecomcontentsimageimageKey=PEDS61087amptopicKey=ID2F7661ampsource
=outline_linkampsearch=tetanus+prophylaxisamputdPopup=true bull httpwwwafsecafmilsharedmediaphotodbweb110609-F-MJ378-009jpg bull httpwwwuptodatecomcontentsimageimageKey=EM75765amptopicKey= bull EM2F6389ampsource=outline_linkampsearch=massive+transfusion+protocolamputdPopup=true bull httpwwwmotifakecomimagedemotivational-postersmall0910whats-the-question-ignorance-
calvin-and-hobbes-demotivational-poster-1255020127jpg
XXXXBoston study ems peds trauma procedures- limited pediatric procedural exposure (but more adult experience) bull Catchment area 590000
over 1 year bull 555 pediatric ALS
transport ndash 19 blunt trauma ndash 10 penetrating trauma
bull IV 33 bull BMV 5 bull Intubation 3 bull 50 ALS providers average
year ndash IV- 37 ndash Intubation- 03 ndash IO- 006
bull 7 ped ems ndash 13 trauma
bull Critical procedures ndash 101000 peds cases ndash Intubation 671000 ndash IO 51000 ndash 81 successful
Pediatr Emerg Care 2001 Feb17(1)5-9 Pediatric pre-hospital advanced life support care in an urban setting
Babl FE1 Vinci RJ Bauchner H Mottley L
Pediatr Crit Care Med 2015 Oct16(8)e260-7 doi 101097PCC0000000000000505 Pediatric Out-of-Hospital Critical Procedures in the United States
Carlson JN1 Gannon E Mann NC Jacobson KE Dai M Colleran C Wang HE
C-spine bull C-spine injuries rare bull Take pt to closest hospital if over injuries
call for it (ie resuscitation altered mental status) primary guide
bull Mechanism ndash Altered mental status focal neuro change
torticollis substantial torso injury diving high speed auto neck pain underlying predisposing condition Acad Emerg Med 2014 Jan21(1)55-64 doi 101111acem12288
Comparison of outcomes for children with cervical spine injury based on destination hospital from scene of injury Anders JF1 Adelgais K Hoyle JD Jr Olsen C Jaffe DM Leonard JC Pediatric Emergency Care Applied Research Network
(PECARN)
Ann Emerg Med 2011 Aug58(2)145-55 doi 101016jannemergmed201008038 Epub 2010 Oct 29 Factors associated with cervical spine injury in children after blunt trauma
Leonard JC Kuppermann N Olsen C Babcock-Cimpello L Brown K Mahajan P Adelgais KM Anders J Borgialli D Donoghue A Hoyle JD Jr Kim E Leonard JR Lillis KA Nigrovic LE Powell EC Rebella
G Reeves SD Rogers AJ Stankovic C Teshome G Jaffe DM Pediatric Emergency Care Applied Research Network
- Itrsquos Hard to Put a Band-Aid on a Broken Spleen Pediatric Trauma
- Disclosures
- Objectives
- Pediatric Prehospital Care
- Mechanism
- Traumatic Pain Management
- Pediatric Trauma
- Deaths by Mechanism of Injury
- Pediatric Trauma
- Pediatric Trauma
- Airway Differences
- Pediatric-Adult Differences
- Pediatric Challenges
- Prehospital Pediatric Challenges
- Pediatric and Adult Trauma
- Scene Response
- Prehospital Intervention
- Where do you take the patient
- Patient arrives at the EDhellip
- Primary Survey
- Order is critical
- Slide Number 22
- Slide Number 23
- Airway
- Indications for Intubation
- Breathing
- ETT Intubation Basics
- Circulation
- Slide Number 29
- CirculationHemodynamic Changes
- Circulation
- Fluid Resuscitation Algorithm
- Reconsidering Crystalloid Resuscitation
- When to start MTP
- Disability
- Finishing Up the Evaluation
- Bad Scene Responses
- OHCA from Trauma
- Blunt Trauma- No Signs of Life
- OHCA with CPR on Arrival
- Pediatric Trauma
- Questions
- References 1
- References 2
- References 3
- References 4
- References 5
- References 5
- XXXXBoston study ems peds trauma procedures- limited pediatric procedural exposure (but more adult experience)
- C-spine
Pediatric Prehospital Care
bull gt110 millions ED visitsyear ndash ~frac14 ED visits are pediatric patients ndash ~10 of EMS transports are pediatric ndash EMS arrivals have higher admission rate
bull Trauma comprises ~13 of all PED visits
Mechanism
bull Falls- most common bull Low mortality
Traumatic Pain Management
bull Pain ndash Under-assessed ndash Undertreated
Pediatric Trauma bull Leading cause of death and disability bull Trauma gt 11000 pediatric deathsyear bull Trauma causes more pediatric death than
all other causes combined Causes of
death Ages 1-14 years
Deaths by Mechanism of Injury
NTDB Pediatric report 2007
Pediatric Trauma bull Kids ne Adults bull Smaller body mass
ndash Crowded trauma bed ndash Less muscle and fat for protection ndash Bones are less calcified and more pliable
bull Underlying injuries occur without fractures ndash Greater force per region
bull More systems often affected bull Waddel and Druckerrsquos Triad
ndash Lower extremity ndash Abdomenchest ndash Head
Pediatric Trauma
bull Larger heads alter airway alignment bull Weaker necks increase c-spine injury risk
wwwebmedicinenet
Airway Differences
bull Smaller airway ndash Smaller oral opening ndash Larger tongue in proportion
bull Larynx ndash More cephalad and anterior ndash More acute angle to access the cords
bull Limited functional residual capacity bull Faster to desaturation
Pediatric-Adult Differences
bull Greater BSA more prone to hypothermia bull Higher risk with radiation exposure bull Weight-based interventions bull Greater success with conservative care
Pediatric Challenges
bull Parents bull Non-accidental trauma bull Neglect bull Medically complex kids bull Pediatric patient exposure bull Pediatric intervention experience
Prehospital Pediatric Challenges
bull Less pediatric exposure ndash Experience
bull Critical procedures ~1 of transports bull CPR BMV or advanced airway in 04 of patients bull ALS specific transports BMV 5 ETI 3
bull Less success in pediatric patients ndash IV access success- 86 adult vs 66 kids ndash Intubating problems- 69 peds vs 21 adults
Pediatric and Adult Trauma
bull Trimodal death distribution ndash 1st peak- seconds to minutes after
bull Impacted by prevention ndash 2nd peak- minutes to hours after
bull ldquoGolden Hourrdquo bull Rapid assessment and treatment
ndash 3rd peak- days to weeks bull Quality pediatric care limits morbidity and mortality bull Infection and multi-organ failure
Scene Response
bull 8 year old male in a rollover atv accident
bull Pt is unresponsive localizes pain wonrsquot open his eyes
bull HR 130 BP 10060 bull RR 10 O2 sat 93 bull What do you want to do
Prehospital Intervention
bull Pre-hospital interventions did not significantly worsen care ndash Similar transport times ndash Similar mortality length of stay
bull ETI vs BMV ndash No difference in survival ndash No difference in neurological outcome
Where do you take the patient
bull Pediatric trauma centers ndash Less surgery on solid organ injuries ndash Less radiation- of scans and dosage ndash Less comorbidities
bull Lower costs bull Shorter length of stay bull Lower infections bull Less multi-organ failure
Patient arrives at the EDhellip
bull Where do you start ndash Primary Survey
Primary Survey bull Your ABCrsquoshellip
bull Airway bull Breathing bull Circulation bull Disability (Neuro- GCS) bull Exposure
Order is critical
bull A before B or C bull Morbiditymortality will
occur much faster from airway compromise than from breathing or circulatory problems
bull Systematic approach is the cornerstone of ATLS success
httpwwwuptodatecomcontentsimageimageKey=EM2F64241amptopicKey=EM2F6571amprank=17E150ampsource=see_linkampsearch=traumaamputdPopup=true
httpwwwuptodatecomcontentsimageimageKey=EM2F64241amptopicKey=EM2F6571amprank=17E150ampsource=see_linkampsearch=traumaamputdPopup=true
Airway bull What are you assessing
ndash Airway patency bull What makes the airway not patent
ndash Foreign bodies ndash Vomitbloodsecretions ndash Edemahematoma ndash Impending obstruction
bull Interventions ndash Clearing foreign bodies ndash Suction secretionsvomit with yankauer ndash Repositioning- jaw thrust ndash Nasal trumpetoral airway ndash Intubation ndash Cricothyrotomy jet ventilation
Indications for Intubation
bull Respiratory arrest bull Impending respiratory failure bull Impending airway obstruction bull Inability to protect the airway bull GCS lt8 bull Declining GCS
Breathing bull What are you assessing
ndash ldquoGoodrdquo symmetric chest rise ndash Lung sounds ndash Aeration ndash Basic RR assessment (fast or minimalnone)
bull Interventions ndash Oxygen ndash Albuterolatrovent racemic epi ndash Positive pressure (CPAP BIPAP BMV) ndash Needle decompression ndash Chest tube thoracostomy ndash Intubation ndash Jet ventilation
ETT Intubation Basics bull Size
ndash Age4 + 4 or (Age +16)4 bull Depth
ndash ~ 3 x ETT size when over 1 year of age bull Blade size mac vs miller
ndash 0~ newborn ndash 1~ up to 2 years of life ndash 2~ 2-10 years ndash 3~ 10+ years
bull RSI medications ndash +-Sedation (Always before paralytic) ndash +-Paralytic (May not need it and never wo sedation)
Circulation
bull What do you assess ndash Central and peripheral pulses ndash Heart rate ndash Blood pressure systolic (age x2) +70 ndash Capillary refill ndash Cardiac activity on FAST ndash End organ perfusion
bull Mental status bull Urine output
Circulation Hemodynamic Changes
Percent Blood Volume Loss 0 15 25 35 45
Heart Rate
Blood Pressure
Cardiac Output
Circulation
ndash Access 2 large bore IVrsquos ndash IVFrsquos ndash pRBCrsquos
bull Hgb lt7gdl or ongoing blood losses
ndash Massive Transfusion Protocol
bull (111 ratio of PRBCS FFP Platelets)
ndash Vasopressors (epi norepi dopamine)
ndash Control of Hemorrhage bull Pelvic binders bull Direct pressure bull Indirectproximal pressure bull Tourniquet (only when
absolutely necessary)
ndash Chest Compressions ndash Pericardiocentesis ndash Delayed resuscitation
controlled hypotension (MAP 50 vs 65)
ndash Tranexamic acid in the near future
bull Interventions
Fluid Resuscitation Algorithm 20 mLkg isotonic crystalloid
Reassess
20 mLkg isotonic crystalloid
Reassess
20 mLkg isotonic crystalloid (31 rule)
or consider 10 to 20 mLkg packed red cells
Reconsidering Crystalloid Resuscitation
bull Less fluid ndash Permissive hypotension to
prevent clot rupture (select cases)
bull Too much fluid ndash Excessive Third Spacing ndash Secondary Compartment
Syndrome ndash Greater risk of ARDS ndash Dilutional Coagulopathy
When to start MTP
bull As soon as you believe you will need it ndash Institution specific guidelines
bull gt4 units or 40mlkg of PRBCrsquos expected bull Earlier use of Massive Transfusion Protocol
(pRBC FFP PLT) in ldquoDamage Controlrdquo resuscitations may improve outcome
bull 111 unit ratio bull Risk of TRALI ARDS etc
Disability bull GCS
ndash Range 3-15 ndash We should be 15 ndash Dead are still 3 ndash Less than 8 intubate ndash Eyes- 4 eyes ndash Verbal- most difficult ndash Motor- V6 engine ndash Intubated T
bull AVPU
Finishing Up the Evaluation
bull Airway bull Breathing bull Circulation bull Disability bull Exposure
ndash Expose and examine all parts ndash Cover quickly and keep warm
bull Secondary Survey
Bad Scene Responses
bull What are the outcomes of out-of-hospital cardiac arrest from blunt trauma
bull What are the outcomes of pediatric drowning patients
OHCA from Trauma
bull 2000-2003 bull 123 pts bull Mean age 73 yrs bull Most common
rhythms ndash Asystole 59 ndash PEA 29 ndash V-fib 35
bull 195 rosc in field ndash 98 survived for 24
hrs ndash 57 survived to
discharge ndash Drowning- 19
survival to discharge ndash Bystander CPR tripled
the survivor rate
Blunt Trauma- No Signs of Life
bull Review from 2002-2010 bull No signs of life- 025 of blunt trauma
ndash 25 resuscitated prior to hospital arrival bull 138 of these patients survived to discharge
bull 44 overall survived to hospital discharge
OHCA with CPR on Arrival
bull 169 children bull 141 deaths bull 69 required cpr on arrival- none survived bull 87 of patients requiring CPR on arrival
expired in the ED bull Of the 28 survivors
ndash 55 of survivors had full neurologic recovery
Pediatric Trauma
bull Fortunately these cases represent only a small fraction of EMS transports
bull Despite a few key differences pediatric trauma care overall is very similar to adult trauma care
Questions
References 1 bull NTDB 2013 pediatric Report bull Monkey bars httpsplaygroundchroniclesfileswordpresscom201307soccerjpg bull Screaming child httpblogsbabycentercomwp-contentuploads201409screaming-child-tantrum-fitjpg bull Pediatric airway image httpwwwcelebritydiagnosiscomwp-contentuploads201003pediatric-airwayjpg bull Child on backboard httpsencrypted-tbn2gstaticcomimagesq=tbnANd9GcQscrDVc8IH4MwkNGF6F1A9p7mSVzik5zrWyNvI-
qSwQT5S3GNyVg bull Elbow fracture httpwwwimageinterpretationcoukimageselbowSUPRACONDYLAR20LAT3jpg bull Bike riding httpsmile-per-daycomwp-contentuploads201412klr03jpg bull Dad and child pic httplaughingsquidcomwp-contentuploads471160jpg bull Weigth estimation inner city Am J Emerg Med 2015 Oct33(10)1364-7 doi 101016jajem201507040 Epub 2015 Jul 29 Weight
estimation in an inner-city pediatric ED the effect of obesity Chavez H1 Peterson RE2 Lo K3 Arel M4
bull Guess weight sign httpmedialiveauctiongroupneti963110572971_1jpgv=8CDDAAF8A5B9E20 bull Broselow tape httpsuploadwikimediaorgwikipediacommons994BTape1jpg bull Parent screaming httpmommyofamonstercomwp-contentuploads201301yellingjpg bull Prehospital pain management Am J Emerg Med 2015 Mar33(3)451-4 doi 101016jajem201412012 Epub 2014 Dec 18
Prehospital pain management of injured children a systematic review of current evidence Samuel N1 Steiner IP2 Shavit I3 bull Prehospital pain ped pain assessment Prehosp Emerg Care 2008 Apr-Jun12(2)182-6 doi 10108010903120801907471 Prehospital
pain assessment in pediatric trauma Izsak E1 Moore JL Stringfellow K Oswanski MF Lindstrom DA Stombaugh HA bull Ped pain management Prehosp Emerg Care 2005 Jan-Mar9(1)40-3 Prehospital pain management in children suffering traumatic
injury Swor R1 McEachin CM Seguin D Grall KH bull Prehospital intervention Allen CJ Teisch LF et al Prehospital care and transportation of pediatric trauma patients J Surg Res 2015
Aug197(2)240-6 JAMA 2000 Feb 9283(6)783-90 bull Effect of out-of-hospital pediatric endotracheal intubation on survival and neurological outcome a controlled clinical trial
Gausche M1 Lewis RJ Stratton SJ Haynes BE Gunter CS Goodrich SM Poore PD McCollough MD Henderson DP Pratt FD Seidel JS
bull Pediatric pain management survey Pediatr Emerg Care 2015 Sep 23 [Epub ahead of print] An Assessment of Newly Identified Barriers to and Enablers for Prehospital Pediatric Pain Management Whitley DE1 Li T Jones CM Cushman JT Williams DM Shah MN
References 2 bull httpwwwuptodatecomcontentsprehospital-pediatrics-and-emergency-medical-services-emsabstract6 bull httpwwwuptodatecomcontentsprehospital-pediatrics-and-emergency-medical-services-emsabstract7 bull Pediatr Crit Care Med 2011 Jul12(4)e166-70 doi 101097PCC0b013e3181f36f6e First responder
performance in pediatric trauma a comparison with an adult cohortBankole S1 Asuncion A Ross S Aghai Z Nollah L Echols H Da-Silva S
bull Drayna pc Browne LR et al Prehospital pediatric care Oppportunities for training treatment and research Prehosp Emerg Care 2015 Jul-Sep 19(3) Epub 2015 Feb 6
bull Pediatr Emerg Care 2001 Feb17(1) 5-9Pediatric pre-hospital advanced life support care in an urban setting Babl FE1 Vinci RJ Bauchner H Mottley L
bull Pediatr Crit Care Med 2015 Oct16(8)e260-7 doi 101097PCC0000000000000505Pediatric Out-of-Hospital Critical Procedures in the United States Carlson JN1 Gannon E Mann NC Jacobson KE Dai M Colleran C Wang HE
bull Pediatr Emerg Care 2009 Aug25(8)508-12 doi 101097PEC0b013e3181b0a0da The efficacy of pediatric advanced life support training in emergency medical service providers Baker TW1 King W Soto W Asher C Stolfi A Rowin ME
bull Sutton RM Case E et al ROC investigators A quantitative analysis of out-of-hospital pediatric and adolescent resuscitation quality A report from the ROC Epistry- Cardiac Arrest Resusciation 201593150-157
bull Resuscitation 2014 Aug85(8)1059-64 doi 101016jresuscitation201403307 Epub 2014 Apr 4 Neurocognitive long term follow-up study on drowned children Suominen PK1 Sutinen N2 Valle S3 Olkkola KT4 Loumlnnqvist T3
bull J Pediatr Surg 2010 Jul45(7)1413-9 doi 101016jjpedsurg200912020 Prehospital cardiopulmonary resuscitation in the pediatric trauma patient Murphy JT1 Jaiswal K Sabella J Vinson L Megison S Maxson RT
References 3 bull Pre atv accident
httpwwwctvnewscapolopoly_fs119871591409741949httpImageimagejpg_genderivativeslandscape_960imagejpg bull atv pic httpswwwutahadvocatescomwp-contentuploads201402atvAccidentLawyerjpg bull Blunt abdominal solid organ injury adult vs pediatric trauma center J Pediatr Surg 2015 Aug 28 pii S0022-3468(15)00526-6 doi
101016jjpedsurg201508012 [Epub ahead of print] Trauma center variation in the management of pediatric patients with blunt abdominal solid organ injury a national trauma data bank analysis Safavi A1 Skarsgard ED2 Rhee P1 Zangbar B1 Kulvatunyou N1 Tang A1 OKeeffe T1 Friese RS1 Joseph B3
bull Pediatric blunt abdominal injury Curr Opin Crit Care 2015 Sep 28 [Epub ahead of print] Pediatric blunt abdominal trauma current management Notrica DM1
bull Pediatric splenic injury management Am J Surg 2015 Jul 31 pii S0002-9610(15)00417-1 doi 101016jamjsurg201506009 [Epub ahead of print] Comparative effectiveness of treatment strategies for severe splenic trauma in the pediatric population Rialon KL1 Englum BR1 Gulack BC1 Guevara CJ2 Bhattacharya SD3 Shapiro ML4 Rice HE5 Scarborough JE4 Adibe OO6
bull Liver pic httpss-media-cache-ak0pinimgcom736x7da50e7da50eb2bb603c99ef6649ff897e26b5jpg bull Solid organ injury non op in peds J Trauma Acute Care Surg 2015 Oct79(4)683-93 doi 101097TA0000000000000808
Nonoperative management of blunt liver and spleen injury in children Evaluation of the ATOMAC guideline using GRADE Notrica DM1 Eubanks JW 3rd Tuggle DW Maxson RT Letton RW Garcia NM Alder AC Lawson KA St Peter SD Megison S Garcia Filion P
bull Pediaric vs nonped trauma ct use J Pediatr 2015 Oct167(4)897-904e3 doi 101016jjpeds201506052 Epub 2015 Jul 29 Variation in Computed Tomography Imaging for Pediatric Injury-Related Emergency Visits Marin JR1 Wang L2 Winger DG2 Mannix RC3
bull Solid organ management in ped population J Trauma Acute Care Surg 2015 Aug79(2)206-14quiz 332 doi 101097TA0000000000000731 Management of children with solid organ injuries after blunt torso trauma Wisner DH1 Kuppermann N Cooper A Menaker J Ehrlich P Kooistra J Mahajan P Lee L Cook LJ Yen K Lillis K Holmes JF
bull Triad of death image httpimageslidesharecdncomdamage-control-resuscitation-1304253390-phpapp0195damage-control-resuscitation-14-728jpgcb=1304235553
bull Tranexamic acid study Eckert MJ Wertin TM Tyner SD et al 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 77852
bull Image care accident httpsuploadwikimediaorgwikipediacommonsthumbee1Car_crash_1jpg1280px-Car_crash_1jpg
References 4 bull httpwwwsurgeryvcuedudivisionsacutesurghtml bull Trauma management Approach to the unstable child
httpwwwuptodatecomcontentstrauma-management-approach-to-the-unstable-childsource=search_resultampsearch=pediatric+trauma+childrenampselectedTitle=17E150
bull Trauma management Unique pediatric considerations httpwwwuptodatecomcontentstrauma-management-unique-pediatric-considerationssource=search_resultampsearch=pediatric+trauma+childrenampselectedTitle=37E150
References 5 bull httpwwwetiquettehellcomsmfindexphptopic=8666360 bull httpwwwstlouischildrensorghealth-care-professionalsems-providers bull httpwwwuchicagokidshospitalorgspecialtiesemergency-medicinespecialhtml bull httpwwwsimsacademyinfoFXpatienthtm bull httptheemtspotcomwp-contentuploads200902another-burn-patient-by-annette-larsonjpg bull httplastangryfancomwp-contentuploads200910Clint-Malarchukjpg bull httpwwwtraumaorgarchiveresusmassivehtml bull httpwwwuptodatecomcontentsimageimageKey=PEDS68694amptopicKey=EM2F6389ampsourc
e=previewampsearch=pediatric+hemorrhagic+shockampselectedTitle=17E150amprank=undefined bull httptheemtspotcomwp-contentuploads200902gcsgif bull httpwwwuptodatecomcontentsimageimageKey=EM2F60409amptopicKey=EM2F6571amprank
=17E150ampsource=see_linkampsearch=traumaamputdPopup=true bull httpwwwuptodatecomcontentsimageimageKey=EM2F80874amptopicKey=EM2F6571amprank
=17E150ampsource=see_linkampsearch=traumaamputdPopup=true bull httpempracticenewswordpresscomcategorynexus-criteria bull httpswwwgooglecomsearchq=pediatric+glasgow+coma+scaleamptbm=ischamptbo=uampsource=uni
vampsa=Xampei=8TiOU7TNC5WuyATp5YG4BQampsqi=2ampved=0CDYQsAQampbiw=1426ampbih=883q=canadian+c-spine+rulesamptbm=ischampfacrc=_ampimgdii=_ampimgrc=WI94QMHgMLTQmM253A3BP5nbsFhNCXK0FM3Bhttp253A252F252Fwwwbmjcom252Fhighwire252Ffilestream252F436003252Ffield_highwire_fragment_image_l252F0jpg3Bhttp253A252F252Fwwwbmjcom252Fcontent252F339252Fbmjb41463B12803B1253
References 5 bull httpwwwuptodatecomcontentsimageimageKey=EM2F76777amptopicKey=EM2F6571amprank
=17E150ampsource=see_linkampsearch=traumaamputdPopup=true bull httpwwwdocumentingrealitycomforumattachmentsf14964898d1246625322-firework-injury-
m80injury1jpg bull httpwwwpediatriceducationorg20050620 bull httpwwwarmstrongmedicalcomindexcfmgoproductdetailsec3ssec19cat61fam515 bull httpwwwuptodatecomcontentsimageimageKey=PEDS61087amptopicKey=ID2F7661ampsource
=outline_linkampsearch=tetanus+prophylaxisamputdPopup=true bull httpwwwafsecafmilsharedmediaphotodbweb110609-F-MJ378-009jpg bull httpwwwuptodatecomcontentsimageimageKey=EM75765amptopicKey= bull EM2F6389ampsource=outline_linkampsearch=massive+transfusion+protocolamputdPopup=true bull httpwwwmotifakecomimagedemotivational-postersmall0910whats-the-question-ignorance-
calvin-and-hobbes-demotivational-poster-1255020127jpg
XXXXBoston study ems peds trauma procedures- limited pediatric procedural exposure (but more adult experience) bull Catchment area 590000
over 1 year bull 555 pediatric ALS
transport ndash 19 blunt trauma ndash 10 penetrating trauma
bull IV 33 bull BMV 5 bull Intubation 3 bull 50 ALS providers average
year ndash IV- 37 ndash Intubation- 03 ndash IO- 006
bull 7 ped ems ndash 13 trauma
bull Critical procedures ndash 101000 peds cases ndash Intubation 671000 ndash IO 51000 ndash 81 successful
Pediatr Emerg Care 2001 Feb17(1)5-9 Pediatric pre-hospital advanced life support care in an urban setting
Babl FE1 Vinci RJ Bauchner H Mottley L
Pediatr Crit Care Med 2015 Oct16(8)e260-7 doi 101097PCC0000000000000505 Pediatric Out-of-Hospital Critical Procedures in the United States
Carlson JN1 Gannon E Mann NC Jacobson KE Dai M Colleran C Wang HE
C-spine bull C-spine injuries rare bull Take pt to closest hospital if over injuries
call for it (ie resuscitation altered mental status) primary guide
bull Mechanism ndash Altered mental status focal neuro change
torticollis substantial torso injury diving high speed auto neck pain underlying predisposing condition Acad Emerg Med 2014 Jan21(1)55-64 doi 101111acem12288
Comparison of outcomes for children with cervical spine injury based on destination hospital from scene of injury Anders JF1 Adelgais K Hoyle JD Jr Olsen C Jaffe DM Leonard JC Pediatric Emergency Care Applied Research Network
(PECARN)
Ann Emerg Med 2011 Aug58(2)145-55 doi 101016jannemergmed201008038 Epub 2010 Oct 29 Factors associated with cervical spine injury in children after blunt trauma
Leonard JC Kuppermann N Olsen C Babcock-Cimpello L Brown K Mahajan P Adelgais KM Anders J Borgialli D Donoghue A Hoyle JD Jr Kim E Leonard JR Lillis KA Nigrovic LE Powell EC Rebella
G Reeves SD Rogers AJ Stankovic C Teshome G Jaffe DM Pediatric Emergency Care Applied Research Network
- Itrsquos Hard to Put a Band-Aid on a Broken Spleen Pediatric Trauma
- Disclosures
- Objectives
- Pediatric Prehospital Care
- Mechanism
- Traumatic Pain Management
- Pediatric Trauma
- Deaths by Mechanism of Injury
- Pediatric Trauma
- Pediatric Trauma
- Airway Differences
- Pediatric-Adult Differences
- Pediatric Challenges
- Prehospital Pediatric Challenges
- Pediatric and Adult Trauma
- Scene Response
- Prehospital Intervention
- Where do you take the patient
- Patient arrives at the EDhellip
- Primary Survey
- Order is critical
- Slide Number 22
- Slide Number 23
- Airway
- Indications for Intubation
- Breathing
- ETT Intubation Basics
- Circulation
- Slide Number 29
- CirculationHemodynamic Changes
- Circulation
- Fluid Resuscitation Algorithm
- Reconsidering Crystalloid Resuscitation
- When to start MTP
- Disability
- Finishing Up the Evaluation
- Bad Scene Responses
- OHCA from Trauma
- Blunt Trauma- No Signs of Life
- OHCA with CPR on Arrival
- Pediatric Trauma
- Questions
- References 1
- References 2
- References 3
- References 4
- References 5
- References 5
- XXXXBoston study ems peds trauma procedures- limited pediatric procedural exposure (but more adult experience)
- C-spine
Mechanism
bull Falls- most common bull Low mortality
Traumatic Pain Management
bull Pain ndash Under-assessed ndash Undertreated
Pediatric Trauma bull Leading cause of death and disability bull Trauma gt 11000 pediatric deathsyear bull Trauma causes more pediatric death than
all other causes combined Causes of
death Ages 1-14 years
Deaths by Mechanism of Injury
NTDB Pediatric report 2007
Pediatric Trauma bull Kids ne Adults bull Smaller body mass
ndash Crowded trauma bed ndash Less muscle and fat for protection ndash Bones are less calcified and more pliable
bull Underlying injuries occur without fractures ndash Greater force per region
bull More systems often affected bull Waddel and Druckerrsquos Triad
ndash Lower extremity ndash Abdomenchest ndash Head
Pediatric Trauma
bull Larger heads alter airway alignment bull Weaker necks increase c-spine injury risk
wwwebmedicinenet
Airway Differences
bull Smaller airway ndash Smaller oral opening ndash Larger tongue in proportion
bull Larynx ndash More cephalad and anterior ndash More acute angle to access the cords
bull Limited functional residual capacity bull Faster to desaturation
Pediatric-Adult Differences
bull Greater BSA more prone to hypothermia bull Higher risk with radiation exposure bull Weight-based interventions bull Greater success with conservative care
Pediatric Challenges
bull Parents bull Non-accidental trauma bull Neglect bull Medically complex kids bull Pediatric patient exposure bull Pediatric intervention experience
Prehospital Pediatric Challenges
bull Less pediatric exposure ndash Experience
bull Critical procedures ~1 of transports bull CPR BMV or advanced airway in 04 of patients bull ALS specific transports BMV 5 ETI 3
bull Less success in pediatric patients ndash IV access success- 86 adult vs 66 kids ndash Intubating problems- 69 peds vs 21 adults
Pediatric and Adult Trauma
bull Trimodal death distribution ndash 1st peak- seconds to minutes after
bull Impacted by prevention ndash 2nd peak- minutes to hours after
bull ldquoGolden Hourrdquo bull Rapid assessment and treatment
ndash 3rd peak- days to weeks bull Quality pediatric care limits morbidity and mortality bull Infection and multi-organ failure
Scene Response
bull 8 year old male in a rollover atv accident
bull Pt is unresponsive localizes pain wonrsquot open his eyes
bull HR 130 BP 10060 bull RR 10 O2 sat 93 bull What do you want to do
Prehospital Intervention
bull Pre-hospital interventions did not significantly worsen care ndash Similar transport times ndash Similar mortality length of stay
bull ETI vs BMV ndash No difference in survival ndash No difference in neurological outcome
Where do you take the patient
bull Pediatric trauma centers ndash Less surgery on solid organ injuries ndash Less radiation- of scans and dosage ndash Less comorbidities
bull Lower costs bull Shorter length of stay bull Lower infections bull Less multi-organ failure
Patient arrives at the EDhellip
bull Where do you start ndash Primary Survey
Primary Survey bull Your ABCrsquoshellip
bull Airway bull Breathing bull Circulation bull Disability (Neuro- GCS) bull Exposure
Order is critical
bull A before B or C bull Morbiditymortality will
occur much faster from airway compromise than from breathing or circulatory problems
bull Systematic approach is the cornerstone of ATLS success
httpwwwuptodatecomcontentsimageimageKey=EM2F64241amptopicKey=EM2F6571amprank=17E150ampsource=see_linkampsearch=traumaamputdPopup=true
httpwwwuptodatecomcontentsimageimageKey=EM2F64241amptopicKey=EM2F6571amprank=17E150ampsource=see_linkampsearch=traumaamputdPopup=true
Airway bull What are you assessing
ndash Airway patency bull What makes the airway not patent
ndash Foreign bodies ndash Vomitbloodsecretions ndash Edemahematoma ndash Impending obstruction
bull Interventions ndash Clearing foreign bodies ndash Suction secretionsvomit with yankauer ndash Repositioning- jaw thrust ndash Nasal trumpetoral airway ndash Intubation ndash Cricothyrotomy jet ventilation
Indications for Intubation
bull Respiratory arrest bull Impending respiratory failure bull Impending airway obstruction bull Inability to protect the airway bull GCS lt8 bull Declining GCS
Breathing bull What are you assessing
ndash ldquoGoodrdquo symmetric chest rise ndash Lung sounds ndash Aeration ndash Basic RR assessment (fast or minimalnone)
bull Interventions ndash Oxygen ndash Albuterolatrovent racemic epi ndash Positive pressure (CPAP BIPAP BMV) ndash Needle decompression ndash Chest tube thoracostomy ndash Intubation ndash Jet ventilation
ETT Intubation Basics bull Size
ndash Age4 + 4 or (Age +16)4 bull Depth
ndash ~ 3 x ETT size when over 1 year of age bull Blade size mac vs miller
ndash 0~ newborn ndash 1~ up to 2 years of life ndash 2~ 2-10 years ndash 3~ 10+ years
bull RSI medications ndash +-Sedation (Always before paralytic) ndash +-Paralytic (May not need it and never wo sedation)
Circulation
bull What do you assess ndash Central and peripheral pulses ndash Heart rate ndash Blood pressure systolic (age x2) +70 ndash Capillary refill ndash Cardiac activity on FAST ndash End organ perfusion
bull Mental status bull Urine output
Circulation Hemodynamic Changes
Percent Blood Volume Loss 0 15 25 35 45
Heart Rate
Blood Pressure
Cardiac Output
Circulation
ndash Access 2 large bore IVrsquos ndash IVFrsquos ndash pRBCrsquos
bull Hgb lt7gdl or ongoing blood losses
ndash Massive Transfusion Protocol
bull (111 ratio of PRBCS FFP Platelets)
ndash Vasopressors (epi norepi dopamine)
ndash Control of Hemorrhage bull Pelvic binders bull Direct pressure bull Indirectproximal pressure bull Tourniquet (only when
absolutely necessary)
ndash Chest Compressions ndash Pericardiocentesis ndash Delayed resuscitation
controlled hypotension (MAP 50 vs 65)
ndash Tranexamic acid in the near future
bull Interventions
Fluid Resuscitation Algorithm 20 mLkg isotonic crystalloid
Reassess
20 mLkg isotonic crystalloid
Reassess
20 mLkg isotonic crystalloid (31 rule)
or consider 10 to 20 mLkg packed red cells
Reconsidering Crystalloid Resuscitation
bull Less fluid ndash Permissive hypotension to
prevent clot rupture (select cases)
bull Too much fluid ndash Excessive Third Spacing ndash Secondary Compartment
Syndrome ndash Greater risk of ARDS ndash Dilutional Coagulopathy
When to start MTP
bull As soon as you believe you will need it ndash Institution specific guidelines
bull gt4 units or 40mlkg of PRBCrsquos expected bull Earlier use of Massive Transfusion Protocol
(pRBC FFP PLT) in ldquoDamage Controlrdquo resuscitations may improve outcome
bull 111 unit ratio bull Risk of TRALI ARDS etc
Disability bull GCS
ndash Range 3-15 ndash We should be 15 ndash Dead are still 3 ndash Less than 8 intubate ndash Eyes- 4 eyes ndash Verbal- most difficult ndash Motor- V6 engine ndash Intubated T
bull AVPU
Finishing Up the Evaluation
bull Airway bull Breathing bull Circulation bull Disability bull Exposure
ndash Expose and examine all parts ndash Cover quickly and keep warm
bull Secondary Survey
Bad Scene Responses
bull What are the outcomes of out-of-hospital cardiac arrest from blunt trauma
bull What are the outcomes of pediatric drowning patients
OHCA from Trauma
bull 2000-2003 bull 123 pts bull Mean age 73 yrs bull Most common
rhythms ndash Asystole 59 ndash PEA 29 ndash V-fib 35
bull 195 rosc in field ndash 98 survived for 24
hrs ndash 57 survived to
discharge ndash Drowning- 19
survival to discharge ndash Bystander CPR tripled
the survivor rate
Blunt Trauma- No Signs of Life
bull Review from 2002-2010 bull No signs of life- 025 of blunt trauma
ndash 25 resuscitated prior to hospital arrival bull 138 of these patients survived to discharge
bull 44 overall survived to hospital discharge
OHCA with CPR on Arrival
bull 169 children bull 141 deaths bull 69 required cpr on arrival- none survived bull 87 of patients requiring CPR on arrival
expired in the ED bull Of the 28 survivors
ndash 55 of survivors had full neurologic recovery
Pediatric Trauma
bull Fortunately these cases represent only a small fraction of EMS transports
bull Despite a few key differences pediatric trauma care overall is very similar to adult trauma care
Questions
References 1 bull NTDB 2013 pediatric Report bull Monkey bars httpsplaygroundchroniclesfileswordpresscom201307soccerjpg bull Screaming child httpblogsbabycentercomwp-contentuploads201409screaming-child-tantrum-fitjpg bull Pediatric airway image httpwwwcelebritydiagnosiscomwp-contentuploads201003pediatric-airwayjpg bull Child on backboard httpsencrypted-tbn2gstaticcomimagesq=tbnANd9GcQscrDVc8IH4MwkNGF6F1A9p7mSVzik5zrWyNvI-
qSwQT5S3GNyVg bull Elbow fracture httpwwwimageinterpretationcoukimageselbowSUPRACONDYLAR20LAT3jpg bull Bike riding httpsmile-per-daycomwp-contentuploads201412klr03jpg bull Dad and child pic httplaughingsquidcomwp-contentuploads471160jpg bull Weigth estimation inner city Am J Emerg Med 2015 Oct33(10)1364-7 doi 101016jajem201507040 Epub 2015 Jul 29 Weight
estimation in an inner-city pediatric ED the effect of obesity Chavez H1 Peterson RE2 Lo K3 Arel M4
bull Guess weight sign httpmedialiveauctiongroupneti963110572971_1jpgv=8CDDAAF8A5B9E20 bull Broselow tape httpsuploadwikimediaorgwikipediacommons994BTape1jpg bull Parent screaming httpmommyofamonstercomwp-contentuploads201301yellingjpg bull Prehospital pain management Am J Emerg Med 2015 Mar33(3)451-4 doi 101016jajem201412012 Epub 2014 Dec 18
Prehospital pain management of injured children a systematic review of current evidence Samuel N1 Steiner IP2 Shavit I3 bull Prehospital pain ped pain assessment Prehosp Emerg Care 2008 Apr-Jun12(2)182-6 doi 10108010903120801907471 Prehospital
pain assessment in pediatric trauma Izsak E1 Moore JL Stringfellow K Oswanski MF Lindstrom DA Stombaugh HA bull Ped pain management Prehosp Emerg Care 2005 Jan-Mar9(1)40-3 Prehospital pain management in children suffering traumatic
injury Swor R1 McEachin CM Seguin D Grall KH bull Prehospital intervention Allen CJ Teisch LF et al Prehospital care and transportation of pediatric trauma patients J Surg Res 2015
Aug197(2)240-6 JAMA 2000 Feb 9283(6)783-90 bull Effect of out-of-hospital pediatric endotracheal intubation on survival and neurological outcome a controlled clinical trial
Gausche M1 Lewis RJ Stratton SJ Haynes BE Gunter CS Goodrich SM Poore PD McCollough MD Henderson DP Pratt FD Seidel JS
bull Pediatric pain management survey Pediatr Emerg Care 2015 Sep 23 [Epub ahead of print] An Assessment of Newly Identified Barriers to and Enablers for Prehospital Pediatric Pain Management Whitley DE1 Li T Jones CM Cushman JT Williams DM Shah MN
References 2 bull httpwwwuptodatecomcontentsprehospital-pediatrics-and-emergency-medical-services-emsabstract6 bull httpwwwuptodatecomcontentsprehospital-pediatrics-and-emergency-medical-services-emsabstract7 bull Pediatr Crit Care Med 2011 Jul12(4)e166-70 doi 101097PCC0b013e3181f36f6e First responder
performance in pediatric trauma a comparison with an adult cohortBankole S1 Asuncion A Ross S Aghai Z Nollah L Echols H Da-Silva S
bull Drayna pc Browne LR et al Prehospital pediatric care Oppportunities for training treatment and research Prehosp Emerg Care 2015 Jul-Sep 19(3) Epub 2015 Feb 6
bull Pediatr Emerg Care 2001 Feb17(1) 5-9Pediatric pre-hospital advanced life support care in an urban setting Babl FE1 Vinci RJ Bauchner H Mottley L
bull Pediatr Crit Care Med 2015 Oct16(8)e260-7 doi 101097PCC0000000000000505Pediatric Out-of-Hospital Critical Procedures in the United States Carlson JN1 Gannon E Mann NC Jacobson KE Dai M Colleran C Wang HE
bull Pediatr Emerg Care 2009 Aug25(8)508-12 doi 101097PEC0b013e3181b0a0da The efficacy of pediatric advanced life support training in emergency medical service providers Baker TW1 King W Soto W Asher C Stolfi A Rowin ME
bull Sutton RM Case E et al ROC investigators A quantitative analysis of out-of-hospital pediatric and adolescent resuscitation quality A report from the ROC Epistry- Cardiac Arrest Resusciation 201593150-157
bull Resuscitation 2014 Aug85(8)1059-64 doi 101016jresuscitation201403307 Epub 2014 Apr 4 Neurocognitive long term follow-up study on drowned children Suominen PK1 Sutinen N2 Valle S3 Olkkola KT4 Loumlnnqvist T3
bull J Pediatr Surg 2010 Jul45(7)1413-9 doi 101016jjpedsurg200912020 Prehospital cardiopulmonary resuscitation in the pediatric trauma patient Murphy JT1 Jaiswal K Sabella J Vinson L Megison S Maxson RT
References 3 bull Pre atv accident
httpwwwctvnewscapolopoly_fs119871591409741949httpImageimagejpg_genderivativeslandscape_960imagejpg bull atv pic httpswwwutahadvocatescomwp-contentuploads201402atvAccidentLawyerjpg bull Blunt abdominal solid organ injury adult vs pediatric trauma center J Pediatr Surg 2015 Aug 28 pii S0022-3468(15)00526-6 doi
101016jjpedsurg201508012 [Epub ahead of print] Trauma center variation in the management of pediatric patients with blunt abdominal solid organ injury a national trauma data bank analysis Safavi A1 Skarsgard ED2 Rhee P1 Zangbar B1 Kulvatunyou N1 Tang A1 OKeeffe T1 Friese RS1 Joseph B3
bull Pediatric blunt abdominal injury Curr Opin Crit Care 2015 Sep 28 [Epub ahead of print] Pediatric blunt abdominal trauma current management Notrica DM1
bull Pediatric splenic injury management Am J Surg 2015 Jul 31 pii S0002-9610(15)00417-1 doi 101016jamjsurg201506009 [Epub ahead of print] Comparative effectiveness of treatment strategies for severe splenic trauma in the pediatric population Rialon KL1 Englum BR1 Gulack BC1 Guevara CJ2 Bhattacharya SD3 Shapiro ML4 Rice HE5 Scarborough JE4 Adibe OO6
bull Liver pic httpss-media-cache-ak0pinimgcom736x7da50e7da50eb2bb603c99ef6649ff897e26b5jpg bull Solid organ injury non op in peds J Trauma Acute Care Surg 2015 Oct79(4)683-93 doi 101097TA0000000000000808
Nonoperative management of blunt liver and spleen injury in children Evaluation of the ATOMAC guideline using GRADE Notrica DM1 Eubanks JW 3rd Tuggle DW Maxson RT Letton RW Garcia NM Alder AC Lawson KA St Peter SD Megison S Garcia Filion P
bull Pediaric vs nonped trauma ct use J Pediatr 2015 Oct167(4)897-904e3 doi 101016jjpeds201506052 Epub 2015 Jul 29 Variation in Computed Tomography Imaging for Pediatric Injury-Related Emergency Visits Marin JR1 Wang L2 Winger DG2 Mannix RC3
bull Solid organ management in ped population J Trauma Acute Care Surg 2015 Aug79(2)206-14quiz 332 doi 101097TA0000000000000731 Management of children with solid organ injuries after blunt torso trauma Wisner DH1 Kuppermann N Cooper A Menaker J Ehrlich P Kooistra J Mahajan P Lee L Cook LJ Yen K Lillis K Holmes JF
bull Triad of death image httpimageslidesharecdncomdamage-control-resuscitation-1304253390-phpapp0195damage-control-resuscitation-14-728jpgcb=1304235553
bull Tranexamic acid study Eckert MJ Wertin TM Tyner SD et al 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 77852
bull Image care accident httpsuploadwikimediaorgwikipediacommonsthumbee1Car_crash_1jpg1280px-Car_crash_1jpg
References 4 bull httpwwwsurgeryvcuedudivisionsacutesurghtml bull Trauma management Approach to the unstable child
httpwwwuptodatecomcontentstrauma-management-approach-to-the-unstable-childsource=search_resultampsearch=pediatric+trauma+childrenampselectedTitle=17E150
bull Trauma management Unique pediatric considerations httpwwwuptodatecomcontentstrauma-management-unique-pediatric-considerationssource=search_resultampsearch=pediatric+trauma+childrenampselectedTitle=37E150
References 5 bull httpwwwetiquettehellcomsmfindexphptopic=8666360 bull httpwwwstlouischildrensorghealth-care-professionalsems-providers bull httpwwwuchicagokidshospitalorgspecialtiesemergency-medicinespecialhtml bull httpwwwsimsacademyinfoFXpatienthtm bull httptheemtspotcomwp-contentuploads200902another-burn-patient-by-annette-larsonjpg bull httplastangryfancomwp-contentuploads200910Clint-Malarchukjpg bull httpwwwtraumaorgarchiveresusmassivehtml bull httpwwwuptodatecomcontentsimageimageKey=PEDS68694amptopicKey=EM2F6389ampsourc
e=previewampsearch=pediatric+hemorrhagic+shockampselectedTitle=17E150amprank=undefined bull httptheemtspotcomwp-contentuploads200902gcsgif bull httpwwwuptodatecomcontentsimageimageKey=EM2F60409amptopicKey=EM2F6571amprank
=17E150ampsource=see_linkampsearch=traumaamputdPopup=true bull httpwwwuptodatecomcontentsimageimageKey=EM2F80874amptopicKey=EM2F6571amprank
=17E150ampsource=see_linkampsearch=traumaamputdPopup=true bull httpempracticenewswordpresscomcategorynexus-criteria bull httpswwwgooglecomsearchq=pediatric+glasgow+coma+scaleamptbm=ischamptbo=uampsource=uni
vampsa=Xampei=8TiOU7TNC5WuyATp5YG4BQampsqi=2ampved=0CDYQsAQampbiw=1426ampbih=883q=canadian+c-spine+rulesamptbm=ischampfacrc=_ampimgdii=_ampimgrc=WI94QMHgMLTQmM253A3BP5nbsFhNCXK0FM3Bhttp253A252F252Fwwwbmjcom252Fhighwire252Ffilestream252F436003252Ffield_highwire_fragment_image_l252F0jpg3Bhttp253A252F252Fwwwbmjcom252Fcontent252F339252Fbmjb41463B12803B1253
References 5 bull httpwwwuptodatecomcontentsimageimageKey=EM2F76777amptopicKey=EM2F6571amprank
=17E150ampsource=see_linkampsearch=traumaamputdPopup=true bull httpwwwdocumentingrealitycomforumattachmentsf14964898d1246625322-firework-injury-
m80injury1jpg bull httpwwwpediatriceducationorg20050620 bull httpwwwarmstrongmedicalcomindexcfmgoproductdetailsec3ssec19cat61fam515 bull httpwwwuptodatecomcontentsimageimageKey=PEDS61087amptopicKey=ID2F7661ampsource
=outline_linkampsearch=tetanus+prophylaxisamputdPopup=true bull httpwwwafsecafmilsharedmediaphotodbweb110609-F-MJ378-009jpg bull httpwwwuptodatecomcontentsimageimageKey=EM75765amptopicKey= bull EM2F6389ampsource=outline_linkampsearch=massive+transfusion+protocolamputdPopup=true bull httpwwwmotifakecomimagedemotivational-postersmall0910whats-the-question-ignorance-
calvin-and-hobbes-demotivational-poster-1255020127jpg
XXXXBoston study ems peds trauma procedures- limited pediatric procedural exposure (but more adult experience) bull Catchment area 590000
over 1 year bull 555 pediatric ALS
transport ndash 19 blunt trauma ndash 10 penetrating trauma
bull IV 33 bull BMV 5 bull Intubation 3 bull 50 ALS providers average
year ndash IV- 37 ndash Intubation- 03 ndash IO- 006
bull 7 ped ems ndash 13 trauma
bull Critical procedures ndash 101000 peds cases ndash Intubation 671000 ndash IO 51000 ndash 81 successful
Pediatr Emerg Care 2001 Feb17(1)5-9 Pediatric pre-hospital advanced life support care in an urban setting
Babl FE1 Vinci RJ Bauchner H Mottley L
Pediatr Crit Care Med 2015 Oct16(8)e260-7 doi 101097PCC0000000000000505 Pediatric Out-of-Hospital Critical Procedures in the United States
Carlson JN1 Gannon E Mann NC Jacobson KE Dai M Colleran C Wang HE
C-spine bull C-spine injuries rare bull Take pt to closest hospital if over injuries
call for it (ie resuscitation altered mental status) primary guide
bull Mechanism ndash Altered mental status focal neuro change
torticollis substantial torso injury diving high speed auto neck pain underlying predisposing condition Acad Emerg Med 2014 Jan21(1)55-64 doi 101111acem12288
Comparison of outcomes for children with cervical spine injury based on destination hospital from scene of injury Anders JF1 Adelgais K Hoyle JD Jr Olsen C Jaffe DM Leonard JC Pediatric Emergency Care Applied Research Network
(PECARN)
Ann Emerg Med 2011 Aug58(2)145-55 doi 101016jannemergmed201008038 Epub 2010 Oct 29 Factors associated with cervical spine injury in children after blunt trauma
Leonard JC Kuppermann N Olsen C Babcock-Cimpello L Brown K Mahajan P Adelgais KM Anders J Borgialli D Donoghue A Hoyle JD Jr Kim E Leonard JR Lillis KA Nigrovic LE Powell EC Rebella
G Reeves SD Rogers AJ Stankovic C Teshome G Jaffe DM Pediatric Emergency Care Applied Research Network
- Itrsquos Hard to Put a Band-Aid on a Broken Spleen Pediatric Trauma
- Disclosures
- Objectives
- Pediatric Prehospital Care
- Mechanism
- Traumatic Pain Management
- Pediatric Trauma
- Deaths by Mechanism of Injury
- Pediatric Trauma
- Pediatric Trauma
- Airway Differences
- Pediatric-Adult Differences
- Pediatric Challenges
- Prehospital Pediatric Challenges
- Pediatric and Adult Trauma
- Scene Response
- Prehospital Intervention
- Where do you take the patient
- Patient arrives at the EDhellip
- Primary Survey
- Order is critical
- Slide Number 22
- Slide Number 23
- Airway
- Indications for Intubation
- Breathing
- ETT Intubation Basics
- Circulation
- Slide Number 29
- CirculationHemodynamic Changes
- Circulation
- Fluid Resuscitation Algorithm
- Reconsidering Crystalloid Resuscitation
- When to start MTP
- Disability
- Finishing Up the Evaluation
- Bad Scene Responses
- OHCA from Trauma
- Blunt Trauma- No Signs of Life
- OHCA with CPR on Arrival
- Pediatric Trauma
- Questions
- References 1
- References 2
- References 3
- References 4
- References 5
- References 5
- XXXXBoston study ems peds trauma procedures- limited pediatric procedural exposure (but more adult experience)
- C-spine
Traumatic Pain Management
bull Pain ndash Under-assessed ndash Undertreated
Pediatric Trauma bull Leading cause of death and disability bull Trauma gt 11000 pediatric deathsyear bull Trauma causes more pediatric death than
all other causes combined Causes of
death Ages 1-14 years
Deaths by Mechanism of Injury
NTDB Pediatric report 2007
Pediatric Trauma bull Kids ne Adults bull Smaller body mass
ndash Crowded trauma bed ndash Less muscle and fat for protection ndash Bones are less calcified and more pliable
bull Underlying injuries occur without fractures ndash Greater force per region
bull More systems often affected bull Waddel and Druckerrsquos Triad
ndash Lower extremity ndash Abdomenchest ndash Head
Pediatric Trauma
bull Larger heads alter airway alignment bull Weaker necks increase c-spine injury risk
wwwebmedicinenet
Airway Differences
bull Smaller airway ndash Smaller oral opening ndash Larger tongue in proportion
bull Larynx ndash More cephalad and anterior ndash More acute angle to access the cords
bull Limited functional residual capacity bull Faster to desaturation
Pediatric-Adult Differences
bull Greater BSA more prone to hypothermia bull Higher risk with radiation exposure bull Weight-based interventions bull Greater success with conservative care
Pediatric Challenges
bull Parents bull Non-accidental trauma bull Neglect bull Medically complex kids bull Pediatric patient exposure bull Pediatric intervention experience
Prehospital Pediatric Challenges
bull Less pediatric exposure ndash Experience
bull Critical procedures ~1 of transports bull CPR BMV or advanced airway in 04 of patients bull ALS specific transports BMV 5 ETI 3
bull Less success in pediatric patients ndash IV access success- 86 adult vs 66 kids ndash Intubating problems- 69 peds vs 21 adults
Pediatric and Adult Trauma
bull Trimodal death distribution ndash 1st peak- seconds to minutes after
bull Impacted by prevention ndash 2nd peak- minutes to hours after
bull ldquoGolden Hourrdquo bull Rapid assessment and treatment
ndash 3rd peak- days to weeks bull Quality pediatric care limits morbidity and mortality bull Infection and multi-organ failure
Scene Response
bull 8 year old male in a rollover atv accident
bull Pt is unresponsive localizes pain wonrsquot open his eyes
bull HR 130 BP 10060 bull RR 10 O2 sat 93 bull What do you want to do
Prehospital Intervention
bull Pre-hospital interventions did not significantly worsen care ndash Similar transport times ndash Similar mortality length of stay
bull ETI vs BMV ndash No difference in survival ndash No difference in neurological outcome
Where do you take the patient
bull Pediatric trauma centers ndash Less surgery on solid organ injuries ndash Less radiation- of scans and dosage ndash Less comorbidities
bull Lower costs bull Shorter length of stay bull Lower infections bull Less multi-organ failure
Patient arrives at the EDhellip
bull Where do you start ndash Primary Survey
Primary Survey bull Your ABCrsquoshellip
bull Airway bull Breathing bull Circulation bull Disability (Neuro- GCS) bull Exposure
Order is critical
bull A before B or C bull Morbiditymortality will
occur much faster from airway compromise than from breathing or circulatory problems
bull Systematic approach is the cornerstone of ATLS success
httpwwwuptodatecomcontentsimageimageKey=EM2F64241amptopicKey=EM2F6571amprank=17E150ampsource=see_linkampsearch=traumaamputdPopup=true
httpwwwuptodatecomcontentsimageimageKey=EM2F64241amptopicKey=EM2F6571amprank=17E150ampsource=see_linkampsearch=traumaamputdPopup=true
Airway bull What are you assessing
ndash Airway patency bull What makes the airway not patent
ndash Foreign bodies ndash Vomitbloodsecretions ndash Edemahematoma ndash Impending obstruction
bull Interventions ndash Clearing foreign bodies ndash Suction secretionsvomit with yankauer ndash Repositioning- jaw thrust ndash Nasal trumpetoral airway ndash Intubation ndash Cricothyrotomy jet ventilation
Indications for Intubation
bull Respiratory arrest bull Impending respiratory failure bull Impending airway obstruction bull Inability to protect the airway bull GCS lt8 bull Declining GCS
Breathing bull What are you assessing
ndash ldquoGoodrdquo symmetric chest rise ndash Lung sounds ndash Aeration ndash Basic RR assessment (fast or minimalnone)
bull Interventions ndash Oxygen ndash Albuterolatrovent racemic epi ndash Positive pressure (CPAP BIPAP BMV) ndash Needle decompression ndash Chest tube thoracostomy ndash Intubation ndash Jet ventilation
ETT Intubation Basics bull Size
ndash Age4 + 4 or (Age +16)4 bull Depth
ndash ~ 3 x ETT size when over 1 year of age bull Blade size mac vs miller
ndash 0~ newborn ndash 1~ up to 2 years of life ndash 2~ 2-10 years ndash 3~ 10+ years
bull RSI medications ndash +-Sedation (Always before paralytic) ndash +-Paralytic (May not need it and never wo sedation)
Circulation
bull What do you assess ndash Central and peripheral pulses ndash Heart rate ndash Blood pressure systolic (age x2) +70 ndash Capillary refill ndash Cardiac activity on FAST ndash End organ perfusion
bull Mental status bull Urine output
Circulation Hemodynamic Changes
Percent Blood Volume Loss 0 15 25 35 45
Heart Rate
Blood Pressure
Cardiac Output
Circulation
ndash Access 2 large bore IVrsquos ndash IVFrsquos ndash pRBCrsquos
bull Hgb lt7gdl or ongoing blood losses
ndash Massive Transfusion Protocol
bull (111 ratio of PRBCS FFP Platelets)
ndash Vasopressors (epi norepi dopamine)
ndash Control of Hemorrhage bull Pelvic binders bull Direct pressure bull Indirectproximal pressure bull Tourniquet (only when
absolutely necessary)
ndash Chest Compressions ndash Pericardiocentesis ndash Delayed resuscitation
controlled hypotension (MAP 50 vs 65)
ndash Tranexamic acid in the near future
bull Interventions
Fluid Resuscitation Algorithm 20 mLkg isotonic crystalloid
Reassess
20 mLkg isotonic crystalloid
Reassess
20 mLkg isotonic crystalloid (31 rule)
or consider 10 to 20 mLkg packed red cells
Reconsidering Crystalloid Resuscitation
bull Less fluid ndash Permissive hypotension to
prevent clot rupture (select cases)
bull Too much fluid ndash Excessive Third Spacing ndash Secondary Compartment
Syndrome ndash Greater risk of ARDS ndash Dilutional Coagulopathy
When to start MTP
bull As soon as you believe you will need it ndash Institution specific guidelines
bull gt4 units or 40mlkg of PRBCrsquos expected bull Earlier use of Massive Transfusion Protocol
(pRBC FFP PLT) in ldquoDamage Controlrdquo resuscitations may improve outcome
bull 111 unit ratio bull Risk of TRALI ARDS etc
Disability bull GCS
ndash Range 3-15 ndash We should be 15 ndash Dead are still 3 ndash Less than 8 intubate ndash Eyes- 4 eyes ndash Verbal- most difficult ndash Motor- V6 engine ndash Intubated T
bull AVPU
Finishing Up the Evaluation
bull Airway bull Breathing bull Circulation bull Disability bull Exposure
ndash Expose and examine all parts ndash Cover quickly and keep warm
bull Secondary Survey
Bad Scene Responses
bull What are the outcomes of out-of-hospital cardiac arrest from blunt trauma
bull What are the outcomes of pediatric drowning patients
OHCA from Trauma
bull 2000-2003 bull 123 pts bull Mean age 73 yrs bull Most common
rhythms ndash Asystole 59 ndash PEA 29 ndash V-fib 35
bull 195 rosc in field ndash 98 survived for 24
hrs ndash 57 survived to
discharge ndash Drowning- 19
survival to discharge ndash Bystander CPR tripled
the survivor rate
Blunt Trauma- No Signs of Life
bull Review from 2002-2010 bull No signs of life- 025 of blunt trauma
ndash 25 resuscitated prior to hospital arrival bull 138 of these patients survived to discharge
bull 44 overall survived to hospital discharge
OHCA with CPR on Arrival
bull 169 children bull 141 deaths bull 69 required cpr on arrival- none survived bull 87 of patients requiring CPR on arrival
expired in the ED bull Of the 28 survivors
ndash 55 of survivors had full neurologic recovery
Pediatric Trauma
bull Fortunately these cases represent only a small fraction of EMS transports
bull Despite a few key differences pediatric trauma care overall is very similar to adult trauma care
Questions
References 1 bull NTDB 2013 pediatric Report bull Monkey bars httpsplaygroundchroniclesfileswordpresscom201307soccerjpg bull Screaming child httpblogsbabycentercomwp-contentuploads201409screaming-child-tantrum-fitjpg bull Pediatric airway image httpwwwcelebritydiagnosiscomwp-contentuploads201003pediatric-airwayjpg bull Child on backboard httpsencrypted-tbn2gstaticcomimagesq=tbnANd9GcQscrDVc8IH4MwkNGF6F1A9p7mSVzik5zrWyNvI-
qSwQT5S3GNyVg bull Elbow fracture httpwwwimageinterpretationcoukimageselbowSUPRACONDYLAR20LAT3jpg bull Bike riding httpsmile-per-daycomwp-contentuploads201412klr03jpg bull Dad and child pic httplaughingsquidcomwp-contentuploads471160jpg bull Weigth estimation inner city Am J Emerg Med 2015 Oct33(10)1364-7 doi 101016jajem201507040 Epub 2015 Jul 29 Weight
estimation in an inner-city pediatric ED the effect of obesity Chavez H1 Peterson RE2 Lo K3 Arel M4
bull Guess weight sign httpmedialiveauctiongroupneti963110572971_1jpgv=8CDDAAF8A5B9E20 bull Broselow tape httpsuploadwikimediaorgwikipediacommons994BTape1jpg bull Parent screaming httpmommyofamonstercomwp-contentuploads201301yellingjpg bull Prehospital pain management Am J Emerg Med 2015 Mar33(3)451-4 doi 101016jajem201412012 Epub 2014 Dec 18
Prehospital pain management of injured children a systematic review of current evidence Samuel N1 Steiner IP2 Shavit I3 bull Prehospital pain ped pain assessment Prehosp Emerg Care 2008 Apr-Jun12(2)182-6 doi 10108010903120801907471 Prehospital
pain assessment in pediatric trauma Izsak E1 Moore JL Stringfellow K Oswanski MF Lindstrom DA Stombaugh HA bull Ped pain management Prehosp Emerg Care 2005 Jan-Mar9(1)40-3 Prehospital pain management in children suffering traumatic
injury Swor R1 McEachin CM Seguin D Grall KH bull Prehospital intervention Allen CJ Teisch LF et al Prehospital care and transportation of pediatric trauma patients J Surg Res 2015
Aug197(2)240-6 JAMA 2000 Feb 9283(6)783-90 bull Effect of out-of-hospital pediatric endotracheal intubation on survival and neurological outcome a controlled clinical trial
Gausche M1 Lewis RJ Stratton SJ Haynes BE Gunter CS Goodrich SM Poore PD McCollough MD Henderson DP Pratt FD Seidel JS
bull Pediatric pain management survey Pediatr Emerg Care 2015 Sep 23 [Epub ahead of print] An Assessment of Newly Identified Barriers to and Enablers for Prehospital Pediatric Pain Management Whitley DE1 Li T Jones CM Cushman JT Williams DM Shah MN
References 2 bull httpwwwuptodatecomcontentsprehospital-pediatrics-and-emergency-medical-services-emsabstract6 bull httpwwwuptodatecomcontentsprehospital-pediatrics-and-emergency-medical-services-emsabstract7 bull Pediatr Crit Care Med 2011 Jul12(4)e166-70 doi 101097PCC0b013e3181f36f6e First responder
performance in pediatric trauma a comparison with an adult cohortBankole S1 Asuncion A Ross S Aghai Z Nollah L Echols H Da-Silva S
bull Drayna pc Browne LR et al Prehospital pediatric care Oppportunities for training treatment and research Prehosp Emerg Care 2015 Jul-Sep 19(3) Epub 2015 Feb 6
bull Pediatr Emerg Care 2001 Feb17(1) 5-9Pediatric pre-hospital advanced life support care in an urban setting Babl FE1 Vinci RJ Bauchner H Mottley L
bull Pediatr Crit Care Med 2015 Oct16(8)e260-7 doi 101097PCC0000000000000505Pediatric Out-of-Hospital Critical Procedures in the United States Carlson JN1 Gannon E Mann NC Jacobson KE Dai M Colleran C Wang HE
bull Pediatr Emerg Care 2009 Aug25(8)508-12 doi 101097PEC0b013e3181b0a0da The efficacy of pediatric advanced life support training in emergency medical service providers Baker TW1 King W Soto W Asher C Stolfi A Rowin ME
bull Sutton RM Case E et al ROC investigators A quantitative analysis of out-of-hospital pediatric and adolescent resuscitation quality A report from the ROC Epistry- Cardiac Arrest Resusciation 201593150-157
bull Resuscitation 2014 Aug85(8)1059-64 doi 101016jresuscitation201403307 Epub 2014 Apr 4 Neurocognitive long term follow-up study on drowned children Suominen PK1 Sutinen N2 Valle S3 Olkkola KT4 Loumlnnqvist T3
bull J Pediatr Surg 2010 Jul45(7)1413-9 doi 101016jjpedsurg200912020 Prehospital cardiopulmonary resuscitation in the pediatric trauma patient Murphy JT1 Jaiswal K Sabella J Vinson L Megison S Maxson RT
References 3 bull Pre atv accident
httpwwwctvnewscapolopoly_fs119871591409741949httpImageimagejpg_genderivativeslandscape_960imagejpg bull atv pic httpswwwutahadvocatescomwp-contentuploads201402atvAccidentLawyerjpg bull Blunt abdominal solid organ injury adult vs pediatric trauma center J Pediatr Surg 2015 Aug 28 pii S0022-3468(15)00526-6 doi
101016jjpedsurg201508012 [Epub ahead of print] Trauma center variation in the management of pediatric patients with blunt abdominal solid organ injury a national trauma data bank analysis Safavi A1 Skarsgard ED2 Rhee P1 Zangbar B1 Kulvatunyou N1 Tang A1 OKeeffe T1 Friese RS1 Joseph B3
bull Pediatric blunt abdominal injury Curr Opin Crit Care 2015 Sep 28 [Epub ahead of print] Pediatric blunt abdominal trauma current management Notrica DM1
bull Pediatric splenic injury management Am J Surg 2015 Jul 31 pii S0002-9610(15)00417-1 doi 101016jamjsurg201506009 [Epub ahead of print] Comparative effectiveness of treatment strategies for severe splenic trauma in the pediatric population Rialon KL1 Englum BR1 Gulack BC1 Guevara CJ2 Bhattacharya SD3 Shapiro ML4 Rice HE5 Scarborough JE4 Adibe OO6
bull Liver pic httpss-media-cache-ak0pinimgcom736x7da50e7da50eb2bb603c99ef6649ff897e26b5jpg bull Solid organ injury non op in peds J Trauma Acute Care Surg 2015 Oct79(4)683-93 doi 101097TA0000000000000808
Nonoperative management of blunt liver and spleen injury in children Evaluation of the ATOMAC guideline using GRADE Notrica DM1 Eubanks JW 3rd Tuggle DW Maxson RT Letton RW Garcia NM Alder AC Lawson KA St Peter SD Megison S Garcia Filion P
bull Pediaric vs nonped trauma ct use J Pediatr 2015 Oct167(4)897-904e3 doi 101016jjpeds201506052 Epub 2015 Jul 29 Variation in Computed Tomography Imaging for Pediatric Injury-Related Emergency Visits Marin JR1 Wang L2 Winger DG2 Mannix RC3
bull Solid organ management in ped population J Trauma Acute Care Surg 2015 Aug79(2)206-14quiz 332 doi 101097TA0000000000000731 Management of children with solid organ injuries after blunt torso trauma Wisner DH1 Kuppermann N Cooper A Menaker J Ehrlich P Kooistra J Mahajan P Lee L Cook LJ Yen K Lillis K Holmes JF
bull Triad of death image httpimageslidesharecdncomdamage-control-resuscitation-1304253390-phpapp0195damage-control-resuscitation-14-728jpgcb=1304235553
bull Tranexamic acid study Eckert MJ Wertin TM Tyner SD et al 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 77852
bull Image care accident httpsuploadwikimediaorgwikipediacommonsthumbee1Car_crash_1jpg1280px-Car_crash_1jpg
References 4 bull httpwwwsurgeryvcuedudivisionsacutesurghtml bull Trauma management Approach to the unstable child
httpwwwuptodatecomcontentstrauma-management-approach-to-the-unstable-childsource=search_resultampsearch=pediatric+trauma+childrenampselectedTitle=17E150
bull Trauma management Unique pediatric considerations httpwwwuptodatecomcontentstrauma-management-unique-pediatric-considerationssource=search_resultampsearch=pediatric+trauma+childrenampselectedTitle=37E150
References 5 bull httpwwwetiquettehellcomsmfindexphptopic=8666360 bull httpwwwstlouischildrensorghealth-care-professionalsems-providers bull httpwwwuchicagokidshospitalorgspecialtiesemergency-medicinespecialhtml bull httpwwwsimsacademyinfoFXpatienthtm bull httptheemtspotcomwp-contentuploads200902another-burn-patient-by-annette-larsonjpg bull httplastangryfancomwp-contentuploads200910Clint-Malarchukjpg bull httpwwwtraumaorgarchiveresusmassivehtml bull httpwwwuptodatecomcontentsimageimageKey=PEDS68694amptopicKey=EM2F6389ampsourc
e=previewampsearch=pediatric+hemorrhagic+shockampselectedTitle=17E150amprank=undefined bull httptheemtspotcomwp-contentuploads200902gcsgif bull httpwwwuptodatecomcontentsimageimageKey=EM2F60409amptopicKey=EM2F6571amprank
=17E150ampsource=see_linkampsearch=traumaamputdPopup=true bull httpwwwuptodatecomcontentsimageimageKey=EM2F80874amptopicKey=EM2F6571amprank
=17E150ampsource=see_linkampsearch=traumaamputdPopup=true bull httpempracticenewswordpresscomcategorynexus-criteria bull httpswwwgooglecomsearchq=pediatric+glasgow+coma+scaleamptbm=ischamptbo=uampsource=uni
vampsa=Xampei=8TiOU7TNC5WuyATp5YG4BQampsqi=2ampved=0CDYQsAQampbiw=1426ampbih=883q=canadian+c-spine+rulesamptbm=ischampfacrc=_ampimgdii=_ampimgrc=WI94QMHgMLTQmM253A3BP5nbsFhNCXK0FM3Bhttp253A252F252Fwwwbmjcom252Fhighwire252Ffilestream252F436003252Ffield_highwire_fragment_image_l252F0jpg3Bhttp253A252F252Fwwwbmjcom252Fcontent252F339252Fbmjb41463B12803B1253
References 5 bull httpwwwuptodatecomcontentsimageimageKey=EM2F76777amptopicKey=EM2F6571amprank
=17E150ampsource=see_linkampsearch=traumaamputdPopup=true bull httpwwwdocumentingrealitycomforumattachmentsf14964898d1246625322-firework-injury-
m80injury1jpg bull httpwwwpediatriceducationorg20050620 bull httpwwwarmstrongmedicalcomindexcfmgoproductdetailsec3ssec19cat61fam515 bull httpwwwuptodatecomcontentsimageimageKey=PEDS61087amptopicKey=ID2F7661ampsource
=outline_linkampsearch=tetanus+prophylaxisamputdPopup=true bull httpwwwafsecafmilsharedmediaphotodbweb110609-F-MJ378-009jpg bull httpwwwuptodatecomcontentsimageimageKey=EM75765amptopicKey= bull EM2F6389ampsource=outline_linkampsearch=massive+transfusion+protocolamputdPopup=true bull httpwwwmotifakecomimagedemotivational-postersmall0910whats-the-question-ignorance-
calvin-and-hobbes-demotivational-poster-1255020127jpg
XXXXBoston study ems peds trauma procedures- limited pediatric procedural exposure (but more adult experience) bull Catchment area 590000
over 1 year bull 555 pediatric ALS
transport ndash 19 blunt trauma ndash 10 penetrating trauma
bull IV 33 bull BMV 5 bull Intubation 3 bull 50 ALS providers average
year ndash IV- 37 ndash Intubation- 03 ndash IO- 006
bull 7 ped ems ndash 13 trauma
bull Critical procedures ndash 101000 peds cases ndash Intubation 671000 ndash IO 51000 ndash 81 successful
Pediatr Emerg Care 2001 Feb17(1)5-9 Pediatric pre-hospital advanced life support care in an urban setting
Babl FE1 Vinci RJ Bauchner H Mottley L
Pediatr Crit Care Med 2015 Oct16(8)e260-7 doi 101097PCC0000000000000505 Pediatric Out-of-Hospital Critical Procedures in the United States
Carlson JN1 Gannon E Mann NC Jacobson KE Dai M Colleran C Wang HE
C-spine bull C-spine injuries rare bull Take pt to closest hospital if over injuries
call for it (ie resuscitation altered mental status) primary guide
bull Mechanism ndash Altered mental status focal neuro change
torticollis substantial torso injury diving high speed auto neck pain underlying predisposing condition Acad Emerg Med 2014 Jan21(1)55-64 doi 101111acem12288
Comparison of outcomes for children with cervical spine injury based on destination hospital from scene of injury Anders JF1 Adelgais K Hoyle JD Jr Olsen C Jaffe DM Leonard JC Pediatric Emergency Care Applied Research Network
(PECARN)
Ann Emerg Med 2011 Aug58(2)145-55 doi 101016jannemergmed201008038 Epub 2010 Oct 29 Factors associated with cervical spine injury in children after blunt trauma
Leonard JC Kuppermann N Olsen C Babcock-Cimpello L Brown K Mahajan P Adelgais KM Anders J Borgialli D Donoghue A Hoyle JD Jr Kim E Leonard JR Lillis KA Nigrovic LE Powell EC Rebella
G Reeves SD Rogers AJ Stankovic C Teshome G Jaffe DM Pediatric Emergency Care Applied Research Network
- Itrsquos Hard to Put a Band-Aid on a Broken Spleen Pediatric Trauma
- Disclosures
- Objectives
- Pediatric Prehospital Care
- Mechanism
- Traumatic Pain Management
- Pediatric Trauma
- Deaths by Mechanism of Injury
- Pediatric Trauma
- Pediatric Trauma
- Airway Differences
- Pediatric-Adult Differences
- Pediatric Challenges
- Prehospital Pediatric Challenges
- Pediatric and Adult Trauma
- Scene Response
- Prehospital Intervention
- Where do you take the patient
- Patient arrives at the EDhellip
- Primary Survey
- Order is critical
- Slide Number 22
- Slide Number 23
- Airway
- Indications for Intubation
- Breathing
- ETT Intubation Basics
- Circulation
- Slide Number 29
- CirculationHemodynamic Changes
- Circulation
- Fluid Resuscitation Algorithm
- Reconsidering Crystalloid Resuscitation
- When to start MTP
- Disability
- Finishing Up the Evaluation
- Bad Scene Responses
- OHCA from Trauma
- Blunt Trauma- No Signs of Life
- OHCA with CPR on Arrival
- Pediatric Trauma
- Questions
- References 1
- References 2
- References 3
- References 4
- References 5
- References 5
- XXXXBoston study ems peds trauma procedures- limited pediatric procedural exposure (but more adult experience)
- C-spine
Pediatric Trauma bull Leading cause of death and disability bull Trauma gt 11000 pediatric deathsyear bull Trauma causes more pediatric death than
all other causes combined Causes of
death Ages 1-14 years
Deaths by Mechanism of Injury
NTDB Pediatric report 2007
Pediatric Trauma bull Kids ne Adults bull Smaller body mass
ndash Crowded trauma bed ndash Less muscle and fat for protection ndash Bones are less calcified and more pliable
bull Underlying injuries occur without fractures ndash Greater force per region
bull More systems often affected bull Waddel and Druckerrsquos Triad
ndash Lower extremity ndash Abdomenchest ndash Head
Pediatric Trauma
bull Larger heads alter airway alignment bull Weaker necks increase c-spine injury risk
wwwebmedicinenet
Airway Differences
bull Smaller airway ndash Smaller oral opening ndash Larger tongue in proportion
bull Larynx ndash More cephalad and anterior ndash More acute angle to access the cords
bull Limited functional residual capacity bull Faster to desaturation
Pediatric-Adult Differences
bull Greater BSA more prone to hypothermia bull Higher risk with radiation exposure bull Weight-based interventions bull Greater success with conservative care
Pediatric Challenges
bull Parents bull Non-accidental trauma bull Neglect bull Medically complex kids bull Pediatric patient exposure bull Pediatric intervention experience
Prehospital Pediatric Challenges
bull Less pediatric exposure ndash Experience
bull Critical procedures ~1 of transports bull CPR BMV or advanced airway in 04 of patients bull ALS specific transports BMV 5 ETI 3
bull Less success in pediatric patients ndash IV access success- 86 adult vs 66 kids ndash Intubating problems- 69 peds vs 21 adults
Pediatric and Adult Trauma
bull Trimodal death distribution ndash 1st peak- seconds to minutes after
bull Impacted by prevention ndash 2nd peak- minutes to hours after
bull ldquoGolden Hourrdquo bull Rapid assessment and treatment
ndash 3rd peak- days to weeks bull Quality pediatric care limits morbidity and mortality bull Infection and multi-organ failure
Scene Response
bull 8 year old male in a rollover atv accident
bull Pt is unresponsive localizes pain wonrsquot open his eyes
bull HR 130 BP 10060 bull RR 10 O2 sat 93 bull What do you want to do
Prehospital Intervention
bull Pre-hospital interventions did not significantly worsen care ndash Similar transport times ndash Similar mortality length of stay
bull ETI vs BMV ndash No difference in survival ndash No difference in neurological outcome
Where do you take the patient
bull Pediatric trauma centers ndash Less surgery on solid organ injuries ndash Less radiation- of scans and dosage ndash Less comorbidities
bull Lower costs bull Shorter length of stay bull Lower infections bull Less multi-organ failure
Patient arrives at the EDhellip
bull Where do you start ndash Primary Survey
Primary Survey bull Your ABCrsquoshellip
bull Airway bull Breathing bull Circulation bull Disability (Neuro- GCS) bull Exposure
Order is critical
bull A before B or C bull Morbiditymortality will
occur much faster from airway compromise than from breathing or circulatory problems
bull Systematic approach is the cornerstone of ATLS success
httpwwwuptodatecomcontentsimageimageKey=EM2F64241amptopicKey=EM2F6571amprank=17E150ampsource=see_linkampsearch=traumaamputdPopup=true
httpwwwuptodatecomcontentsimageimageKey=EM2F64241amptopicKey=EM2F6571amprank=17E150ampsource=see_linkampsearch=traumaamputdPopup=true
Airway bull What are you assessing
ndash Airway patency bull What makes the airway not patent
ndash Foreign bodies ndash Vomitbloodsecretions ndash Edemahematoma ndash Impending obstruction
bull Interventions ndash Clearing foreign bodies ndash Suction secretionsvomit with yankauer ndash Repositioning- jaw thrust ndash Nasal trumpetoral airway ndash Intubation ndash Cricothyrotomy jet ventilation
Indications for Intubation
bull Respiratory arrest bull Impending respiratory failure bull Impending airway obstruction bull Inability to protect the airway bull GCS lt8 bull Declining GCS
Breathing bull What are you assessing
ndash ldquoGoodrdquo symmetric chest rise ndash Lung sounds ndash Aeration ndash Basic RR assessment (fast or minimalnone)
bull Interventions ndash Oxygen ndash Albuterolatrovent racemic epi ndash Positive pressure (CPAP BIPAP BMV) ndash Needle decompression ndash Chest tube thoracostomy ndash Intubation ndash Jet ventilation
ETT Intubation Basics bull Size
ndash Age4 + 4 or (Age +16)4 bull Depth
ndash ~ 3 x ETT size when over 1 year of age bull Blade size mac vs miller
ndash 0~ newborn ndash 1~ up to 2 years of life ndash 2~ 2-10 years ndash 3~ 10+ years
bull RSI medications ndash +-Sedation (Always before paralytic) ndash +-Paralytic (May not need it and never wo sedation)
Circulation
bull What do you assess ndash Central and peripheral pulses ndash Heart rate ndash Blood pressure systolic (age x2) +70 ndash Capillary refill ndash Cardiac activity on FAST ndash End organ perfusion
bull Mental status bull Urine output
Circulation Hemodynamic Changes
Percent Blood Volume Loss 0 15 25 35 45
Heart Rate
Blood Pressure
Cardiac Output
Circulation
ndash Access 2 large bore IVrsquos ndash IVFrsquos ndash pRBCrsquos
bull Hgb lt7gdl or ongoing blood losses
ndash Massive Transfusion Protocol
bull (111 ratio of PRBCS FFP Platelets)
ndash Vasopressors (epi norepi dopamine)
ndash Control of Hemorrhage bull Pelvic binders bull Direct pressure bull Indirectproximal pressure bull Tourniquet (only when
absolutely necessary)
ndash Chest Compressions ndash Pericardiocentesis ndash Delayed resuscitation
controlled hypotension (MAP 50 vs 65)
ndash Tranexamic acid in the near future
bull Interventions
Fluid Resuscitation Algorithm 20 mLkg isotonic crystalloid
Reassess
20 mLkg isotonic crystalloid
Reassess
20 mLkg isotonic crystalloid (31 rule)
or consider 10 to 20 mLkg packed red cells
Reconsidering Crystalloid Resuscitation
bull Less fluid ndash Permissive hypotension to
prevent clot rupture (select cases)
bull Too much fluid ndash Excessive Third Spacing ndash Secondary Compartment
Syndrome ndash Greater risk of ARDS ndash Dilutional Coagulopathy
When to start MTP
bull As soon as you believe you will need it ndash Institution specific guidelines
bull gt4 units or 40mlkg of PRBCrsquos expected bull Earlier use of Massive Transfusion Protocol
(pRBC FFP PLT) in ldquoDamage Controlrdquo resuscitations may improve outcome
bull 111 unit ratio bull Risk of TRALI ARDS etc
Disability bull GCS
ndash Range 3-15 ndash We should be 15 ndash Dead are still 3 ndash Less than 8 intubate ndash Eyes- 4 eyes ndash Verbal- most difficult ndash Motor- V6 engine ndash Intubated T
bull AVPU
Finishing Up the Evaluation
bull Airway bull Breathing bull Circulation bull Disability bull Exposure
ndash Expose and examine all parts ndash Cover quickly and keep warm
bull Secondary Survey
Bad Scene Responses
bull What are the outcomes of out-of-hospital cardiac arrest from blunt trauma
bull What are the outcomes of pediatric drowning patients
OHCA from Trauma
bull 2000-2003 bull 123 pts bull Mean age 73 yrs bull Most common
rhythms ndash Asystole 59 ndash PEA 29 ndash V-fib 35
bull 195 rosc in field ndash 98 survived for 24
hrs ndash 57 survived to
discharge ndash Drowning- 19
survival to discharge ndash Bystander CPR tripled
the survivor rate
Blunt Trauma- No Signs of Life
bull Review from 2002-2010 bull No signs of life- 025 of blunt trauma
ndash 25 resuscitated prior to hospital arrival bull 138 of these patients survived to discharge
bull 44 overall survived to hospital discharge
OHCA with CPR on Arrival
bull 169 children bull 141 deaths bull 69 required cpr on arrival- none survived bull 87 of patients requiring CPR on arrival
expired in the ED bull Of the 28 survivors
ndash 55 of survivors had full neurologic recovery
Pediatric Trauma
bull Fortunately these cases represent only a small fraction of EMS transports
bull Despite a few key differences pediatric trauma care overall is very similar to adult trauma care
Questions
References 1 bull NTDB 2013 pediatric Report bull Monkey bars httpsplaygroundchroniclesfileswordpresscom201307soccerjpg bull Screaming child httpblogsbabycentercomwp-contentuploads201409screaming-child-tantrum-fitjpg bull Pediatric airway image httpwwwcelebritydiagnosiscomwp-contentuploads201003pediatric-airwayjpg bull Child on backboard httpsencrypted-tbn2gstaticcomimagesq=tbnANd9GcQscrDVc8IH4MwkNGF6F1A9p7mSVzik5zrWyNvI-
qSwQT5S3GNyVg bull Elbow fracture httpwwwimageinterpretationcoukimageselbowSUPRACONDYLAR20LAT3jpg bull Bike riding httpsmile-per-daycomwp-contentuploads201412klr03jpg bull Dad and child pic httplaughingsquidcomwp-contentuploads471160jpg bull Weigth estimation inner city Am J Emerg Med 2015 Oct33(10)1364-7 doi 101016jajem201507040 Epub 2015 Jul 29 Weight
estimation in an inner-city pediatric ED the effect of obesity Chavez H1 Peterson RE2 Lo K3 Arel M4
bull Guess weight sign httpmedialiveauctiongroupneti963110572971_1jpgv=8CDDAAF8A5B9E20 bull Broselow tape httpsuploadwikimediaorgwikipediacommons994BTape1jpg bull Parent screaming httpmommyofamonstercomwp-contentuploads201301yellingjpg bull Prehospital pain management Am J Emerg Med 2015 Mar33(3)451-4 doi 101016jajem201412012 Epub 2014 Dec 18
Prehospital pain management of injured children a systematic review of current evidence Samuel N1 Steiner IP2 Shavit I3 bull Prehospital pain ped pain assessment Prehosp Emerg Care 2008 Apr-Jun12(2)182-6 doi 10108010903120801907471 Prehospital
pain assessment in pediatric trauma Izsak E1 Moore JL Stringfellow K Oswanski MF Lindstrom DA Stombaugh HA bull Ped pain management Prehosp Emerg Care 2005 Jan-Mar9(1)40-3 Prehospital pain management in children suffering traumatic
injury Swor R1 McEachin CM Seguin D Grall KH bull Prehospital intervention Allen CJ Teisch LF et al Prehospital care and transportation of pediatric trauma patients J Surg Res 2015
Aug197(2)240-6 JAMA 2000 Feb 9283(6)783-90 bull Effect of out-of-hospital pediatric endotracheal intubation on survival and neurological outcome a controlled clinical trial
Gausche M1 Lewis RJ Stratton SJ Haynes BE Gunter CS Goodrich SM Poore PD McCollough MD Henderson DP Pratt FD Seidel JS
bull Pediatric pain management survey Pediatr Emerg Care 2015 Sep 23 [Epub ahead of print] An Assessment of Newly Identified Barriers to and Enablers for Prehospital Pediatric Pain Management Whitley DE1 Li T Jones CM Cushman JT Williams DM Shah MN
References 2 bull httpwwwuptodatecomcontentsprehospital-pediatrics-and-emergency-medical-services-emsabstract6 bull httpwwwuptodatecomcontentsprehospital-pediatrics-and-emergency-medical-services-emsabstract7 bull Pediatr Crit Care Med 2011 Jul12(4)e166-70 doi 101097PCC0b013e3181f36f6e First responder
performance in pediatric trauma a comparison with an adult cohortBankole S1 Asuncion A Ross S Aghai Z Nollah L Echols H Da-Silva S
bull Drayna pc Browne LR et al Prehospital pediatric care Oppportunities for training treatment and research Prehosp Emerg Care 2015 Jul-Sep 19(3) Epub 2015 Feb 6
bull Pediatr Emerg Care 2001 Feb17(1) 5-9Pediatric pre-hospital advanced life support care in an urban setting Babl FE1 Vinci RJ Bauchner H Mottley L
bull Pediatr Crit Care Med 2015 Oct16(8)e260-7 doi 101097PCC0000000000000505Pediatric Out-of-Hospital Critical Procedures in the United States Carlson JN1 Gannon E Mann NC Jacobson KE Dai M Colleran C Wang HE
bull Pediatr Emerg Care 2009 Aug25(8)508-12 doi 101097PEC0b013e3181b0a0da The efficacy of pediatric advanced life support training in emergency medical service providers Baker TW1 King W Soto W Asher C Stolfi A Rowin ME
bull Sutton RM Case E et al ROC investigators A quantitative analysis of out-of-hospital pediatric and adolescent resuscitation quality A report from the ROC Epistry- Cardiac Arrest Resusciation 201593150-157
bull Resuscitation 2014 Aug85(8)1059-64 doi 101016jresuscitation201403307 Epub 2014 Apr 4 Neurocognitive long term follow-up study on drowned children Suominen PK1 Sutinen N2 Valle S3 Olkkola KT4 Loumlnnqvist T3
bull J Pediatr Surg 2010 Jul45(7)1413-9 doi 101016jjpedsurg200912020 Prehospital cardiopulmonary resuscitation in the pediatric trauma patient Murphy JT1 Jaiswal K Sabella J Vinson L Megison S Maxson RT
References 3 bull Pre atv accident
httpwwwctvnewscapolopoly_fs119871591409741949httpImageimagejpg_genderivativeslandscape_960imagejpg bull atv pic httpswwwutahadvocatescomwp-contentuploads201402atvAccidentLawyerjpg bull Blunt abdominal solid organ injury adult vs pediatric trauma center J Pediatr Surg 2015 Aug 28 pii S0022-3468(15)00526-6 doi
101016jjpedsurg201508012 [Epub ahead of print] Trauma center variation in the management of pediatric patients with blunt abdominal solid organ injury a national trauma data bank analysis Safavi A1 Skarsgard ED2 Rhee P1 Zangbar B1 Kulvatunyou N1 Tang A1 OKeeffe T1 Friese RS1 Joseph B3
bull Pediatric blunt abdominal injury Curr Opin Crit Care 2015 Sep 28 [Epub ahead of print] Pediatric blunt abdominal trauma current management Notrica DM1
bull Pediatric splenic injury management Am J Surg 2015 Jul 31 pii S0002-9610(15)00417-1 doi 101016jamjsurg201506009 [Epub ahead of print] Comparative effectiveness of treatment strategies for severe splenic trauma in the pediatric population Rialon KL1 Englum BR1 Gulack BC1 Guevara CJ2 Bhattacharya SD3 Shapiro ML4 Rice HE5 Scarborough JE4 Adibe OO6
bull Liver pic httpss-media-cache-ak0pinimgcom736x7da50e7da50eb2bb603c99ef6649ff897e26b5jpg bull Solid organ injury non op in peds J Trauma Acute Care Surg 2015 Oct79(4)683-93 doi 101097TA0000000000000808
Nonoperative management of blunt liver and spleen injury in children Evaluation of the ATOMAC guideline using GRADE Notrica DM1 Eubanks JW 3rd Tuggle DW Maxson RT Letton RW Garcia NM Alder AC Lawson KA St Peter SD Megison S Garcia Filion P
bull Pediaric vs nonped trauma ct use J Pediatr 2015 Oct167(4)897-904e3 doi 101016jjpeds201506052 Epub 2015 Jul 29 Variation in Computed Tomography Imaging for Pediatric Injury-Related Emergency Visits Marin JR1 Wang L2 Winger DG2 Mannix RC3
bull Solid organ management in ped population J Trauma Acute Care Surg 2015 Aug79(2)206-14quiz 332 doi 101097TA0000000000000731 Management of children with solid organ injuries after blunt torso trauma Wisner DH1 Kuppermann N Cooper A Menaker J Ehrlich P Kooistra J Mahajan P Lee L Cook LJ Yen K Lillis K Holmes JF
bull Triad of death image httpimageslidesharecdncomdamage-control-resuscitation-1304253390-phpapp0195damage-control-resuscitation-14-728jpgcb=1304235553
bull Tranexamic acid study Eckert MJ Wertin TM Tyner SD et al 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 77852
bull Image care accident httpsuploadwikimediaorgwikipediacommonsthumbee1Car_crash_1jpg1280px-Car_crash_1jpg
References 4 bull httpwwwsurgeryvcuedudivisionsacutesurghtml bull Trauma management Approach to the unstable child
httpwwwuptodatecomcontentstrauma-management-approach-to-the-unstable-childsource=search_resultampsearch=pediatric+trauma+childrenampselectedTitle=17E150
bull Trauma management Unique pediatric considerations httpwwwuptodatecomcontentstrauma-management-unique-pediatric-considerationssource=search_resultampsearch=pediatric+trauma+childrenampselectedTitle=37E150
References 5 bull httpwwwetiquettehellcomsmfindexphptopic=8666360 bull httpwwwstlouischildrensorghealth-care-professionalsems-providers bull httpwwwuchicagokidshospitalorgspecialtiesemergency-medicinespecialhtml bull httpwwwsimsacademyinfoFXpatienthtm bull httptheemtspotcomwp-contentuploads200902another-burn-patient-by-annette-larsonjpg bull httplastangryfancomwp-contentuploads200910Clint-Malarchukjpg bull httpwwwtraumaorgarchiveresusmassivehtml bull httpwwwuptodatecomcontentsimageimageKey=PEDS68694amptopicKey=EM2F6389ampsourc
e=previewampsearch=pediatric+hemorrhagic+shockampselectedTitle=17E150amprank=undefined bull httptheemtspotcomwp-contentuploads200902gcsgif bull httpwwwuptodatecomcontentsimageimageKey=EM2F60409amptopicKey=EM2F6571amprank
=17E150ampsource=see_linkampsearch=traumaamputdPopup=true bull httpwwwuptodatecomcontentsimageimageKey=EM2F80874amptopicKey=EM2F6571amprank
=17E150ampsource=see_linkampsearch=traumaamputdPopup=true bull httpempracticenewswordpresscomcategorynexus-criteria bull httpswwwgooglecomsearchq=pediatric+glasgow+coma+scaleamptbm=ischamptbo=uampsource=uni
vampsa=Xampei=8TiOU7TNC5WuyATp5YG4BQampsqi=2ampved=0CDYQsAQampbiw=1426ampbih=883q=canadian+c-spine+rulesamptbm=ischampfacrc=_ampimgdii=_ampimgrc=WI94QMHgMLTQmM253A3BP5nbsFhNCXK0FM3Bhttp253A252F252Fwwwbmjcom252Fhighwire252Ffilestream252F436003252Ffield_highwire_fragment_image_l252F0jpg3Bhttp253A252F252Fwwwbmjcom252Fcontent252F339252Fbmjb41463B12803B1253
References 5 bull httpwwwuptodatecomcontentsimageimageKey=EM2F76777amptopicKey=EM2F6571amprank
=17E150ampsource=see_linkampsearch=traumaamputdPopup=true bull httpwwwdocumentingrealitycomforumattachmentsf14964898d1246625322-firework-injury-
m80injury1jpg bull httpwwwpediatriceducationorg20050620 bull httpwwwarmstrongmedicalcomindexcfmgoproductdetailsec3ssec19cat61fam515 bull httpwwwuptodatecomcontentsimageimageKey=PEDS61087amptopicKey=ID2F7661ampsource
=outline_linkampsearch=tetanus+prophylaxisamputdPopup=true bull httpwwwafsecafmilsharedmediaphotodbweb110609-F-MJ378-009jpg bull httpwwwuptodatecomcontentsimageimageKey=EM75765amptopicKey= bull EM2F6389ampsource=outline_linkampsearch=massive+transfusion+protocolamputdPopup=true bull httpwwwmotifakecomimagedemotivational-postersmall0910whats-the-question-ignorance-
calvin-and-hobbes-demotivational-poster-1255020127jpg
XXXXBoston study ems peds trauma procedures- limited pediatric procedural exposure (but more adult experience) bull Catchment area 590000
over 1 year bull 555 pediatric ALS
transport ndash 19 blunt trauma ndash 10 penetrating trauma
bull IV 33 bull BMV 5 bull Intubation 3 bull 50 ALS providers average
year ndash IV- 37 ndash Intubation- 03 ndash IO- 006
bull 7 ped ems ndash 13 trauma
bull Critical procedures ndash 101000 peds cases ndash Intubation 671000 ndash IO 51000 ndash 81 successful
Pediatr Emerg Care 2001 Feb17(1)5-9 Pediatric pre-hospital advanced life support care in an urban setting
Babl FE1 Vinci RJ Bauchner H Mottley L
Pediatr Crit Care Med 2015 Oct16(8)e260-7 doi 101097PCC0000000000000505 Pediatric Out-of-Hospital Critical Procedures in the United States
Carlson JN1 Gannon E Mann NC Jacobson KE Dai M Colleran C Wang HE
C-spine bull C-spine injuries rare bull Take pt to closest hospital if over injuries
call for it (ie resuscitation altered mental status) primary guide
bull Mechanism ndash Altered mental status focal neuro change
torticollis substantial torso injury diving high speed auto neck pain underlying predisposing condition Acad Emerg Med 2014 Jan21(1)55-64 doi 101111acem12288
Comparison of outcomes for children with cervical spine injury based on destination hospital from scene of injury Anders JF1 Adelgais K Hoyle JD Jr Olsen C Jaffe DM Leonard JC Pediatric Emergency Care Applied Research Network
(PECARN)
Ann Emerg Med 2011 Aug58(2)145-55 doi 101016jannemergmed201008038 Epub 2010 Oct 29 Factors associated with cervical spine injury in children after blunt trauma
Leonard JC Kuppermann N Olsen C Babcock-Cimpello L Brown K Mahajan P Adelgais KM Anders J Borgialli D Donoghue A Hoyle JD Jr Kim E Leonard JR Lillis KA Nigrovic LE Powell EC Rebella
G Reeves SD Rogers AJ Stankovic C Teshome G Jaffe DM Pediatric Emergency Care Applied Research Network
- Itrsquos Hard to Put a Band-Aid on a Broken Spleen Pediatric Trauma
- Disclosures
- Objectives
- Pediatric Prehospital Care
- Mechanism
- Traumatic Pain Management
- Pediatric Trauma
- Deaths by Mechanism of Injury
- Pediatric Trauma
- Pediatric Trauma
- Airway Differences
- Pediatric-Adult Differences
- Pediatric Challenges
- Prehospital Pediatric Challenges
- Pediatric and Adult Trauma
- Scene Response
- Prehospital Intervention
- Where do you take the patient
- Patient arrives at the EDhellip
- Primary Survey
- Order is critical
- Slide Number 22
- Slide Number 23
- Airway
- Indications for Intubation
- Breathing
- ETT Intubation Basics
- Circulation
- Slide Number 29
- CirculationHemodynamic Changes
- Circulation
- Fluid Resuscitation Algorithm
- Reconsidering Crystalloid Resuscitation
- When to start MTP
- Disability
- Finishing Up the Evaluation
- Bad Scene Responses
- OHCA from Trauma
- Blunt Trauma- No Signs of Life
- OHCA with CPR on Arrival
- Pediatric Trauma
- Questions
- References 1
- References 2
- References 3
- References 4
- References 5
- References 5
- XXXXBoston study ems peds trauma procedures- limited pediatric procedural exposure (but more adult experience)
- C-spine
Deaths by Mechanism of Injury
NTDB Pediatric report 2007
Pediatric Trauma bull Kids ne Adults bull Smaller body mass
ndash Crowded trauma bed ndash Less muscle and fat for protection ndash Bones are less calcified and more pliable
bull Underlying injuries occur without fractures ndash Greater force per region
bull More systems often affected bull Waddel and Druckerrsquos Triad
ndash Lower extremity ndash Abdomenchest ndash Head
Pediatric Trauma
bull Larger heads alter airway alignment bull Weaker necks increase c-spine injury risk
wwwebmedicinenet
Airway Differences
bull Smaller airway ndash Smaller oral opening ndash Larger tongue in proportion
bull Larynx ndash More cephalad and anterior ndash More acute angle to access the cords
bull Limited functional residual capacity bull Faster to desaturation
Pediatric-Adult Differences
bull Greater BSA more prone to hypothermia bull Higher risk with radiation exposure bull Weight-based interventions bull Greater success with conservative care
Pediatric Challenges
bull Parents bull Non-accidental trauma bull Neglect bull Medically complex kids bull Pediatric patient exposure bull Pediatric intervention experience
Prehospital Pediatric Challenges
bull Less pediatric exposure ndash Experience
bull Critical procedures ~1 of transports bull CPR BMV or advanced airway in 04 of patients bull ALS specific transports BMV 5 ETI 3
bull Less success in pediatric patients ndash IV access success- 86 adult vs 66 kids ndash Intubating problems- 69 peds vs 21 adults
Pediatric and Adult Trauma
bull Trimodal death distribution ndash 1st peak- seconds to minutes after
bull Impacted by prevention ndash 2nd peak- minutes to hours after
bull ldquoGolden Hourrdquo bull Rapid assessment and treatment
ndash 3rd peak- days to weeks bull Quality pediatric care limits morbidity and mortality bull Infection and multi-organ failure
Scene Response
bull 8 year old male in a rollover atv accident
bull Pt is unresponsive localizes pain wonrsquot open his eyes
bull HR 130 BP 10060 bull RR 10 O2 sat 93 bull What do you want to do
Prehospital Intervention
bull Pre-hospital interventions did not significantly worsen care ndash Similar transport times ndash Similar mortality length of stay
bull ETI vs BMV ndash No difference in survival ndash No difference in neurological outcome
Where do you take the patient
bull Pediatric trauma centers ndash Less surgery on solid organ injuries ndash Less radiation- of scans and dosage ndash Less comorbidities
bull Lower costs bull Shorter length of stay bull Lower infections bull Less multi-organ failure
Patient arrives at the EDhellip
bull Where do you start ndash Primary Survey
Primary Survey bull Your ABCrsquoshellip
bull Airway bull Breathing bull Circulation bull Disability (Neuro- GCS) bull Exposure
Order is critical
bull A before B or C bull Morbiditymortality will
occur much faster from airway compromise than from breathing or circulatory problems
bull Systematic approach is the cornerstone of ATLS success
httpwwwuptodatecomcontentsimageimageKey=EM2F64241amptopicKey=EM2F6571amprank=17E150ampsource=see_linkampsearch=traumaamputdPopup=true
httpwwwuptodatecomcontentsimageimageKey=EM2F64241amptopicKey=EM2F6571amprank=17E150ampsource=see_linkampsearch=traumaamputdPopup=true
Airway bull What are you assessing
ndash Airway patency bull What makes the airway not patent
ndash Foreign bodies ndash Vomitbloodsecretions ndash Edemahematoma ndash Impending obstruction
bull Interventions ndash Clearing foreign bodies ndash Suction secretionsvomit with yankauer ndash Repositioning- jaw thrust ndash Nasal trumpetoral airway ndash Intubation ndash Cricothyrotomy jet ventilation
Indications for Intubation
bull Respiratory arrest bull Impending respiratory failure bull Impending airway obstruction bull Inability to protect the airway bull GCS lt8 bull Declining GCS
Breathing bull What are you assessing
ndash ldquoGoodrdquo symmetric chest rise ndash Lung sounds ndash Aeration ndash Basic RR assessment (fast or minimalnone)
bull Interventions ndash Oxygen ndash Albuterolatrovent racemic epi ndash Positive pressure (CPAP BIPAP BMV) ndash Needle decompression ndash Chest tube thoracostomy ndash Intubation ndash Jet ventilation
ETT Intubation Basics bull Size
ndash Age4 + 4 or (Age +16)4 bull Depth
ndash ~ 3 x ETT size when over 1 year of age bull Blade size mac vs miller
ndash 0~ newborn ndash 1~ up to 2 years of life ndash 2~ 2-10 years ndash 3~ 10+ years
bull RSI medications ndash +-Sedation (Always before paralytic) ndash +-Paralytic (May not need it and never wo sedation)
Circulation
bull What do you assess ndash Central and peripheral pulses ndash Heart rate ndash Blood pressure systolic (age x2) +70 ndash Capillary refill ndash Cardiac activity on FAST ndash End organ perfusion
bull Mental status bull Urine output
Circulation Hemodynamic Changes
Percent Blood Volume Loss 0 15 25 35 45
Heart Rate
Blood Pressure
Cardiac Output
Circulation
ndash Access 2 large bore IVrsquos ndash IVFrsquos ndash pRBCrsquos
bull Hgb lt7gdl or ongoing blood losses
ndash Massive Transfusion Protocol
bull (111 ratio of PRBCS FFP Platelets)
ndash Vasopressors (epi norepi dopamine)
ndash Control of Hemorrhage bull Pelvic binders bull Direct pressure bull Indirectproximal pressure bull Tourniquet (only when
absolutely necessary)
ndash Chest Compressions ndash Pericardiocentesis ndash Delayed resuscitation
controlled hypotension (MAP 50 vs 65)
ndash Tranexamic acid in the near future
bull Interventions
Fluid Resuscitation Algorithm 20 mLkg isotonic crystalloid
Reassess
20 mLkg isotonic crystalloid
Reassess
20 mLkg isotonic crystalloid (31 rule)
or consider 10 to 20 mLkg packed red cells
Reconsidering Crystalloid Resuscitation
bull Less fluid ndash Permissive hypotension to
prevent clot rupture (select cases)
bull Too much fluid ndash Excessive Third Spacing ndash Secondary Compartment
Syndrome ndash Greater risk of ARDS ndash Dilutional Coagulopathy
When to start MTP
bull As soon as you believe you will need it ndash Institution specific guidelines
bull gt4 units or 40mlkg of PRBCrsquos expected bull Earlier use of Massive Transfusion Protocol
(pRBC FFP PLT) in ldquoDamage Controlrdquo resuscitations may improve outcome
bull 111 unit ratio bull Risk of TRALI ARDS etc
Disability bull GCS
ndash Range 3-15 ndash We should be 15 ndash Dead are still 3 ndash Less than 8 intubate ndash Eyes- 4 eyes ndash Verbal- most difficult ndash Motor- V6 engine ndash Intubated T
bull AVPU
Finishing Up the Evaluation
bull Airway bull Breathing bull Circulation bull Disability bull Exposure
ndash Expose and examine all parts ndash Cover quickly and keep warm
bull Secondary Survey
Bad Scene Responses
bull What are the outcomes of out-of-hospital cardiac arrest from blunt trauma
bull What are the outcomes of pediatric drowning patients
OHCA from Trauma
bull 2000-2003 bull 123 pts bull Mean age 73 yrs bull Most common
rhythms ndash Asystole 59 ndash PEA 29 ndash V-fib 35
bull 195 rosc in field ndash 98 survived for 24
hrs ndash 57 survived to
discharge ndash Drowning- 19
survival to discharge ndash Bystander CPR tripled
the survivor rate
Blunt Trauma- No Signs of Life
bull Review from 2002-2010 bull No signs of life- 025 of blunt trauma
ndash 25 resuscitated prior to hospital arrival bull 138 of these patients survived to discharge
bull 44 overall survived to hospital discharge
OHCA with CPR on Arrival
bull 169 children bull 141 deaths bull 69 required cpr on arrival- none survived bull 87 of patients requiring CPR on arrival
expired in the ED bull Of the 28 survivors
ndash 55 of survivors had full neurologic recovery
Pediatric Trauma
bull Fortunately these cases represent only a small fraction of EMS transports
bull Despite a few key differences pediatric trauma care overall is very similar to adult trauma care
Questions
References 1 bull NTDB 2013 pediatric Report bull Monkey bars httpsplaygroundchroniclesfileswordpresscom201307soccerjpg bull Screaming child httpblogsbabycentercomwp-contentuploads201409screaming-child-tantrum-fitjpg bull Pediatric airway image httpwwwcelebritydiagnosiscomwp-contentuploads201003pediatric-airwayjpg bull Child on backboard httpsencrypted-tbn2gstaticcomimagesq=tbnANd9GcQscrDVc8IH4MwkNGF6F1A9p7mSVzik5zrWyNvI-
qSwQT5S3GNyVg bull Elbow fracture httpwwwimageinterpretationcoukimageselbowSUPRACONDYLAR20LAT3jpg bull Bike riding httpsmile-per-daycomwp-contentuploads201412klr03jpg bull Dad and child pic httplaughingsquidcomwp-contentuploads471160jpg bull Weigth estimation inner city Am J Emerg Med 2015 Oct33(10)1364-7 doi 101016jajem201507040 Epub 2015 Jul 29 Weight
estimation in an inner-city pediatric ED the effect of obesity Chavez H1 Peterson RE2 Lo K3 Arel M4
bull Guess weight sign httpmedialiveauctiongroupneti963110572971_1jpgv=8CDDAAF8A5B9E20 bull Broselow tape httpsuploadwikimediaorgwikipediacommons994BTape1jpg bull Parent screaming httpmommyofamonstercomwp-contentuploads201301yellingjpg bull Prehospital pain management Am J Emerg Med 2015 Mar33(3)451-4 doi 101016jajem201412012 Epub 2014 Dec 18
Prehospital pain management of injured children a systematic review of current evidence Samuel N1 Steiner IP2 Shavit I3 bull Prehospital pain ped pain assessment Prehosp Emerg Care 2008 Apr-Jun12(2)182-6 doi 10108010903120801907471 Prehospital
pain assessment in pediatric trauma Izsak E1 Moore JL Stringfellow K Oswanski MF Lindstrom DA Stombaugh HA bull Ped pain management Prehosp Emerg Care 2005 Jan-Mar9(1)40-3 Prehospital pain management in children suffering traumatic
injury Swor R1 McEachin CM Seguin D Grall KH bull Prehospital intervention Allen CJ Teisch LF et al Prehospital care and transportation of pediatric trauma patients J Surg Res 2015
Aug197(2)240-6 JAMA 2000 Feb 9283(6)783-90 bull Effect of out-of-hospital pediatric endotracheal intubation on survival and neurological outcome a controlled clinical trial
Gausche M1 Lewis RJ Stratton SJ Haynes BE Gunter CS Goodrich SM Poore PD McCollough MD Henderson DP Pratt FD Seidel JS
bull Pediatric pain management survey Pediatr Emerg Care 2015 Sep 23 [Epub ahead of print] An Assessment of Newly Identified Barriers to and Enablers for Prehospital Pediatric Pain Management Whitley DE1 Li T Jones CM Cushman JT Williams DM Shah MN
References 2 bull httpwwwuptodatecomcontentsprehospital-pediatrics-and-emergency-medical-services-emsabstract6 bull httpwwwuptodatecomcontentsprehospital-pediatrics-and-emergency-medical-services-emsabstract7 bull Pediatr Crit Care Med 2011 Jul12(4)e166-70 doi 101097PCC0b013e3181f36f6e First responder
performance in pediatric trauma a comparison with an adult cohortBankole S1 Asuncion A Ross S Aghai Z Nollah L Echols H Da-Silva S
bull Drayna pc Browne LR et al Prehospital pediatric care Oppportunities for training treatment and research Prehosp Emerg Care 2015 Jul-Sep 19(3) Epub 2015 Feb 6
bull Pediatr Emerg Care 2001 Feb17(1) 5-9Pediatric pre-hospital advanced life support care in an urban setting Babl FE1 Vinci RJ Bauchner H Mottley L
bull Pediatr Crit Care Med 2015 Oct16(8)e260-7 doi 101097PCC0000000000000505Pediatric Out-of-Hospital Critical Procedures in the United States Carlson JN1 Gannon E Mann NC Jacobson KE Dai M Colleran C Wang HE
bull Pediatr Emerg Care 2009 Aug25(8)508-12 doi 101097PEC0b013e3181b0a0da The efficacy of pediatric advanced life support training in emergency medical service providers Baker TW1 King W Soto W Asher C Stolfi A Rowin ME
bull Sutton RM Case E et al ROC investigators A quantitative analysis of out-of-hospital pediatric and adolescent resuscitation quality A report from the ROC Epistry- Cardiac Arrest Resusciation 201593150-157
bull Resuscitation 2014 Aug85(8)1059-64 doi 101016jresuscitation201403307 Epub 2014 Apr 4 Neurocognitive long term follow-up study on drowned children Suominen PK1 Sutinen N2 Valle S3 Olkkola KT4 Loumlnnqvist T3
bull J Pediatr Surg 2010 Jul45(7)1413-9 doi 101016jjpedsurg200912020 Prehospital cardiopulmonary resuscitation in the pediatric trauma patient Murphy JT1 Jaiswal K Sabella J Vinson L Megison S Maxson RT
References 3 bull Pre atv accident
httpwwwctvnewscapolopoly_fs119871591409741949httpImageimagejpg_genderivativeslandscape_960imagejpg bull atv pic httpswwwutahadvocatescomwp-contentuploads201402atvAccidentLawyerjpg bull Blunt abdominal solid organ injury adult vs pediatric trauma center J Pediatr Surg 2015 Aug 28 pii S0022-3468(15)00526-6 doi
101016jjpedsurg201508012 [Epub ahead of print] Trauma center variation in the management of pediatric patients with blunt abdominal solid organ injury a national trauma data bank analysis Safavi A1 Skarsgard ED2 Rhee P1 Zangbar B1 Kulvatunyou N1 Tang A1 OKeeffe T1 Friese RS1 Joseph B3
bull Pediatric blunt abdominal injury Curr Opin Crit Care 2015 Sep 28 [Epub ahead of print] Pediatric blunt abdominal trauma current management Notrica DM1
bull Pediatric splenic injury management Am J Surg 2015 Jul 31 pii S0002-9610(15)00417-1 doi 101016jamjsurg201506009 [Epub ahead of print] Comparative effectiveness of treatment strategies for severe splenic trauma in the pediatric population Rialon KL1 Englum BR1 Gulack BC1 Guevara CJ2 Bhattacharya SD3 Shapiro ML4 Rice HE5 Scarborough JE4 Adibe OO6
bull Liver pic httpss-media-cache-ak0pinimgcom736x7da50e7da50eb2bb603c99ef6649ff897e26b5jpg bull Solid organ injury non op in peds J Trauma Acute Care Surg 2015 Oct79(4)683-93 doi 101097TA0000000000000808
Nonoperative management of blunt liver and spleen injury in children Evaluation of the ATOMAC guideline using GRADE Notrica DM1 Eubanks JW 3rd Tuggle DW Maxson RT Letton RW Garcia NM Alder AC Lawson KA St Peter SD Megison S Garcia Filion P
bull Pediaric vs nonped trauma ct use J Pediatr 2015 Oct167(4)897-904e3 doi 101016jjpeds201506052 Epub 2015 Jul 29 Variation in Computed Tomography Imaging for Pediatric Injury-Related Emergency Visits Marin JR1 Wang L2 Winger DG2 Mannix RC3
bull Solid organ management in ped population J Trauma Acute Care Surg 2015 Aug79(2)206-14quiz 332 doi 101097TA0000000000000731 Management of children with solid organ injuries after blunt torso trauma Wisner DH1 Kuppermann N Cooper A Menaker J Ehrlich P Kooistra J Mahajan P Lee L Cook LJ Yen K Lillis K Holmes JF
bull Triad of death image httpimageslidesharecdncomdamage-control-resuscitation-1304253390-phpapp0195damage-control-resuscitation-14-728jpgcb=1304235553
bull Tranexamic acid study Eckert MJ Wertin TM Tyner SD et al 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 77852
bull Image care accident httpsuploadwikimediaorgwikipediacommonsthumbee1Car_crash_1jpg1280px-Car_crash_1jpg
References 4 bull httpwwwsurgeryvcuedudivisionsacutesurghtml bull Trauma management Approach to the unstable child
httpwwwuptodatecomcontentstrauma-management-approach-to-the-unstable-childsource=search_resultampsearch=pediatric+trauma+childrenampselectedTitle=17E150
bull Trauma management Unique pediatric considerations httpwwwuptodatecomcontentstrauma-management-unique-pediatric-considerationssource=search_resultampsearch=pediatric+trauma+childrenampselectedTitle=37E150
References 5 bull httpwwwetiquettehellcomsmfindexphptopic=8666360 bull httpwwwstlouischildrensorghealth-care-professionalsems-providers bull httpwwwuchicagokidshospitalorgspecialtiesemergency-medicinespecialhtml bull httpwwwsimsacademyinfoFXpatienthtm bull httptheemtspotcomwp-contentuploads200902another-burn-patient-by-annette-larsonjpg bull httplastangryfancomwp-contentuploads200910Clint-Malarchukjpg bull httpwwwtraumaorgarchiveresusmassivehtml bull httpwwwuptodatecomcontentsimageimageKey=PEDS68694amptopicKey=EM2F6389ampsourc
e=previewampsearch=pediatric+hemorrhagic+shockampselectedTitle=17E150amprank=undefined bull httptheemtspotcomwp-contentuploads200902gcsgif bull httpwwwuptodatecomcontentsimageimageKey=EM2F60409amptopicKey=EM2F6571amprank
=17E150ampsource=see_linkampsearch=traumaamputdPopup=true bull httpwwwuptodatecomcontentsimageimageKey=EM2F80874amptopicKey=EM2F6571amprank
=17E150ampsource=see_linkampsearch=traumaamputdPopup=true bull httpempracticenewswordpresscomcategorynexus-criteria bull httpswwwgooglecomsearchq=pediatric+glasgow+coma+scaleamptbm=ischamptbo=uampsource=uni
vampsa=Xampei=8TiOU7TNC5WuyATp5YG4BQampsqi=2ampved=0CDYQsAQampbiw=1426ampbih=883q=canadian+c-spine+rulesamptbm=ischampfacrc=_ampimgdii=_ampimgrc=WI94QMHgMLTQmM253A3BP5nbsFhNCXK0FM3Bhttp253A252F252Fwwwbmjcom252Fhighwire252Ffilestream252F436003252Ffield_highwire_fragment_image_l252F0jpg3Bhttp253A252F252Fwwwbmjcom252Fcontent252F339252Fbmjb41463B12803B1253
References 5 bull httpwwwuptodatecomcontentsimageimageKey=EM2F76777amptopicKey=EM2F6571amprank
=17E150ampsource=see_linkampsearch=traumaamputdPopup=true bull httpwwwdocumentingrealitycomforumattachmentsf14964898d1246625322-firework-injury-
m80injury1jpg bull httpwwwpediatriceducationorg20050620 bull httpwwwarmstrongmedicalcomindexcfmgoproductdetailsec3ssec19cat61fam515 bull httpwwwuptodatecomcontentsimageimageKey=PEDS61087amptopicKey=ID2F7661ampsource
=outline_linkampsearch=tetanus+prophylaxisamputdPopup=true bull httpwwwafsecafmilsharedmediaphotodbweb110609-F-MJ378-009jpg bull httpwwwuptodatecomcontentsimageimageKey=EM75765amptopicKey= bull EM2F6389ampsource=outline_linkampsearch=massive+transfusion+protocolamputdPopup=true bull httpwwwmotifakecomimagedemotivational-postersmall0910whats-the-question-ignorance-
calvin-and-hobbes-demotivational-poster-1255020127jpg
XXXXBoston study ems peds trauma procedures- limited pediatric procedural exposure (but more adult experience) bull Catchment area 590000
over 1 year bull 555 pediatric ALS
transport ndash 19 blunt trauma ndash 10 penetrating trauma
bull IV 33 bull BMV 5 bull Intubation 3 bull 50 ALS providers average
year ndash IV- 37 ndash Intubation- 03 ndash IO- 006
bull 7 ped ems ndash 13 trauma
bull Critical procedures ndash 101000 peds cases ndash Intubation 671000 ndash IO 51000 ndash 81 successful
Pediatr Emerg Care 2001 Feb17(1)5-9 Pediatric pre-hospital advanced life support care in an urban setting
Babl FE1 Vinci RJ Bauchner H Mottley L
Pediatr Crit Care Med 2015 Oct16(8)e260-7 doi 101097PCC0000000000000505 Pediatric Out-of-Hospital Critical Procedures in the United States
Carlson JN1 Gannon E Mann NC Jacobson KE Dai M Colleran C Wang HE
C-spine bull C-spine injuries rare bull Take pt to closest hospital if over injuries
call for it (ie resuscitation altered mental status) primary guide
bull Mechanism ndash Altered mental status focal neuro change
torticollis substantial torso injury diving high speed auto neck pain underlying predisposing condition Acad Emerg Med 2014 Jan21(1)55-64 doi 101111acem12288
Comparison of outcomes for children with cervical spine injury based on destination hospital from scene of injury Anders JF1 Adelgais K Hoyle JD Jr Olsen C Jaffe DM Leonard JC Pediatric Emergency Care Applied Research Network
(PECARN)
Ann Emerg Med 2011 Aug58(2)145-55 doi 101016jannemergmed201008038 Epub 2010 Oct 29 Factors associated with cervical spine injury in children after blunt trauma
Leonard JC Kuppermann N Olsen C Babcock-Cimpello L Brown K Mahajan P Adelgais KM Anders J Borgialli D Donoghue A Hoyle JD Jr Kim E Leonard JR Lillis KA Nigrovic LE Powell EC Rebella
G Reeves SD Rogers AJ Stankovic C Teshome G Jaffe DM Pediatric Emergency Care Applied Research Network
- Itrsquos Hard to Put a Band-Aid on a Broken Spleen Pediatric Trauma
- Disclosures
- Objectives
- Pediatric Prehospital Care
- Mechanism
- Traumatic Pain Management
- Pediatric Trauma
- Deaths by Mechanism of Injury
- Pediatric Trauma
- Pediatric Trauma
- Airway Differences
- Pediatric-Adult Differences
- Pediatric Challenges
- Prehospital Pediatric Challenges
- Pediatric and Adult Trauma
- Scene Response
- Prehospital Intervention
- Where do you take the patient
- Patient arrives at the EDhellip
- Primary Survey
- Order is critical
- Slide Number 22
- Slide Number 23
- Airway
- Indications for Intubation
- Breathing
- ETT Intubation Basics
- Circulation
- Slide Number 29
- CirculationHemodynamic Changes
- Circulation
- Fluid Resuscitation Algorithm
- Reconsidering Crystalloid Resuscitation
- When to start MTP
- Disability
- Finishing Up the Evaluation
- Bad Scene Responses
- OHCA from Trauma
- Blunt Trauma- No Signs of Life
- OHCA with CPR on Arrival
- Pediatric Trauma
- Questions
- References 1
- References 2
- References 3
- References 4
- References 5
- References 5
- XXXXBoston study ems peds trauma procedures- limited pediatric procedural exposure (but more adult experience)
- C-spine
Pediatric Trauma bull Kids ne Adults bull Smaller body mass
ndash Crowded trauma bed ndash Less muscle and fat for protection ndash Bones are less calcified and more pliable
bull Underlying injuries occur without fractures ndash Greater force per region
bull More systems often affected bull Waddel and Druckerrsquos Triad
ndash Lower extremity ndash Abdomenchest ndash Head
Pediatric Trauma
bull Larger heads alter airway alignment bull Weaker necks increase c-spine injury risk
wwwebmedicinenet
Airway Differences
bull Smaller airway ndash Smaller oral opening ndash Larger tongue in proportion
bull Larynx ndash More cephalad and anterior ndash More acute angle to access the cords
bull Limited functional residual capacity bull Faster to desaturation
Pediatric-Adult Differences
bull Greater BSA more prone to hypothermia bull Higher risk with radiation exposure bull Weight-based interventions bull Greater success with conservative care
Pediatric Challenges
bull Parents bull Non-accidental trauma bull Neglect bull Medically complex kids bull Pediatric patient exposure bull Pediatric intervention experience
Prehospital Pediatric Challenges
bull Less pediatric exposure ndash Experience
bull Critical procedures ~1 of transports bull CPR BMV or advanced airway in 04 of patients bull ALS specific transports BMV 5 ETI 3
bull Less success in pediatric patients ndash IV access success- 86 adult vs 66 kids ndash Intubating problems- 69 peds vs 21 adults
Pediatric and Adult Trauma
bull Trimodal death distribution ndash 1st peak- seconds to minutes after
bull Impacted by prevention ndash 2nd peak- minutes to hours after
bull ldquoGolden Hourrdquo bull Rapid assessment and treatment
ndash 3rd peak- days to weeks bull Quality pediatric care limits morbidity and mortality bull Infection and multi-organ failure
Scene Response
bull 8 year old male in a rollover atv accident
bull Pt is unresponsive localizes pain wonrsquot open his eyes
bull HR 130 BP 10060 bull RR 10 O2 sat 93 bull What do you want to do
Prehospital Intervention
bull Pre-hospital interventions did not significantly worsen care ndash Similar transport times ndash Similar mortality length of stay
bull ETI vs BMV ndash No difference in survival ndash No difference in neurological outcome
Where do you take the patient
bull Pediatric trauma centers ndash Less surgery on solid organ injuries ndash Less radiation- of scans and dosage ndash Less comorbidities
bull Lower costs bull Shorter length of stay bull Lower infections bull Less multi-organ failure
Patient arrives at the EDhellip
bull Where do you start ndash Primary Survey
Primary Survey bull Your ABCrsquoshellip
bull Airway bull Breathing bull Circulation bull Disability (Neuro- GCS) bull Exposure
Order is critical
bull A before B or C bull Morbiditymortality will
occur much faster from airway compromise than from breathing or circulatory problems
bull Systematic approach is the cornerstone of ATLS success
httpwwwuptodatecomcontentsimageimageKey=EM2F64241amptopicKey=EM2F6571amprank=17E150ampsource=see_linkampsearch=traumaamputdPopup=true
httpwwwuptodatecomcontentsimageimageKey=EM2F64241amptopicKey=EM2F6571amprank=17E150ampsource=see_linkampsearch=traumaamputdPopup=true
Airway bull What are you assessing
ndash Airway patency bull What makes the airway not patent
ndash Foreign bodies ndash Vomitbloodsecretions ndash Edemahematoma ndash Impending obstruction
bull Interventions ndash Clearing foreign bodies ndash Suction secretionsvomit with yankauer ndash Repositioning- jaw thrust ndash Nasal trumpetoral airway ndash Intubation ndash Cricothyrotomy jet ventilation
Indications for Intubation
bull Respiratory arrest bull Impending respiratory failure bull Impending airway obstruction bull Inability to protect the airway bull GCS lt8 bull Declining GCS
Breathing bull What are you assessing
ndash ldquoGoodrdquo symmetric chest rise ndash Lung sounds ndash Aeration ndash Basic RR assessment (fast or minimalnone)
bull Interventions ndash Oxygen ndash Albuterolatrovent racemic epi ndash Positive pressure (CPAP BIPAP BMV) ndash Needle decompression ndash Chest tube thoracostomy ndash Intubation ndash Jet ventilation
ETT Intubation Basics bull Size
ndash Age4 + 4 or (Age +16)4 bull Depth
ndash ~ 3 x ETT size when over 1 year of age bull Blade size mac vs miller
ndash 0~ newborn ndash 1~ up to 2 years of life ndash 2~ 2-10 years ndash 3~ 10+ years
bull RSI medications ndash +-Sedation (Always before paralytic) ndash +-Paralytic (May not need it and never wo sedation)
Circulation
bull What do you assess ndash Central and peripheral pulses ndash Heart rate ndash Blood pressure systolic (age x2) +70 ndash Capillary refill ndash Cardiac activity on FAST ndash End organ perfusion
bull Mental status bull Urine output
Circulation Hemodynamic Changes
Percent Blood Volume Loss 0 15 25 35 45
Heart Rate
Blood Pressure
Cardiac Output
Circulation
ndash Access 2 large bore IVrsquos ndash IVFrsquos ndash pRBCrsquos
bull Hgb lt7gdl or ongoing blood losses
ndash Massive Transfusion Protocol
bull (111 ratio of PRBCS FFP Platelets)
ndash Vasopressors (epi norepi dopamine)
ndash Control of Hemorrhage bull Pelvic binders bull Direct pressure bull Indirectproximal pressure bull Tourniquet (only when
absolutely necessary)
ndash Chest Compressions ndash Pericardiocentesis ndash Delayed resuscitation
controlled hypotension (MAP 50 vs 65)
ndash Tranexamic acid in the near future
bull Interventions
Fluid Resuscitation Algorithm 20 mLkg isotonic crystalloid
Reassess
20 mLkg isotonic crystalloid
Reassess
20 mLkg isotonic crystalloid (31 rule)
or consider 10 to 20 mLkg packed red cells
Reconsidering Crystalloid Resuscitation
bull Less fluid ndash Permissive hypotension to
prevent clot rupture (select cases)
bull Too much fluid ndash Excessive Third Spacing ndash Secondary Compartment
Syndrome ndash Greater risk of ARDS ndash Dilutional Coagulopathy
When to start MTP
bull As soon as you believe you will need it ndash Institution specific guidelines
bull gt4 units or 40mlkg of PRBCrsquos expected bull Earlier use of Massive Transfusion Protocol
(pRBC FFP PLT) in ldquoDamage Controlrdquo resuscitations may improve outcome
bull 111 unit ratio bull Risk of TRALI ARDS etc
Disability bull GCS
ndash Range 3-15 ndash We should be 15 ndash Dead are still 3 ndash Less than 8 intubate ndash Eyes- 4 eyes ndash Verbal- most difficult ndash Motor- V6 engine ndash Intubated T
bull AVPU
Finishing Up the Evaluation
bull Airway bull Breathing bull Circulation bull Disability bull Exposure
ndash Expose and examine all parts ndash Cover quickly and keep warm
bull Secondary Survey
Bad Scene Responses
bull What are the outcomes of out-of-hospital cardiac arrest from blunt trauma
bull What are the outcomes of pediatric drowning patients
OHCA from Trauma
bull 2000-2003 bull 123 pts bull Mean age 73 yrs bull Most common
rhythms ndash Asystole 59 ndash PEA 29 ndash V-fib 35
bull 195 rosc in field ndash 98 survived for 24
hrs ndash 57 survived to
discharge ndash Drowning- 19
survival to discharge ndash Bystander CPR tripled
the survivor rate
Blunt Trauma- No Signs of Life
bull Review from 2002-2010 bull No signs of life- 025 of blunt trauma
ndash 25 resuscitated prior to hospital arrival bull 138 of these patients survived to discharge
bull 44 overall survived to hospital discharge
OHCA with CPR on Arrival
bull 169 children bull 141 deaths bull 69 required cpr on arrival- none survived bull 87 of patients requiring CPR on arrival
expired in the ED bull Of the 28 survivors
ndash 55 of survivors had full neurologic recovery
Pediatric Trauma
bull Fortunately these cases represent only a small fraction of EMS transports
bull Despite a few key differences pediatric trauma care overall is very similar to adult trauma care
Questions
References 1 bull NTDB 2013 pediatric Report bull Monkey bars httpsplaygroundchroniclesfileswordpresscom201307soccerjpg bull Screaming child httpblogsbabycentercomwp-contentuploads201409screaming-child-tantrum-fitjpg bull Pediatric airway image httpwwwcelebritydiagnosiscomwp-contentuploads201003pediatric-airwayjpg bull Child on backboard httpsencrypted-tbn2gstaticcomimagesq=tbnANd9GcQscrDVc8IH4MwkNGF6F1A9p7mSVzik5zrWyNvI-
qSwQT5S3GNyVg bull Elbow fracture httpwwwimageinterpretationcoukimageselbowSUPRACONDYLAR20LAT3jpg bull Bike riding httpsmile-per-daycomwp-contentuploads201412klr03jpg bull Dad and child pic httplaughingsquidcomwp-contentuploads471160jpg bull Weigth estimation inner city Am J Emerg Med 2015 Oct33(10)1364-7 doi 101016jajem201507040 Epub 2015 Jul 29 Weight
estimation in an inner-city pediatric ED the effect of obesity Chavez H1 Peterson RE2 Lo K3 Arel M4
bull Guess weight sign httpmedialiveauctiongroupneti963110572971_1jpgv=8CDDAAF8A5B9E20 bull Broselow tape httpsuploadwikimediaorgwikipediacommons994BTape1jpg bull Parent screaming httpmommyofamonstercomwp-contentuploads201301yellingjpg bull Prehospital pain management Am J Emerg Med 2015 Mar33(3)451-4 doi 101016jajem201412012 Epub 2014 Dec 18
Prehospital pain management of injured children a systematic review of current evidence Samuel N1 Steiner IP2 Shavit I3 bull Prehospital pain ped pain assessment Prehosp Emerg Care 2008 Apr-Jun12(2)182-6 doi 10108010903120801907471 Prehospital
pain assessment in pediatric trauma Izsak E1 Moore JL Stringfellow K Oswanski MF Lindstrom DA Stombaugh HA bull Ped pain management Prehosp Emerg Care 2005 Jan-Mar9(1)40-3 Prehospital pain management in children suffering traumatic
injury Swor R1 McEachin CM Seguin D Grall KH bull Prehospital intervention Allen CJ Teisch LF et al Prehospital care and transportation of pediatric trauma patients J Surg Res 2015
Aug197(2)240-6 JAMA 2000 Feb 9283(6)783-90 bull Effect of out-of-hospital pediatric endotracheal intubation on survival and neurological outcome a controlled clinical trial
Gausche M1 Lewis RJ Stratton SJ Haynes BE Gunter CS Goodrich SM Poore PD McCollough MD Henderson DP Pratt FD Seidel JS
bull Pediatric pain management survey Pediatr Emerg Care 2015 Sep 23 [Epub ahead of print] An Assessment of Newly Identified Barriers to and Enablers for Prehospital Pediatric Pain Management Whitley DE1 Li T Jones CM Cushman JT Williams DM Shah MN
References 2 bull httpwwwuptodatecomcontentsprehospital-pediatrics-and-emergency-medical-services-emsabstract6 bull httpwwwuptodatecomcontentsprehospital-pediatrics-and-emergency-medical-services-emsabstract7 bull Pediatr Crit Care Med 2011 Jul12(4)e166-70 doi 101097PCC0b013e3181f36f6e First responder
performance in pediatric trauma a comparison with an adult cohortBankole S1 Asuncion A Ross S Aghai Z Nollah L Echols H Da-Silva S
bull Drayna pc Browne LR et al Prehospital pediatric care Oppportunities for training treatment and research Prehosp Emerg Care 2015 Jul-Sep 19(3) Epub 2015 Feb 6
bull Pediatr Emerg Care 2001 Feb17(1) 5-9Pediatric pre-hospital advanced life support care in an urban setting Babl FE1 Vinci RJ Bauchner H Mottley L
bull Pediatr Crit Care Med 2015 Oct16(8)e260-7 doi 101097PCC0000000000000505Pediatric Out-of-Hospital Critical Procedures in the United States Carlson JN1 Gannon E Mann NC Jacobson KE Dai M Colleran C Wang HE
bull Pediatr Emerg Care 2009 Aug25(8)508-12 doi 101097PEC0b013e3181b0a0da The efficacy of pediatric advanced life support training in emergency medical service providers Baker TW1 King W Soto W Asher C Stolfi A Rowin ME
bull Sutton RM Case E et al ROC investigators A quantitative analysis of out-of-hospital pediatric and adolescent resuscitation quality A report from the ROC Epistry- Cardiac Arrest Resusciation 201593150-157
bull Resuscitation 2014 Aug85(8)1059-64 doi 101016jresuscitation201403307 Epub 2014 Apr 4 Neurocognitive long term follow-up study on drowned children Suominen PK1 Sutinen N2 Valle S3 Olkkola KT4 Loumlnnqvist T3
bull J Pediatr Surg 2010 Jul45(7)1413-9 doi 101016jjpedsurg200912020 Prehospital cardiopulmonary resuscitation in the pediatric trauma patient Murphy JT1 Jaiswal K Sabella J Vinson L Megison S Maxson RT
References 3 bull Pre atv accident
httpwwwctvnewscapolopoly_fs119871591409741949httpImageimagejpg_genderivativeslandscape_960imagejpg bull atv pic httpswwwutahadvocatescomwp-contentuploads201402atvAccidentLawyerjpg bull Blunt abdominal solid organ injury adult vs pediatric trauma center J Pediatr Surg 2015 Aug 28 pii S0022-3468(15)00526-6 doi
101016jjpedsurg201508012 [Epub ahead of print] Trauma center variation in the management of pediatric patients with blunt abdominal solid organ injury a national trauma data bank analysis Safavi A1 Skarsgard ED2 Rhee P1 Zangbar B1 Kulvatunyou N1 Tang A1 OKeeffe T1 Friese RS1 Joseph B3
bull Pediatric blunt abdominal injury Curr Opin Crit Care 2015 Sep 28 [Epub ahead of print] Pediatric blunt abdominal trauma current management Notrica DM1
bull Pediatric splenic injury management Am J Surg 2015 Jul 31 pii S0002-9610(15)00417-1 doi 101016jamjsurg201506009 [Epub ahead of print] Comparative effectiveness of treatment strategies for severe splenic trauma in the pediatric population Rialon KL1 Englum BR1 Gulack BC1 Guevara CJ2 Bhattacharya SD3 Shapiro ML4 Rice HE5 Scarborough JE4 Adibe OO6
bull Liver pic httpss-media-cache-ak0pinimgcom736x7da50e7da50eb2bb603c99ef6649ff897e26b5jpg bull Solid organ injury non op in peds J Trauma Acute Care Surg 2015 Oct79(4)683-93 doi 101097TA0000000000000808
Nonoperative management of blunt liver and spleen injury in children Evaluation of the ATOMAC guideline using GRADE Notrica DM1 Eubanks JW 3rd Tuggle DW Maxson RT Letton RW Garcia NM Alder AC Lawson KA St Peter SD Megison S Garcia Filion P
bull Pediaric vs nonped trauma ct use J Pediatr 2015 Oct167(4)897-904e3 doi 101016jjpeds201506052 Epub 2015 Jul 29 Variation in Computed Tomography Imaging for Pediatric Injury-Related Emergency Visits Marin JR1 Wang L2 Winger DG2 Mannix RC3
bull Solid organ management in ped population J Trauma Acute Care Surg 2015 Aug79(2)206-14quiz 332 doi 101097TA0000000000000731 Management of children with solid organ injuries after blunt torso trauma Wisner DH1 Kuppermann N Cooper A Menaker J Ehrlich P Kooistra J Mahajan P Lee L Cook LJ Yen K Lillis K Holmes JF
bull Triad of death image httpimageslidesharecdncomdamage-control-resuscitation-1304253390-phpapp0195damage-control-resuscitation-14-728jpgcb=1304235553
bull Tranexamic acid study Eckert MJ Wertin TM Tyner SD et al 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 77852
bull Image care accident httpsuploadwikimediaorgwikipediacommonsthumbee1Car_crash_1jpg1280px-Car_crash_1jpg
References 4 bull httpwwwsurgeryvcuedudivisionsacutesurghtml bull Trauma management Approach to the unstable child
httpwwwuptodatecomcontentstrauma-management-approach-to-the-unstable-childsource=search_resultampsearch=pediatric+trauma+childrenampselectedTitle=17E150
bull Trauma management Unique pediatric considerations httpwwwuptodatecomcontentstrauma-management-unique-pediatric-considerationssource=search_resultampsearch=pediatric+trauma+childrenampselectedTitle=37E150
References 5 bull httpwwwetiquettehellcomsmfindexphptopic=8666360 bull httpwwwstlouischildrensorghealth-care-professionalsems-providers bull httpwwwuchicagokidshospitalorgspecialtiesemergency-medicinespecialhtml bull httpwwwsimsacademyinfoFXpatienthtm bull httptheemtspotcomwp-contentuploads200902another-burn-patient-by-annette-larsonjpg bull httplastangryfancomwp-contentuploads200910Clint-Malarchukjpg bull httpwwwtraumaorgarchiveresusmassivehtml bull httpwwwuptodatecomcontentsimageimageKey=PEDS68694amptopicKey=EM2F6389ampsourc
e=previewampsearch=pediatric+hemorrhagic+shockampselectedTitle=17E150amprank=undefined bull httptheemtspotcomwp-contentuploads200902gcsgif bull httpwwwuptodatecomcontentsimageimageKey=EM2F60409amptopicKey=EM2F6571amprank
=17E150ampsource=see_linkampsearch=traumaamputdPopup=true bull httpwwwuptodatecomcontentsimageimageKey=EM2F80874amptopicKey=EM2F6571amprank
=17E150ampsource=see_linkampsearch=traumaamputdPopup=true bull httpempracticenewswordpresscomcategorynexus-criteria bull httpswwwgooglecomsearchq=pediatric+glasgow+coma+scaleamptbm=ischamptbo=uampsource=uni
vampsa=Xampei=8TiOU7TNC5WuyATp5YG4BQampsqi=2ampved=0CDYQsAQampbiw=1426ampbih=883q=canadian+c-spine+rulesamptbm=ischampfacrc=_ampimgdii=_ampimgrc=WI94QMHgMLTQmM253A3BP5nbsFhNCXK0FM3Bhttp253A252F252Fwwwbmjcom252Fhighwire252Ffilestream252F436003252Ffield_highwire_fragment_image_l252F0jpg3Bhttp253A252F252Fwwwbmjcom252Fcontent252F339252Fbmjb41463B12803B1253
References 5 bull httpwwwuptodatecomcontentsimageimageKey=EM2F76777amptopicKey=EM2F6571amprank
=17E150ampsource=see_linkampsearch=traumaamputdPopup=true bull httpwwwdocumentingrealitycomforumattachmentsf14964898d1246625322-firework-injury-
m80injury1jpg bull httpwwwpediatriceducationorg20050620 bull httpwwwarmstrongmedicalcomindexcfmgoproductdetailsec3ssec19cat61fam515 bull httpwwwuptodatecomcontentsimageimageKey=PEDS61087amptopicKey=ID2F7661ampsource
=outline_linkampsearch=tetanus+prophylaxisamputdPopup=true bull httpwwwafsecafmilsharedmediaphotodbweb110609-F-MJ378-009jpg bull httpwwwuptodatecomcontentsimageimageKey=EM75765amptopicKey= bull EM2F6389ampsource=outline_linkampsearch=massive+transfusion+protocolamputdPopup=true bull httpwwwmotifakecomimagedemotivational-postersmall0910whats-the-question-ignorance-
calvin-and-hobbes-demotivational-poster-1255020127jpg
XXXXBoston study ems peds trauma procedures- limited pediatric procedural exposure (but more adult experience) bull Catchment area 590000
over 1 year bull 555 pediatric ALS
transport ndash 19 blunt trauma ndash 10 penetrating trauma
bull IV 33 bull BMV 5 bull Intubation 3 bull 50 ALS providers average
year ndash IV- 37 ndash Intubation- 03 ndash IO- 006
bull 7 ped ems ndash 13 trauma
bull Critical procedures ndash 101000 peds cases ndash Intubation 671000 ndash IO 51000 ndash 81 successful
Pediatr Emerg Care 2001 Feb17(1)5-9 Pediatric pre-hospital advanced life support care in an urban setting
Babl FE1 Vinci RJ Bauchner H Mottley L
Pediatr Crit Care Med 2015 Oct16(8)e260-7 doi 101097PCC0000000000000505 Pediatric Out-of-Hospital Critical Procedures in the United States
Carlson JN1 Gannon E Mann NC Jacobson KE Dai M Colleran C Wang HE
C-spine bull C-spine injuries rare bull Take pt to closest hospital if over injuries
call for it (ie resuscitation altered mental status) primary guide
bull Mechanism ndash Altered mental status focal neuro change
torticollis substantial torso injury diving high speed auto neck pain underlying predisposing condition Acad Emerg Med 2014 Jan21(1)55-64 doi 101111acem12288
Comparison of outcomes for children with cervical spine injury based on destination hospital from scene of injury Anders JF1 Adelgais K Hoyle JD Jr Olsen C Jaffe DM Leonard JC Pediatric Emergency Care Applied Research Network
(PECARN)
Ann Emerg Med 2011 Aug58(2)145-55 doi 101016jannemergmed201008038 Epub 2010 Oct 29 Factors associated with cervical spine injury in children after blunt trauma
Leonard JC Kuppermann N Olsen C Babcock-Cimpello L Brown K Mahajan P Adelgais KM Anders J Borgialli D Donoghue A Hoyle JD Jr Kim E Leonard JR Lillis KA Nigrovic LE Powell EC Rebella
G Reeves SD Rogers AJ Stankovic C Teshome G Jaffe DM Pediatric Emergency Care Applied Research Network
- Itrsquos Hard to Put a Band-Aid on a Broken Spleen Pediatric Trauma
- Disclosures
- Objectives
- Pediatric Prehospital Care
- Mechanism
- Traumatic Pain Management
- Pediatric Trauma
- Deaths by Mechanism of Injury
- Pediatric Trauma
- Pediatric Trauma
- Airway Differences
- Pediatric-Adult Differences
- Pediatric Challenges
- Prehospital Pediatric Challenges
- Pediatric and Adult Trauma
- Scene Response
- Prehospital Intervention
- Where do you take the patient
- Patient arrives at the EDhellip
- Primary Survey
- Order is critical
- Slide Number 22
- Slide Number 23
- Airway
- Indications for Intubation
- Breathing
- ETT Intubation Basics
- Circulation
- Slide Number 29
- CirculationHemodynamic Changes
- Circulation
- Fluid Resuscitation Algorithm
- Reconsidering Crystalloid Resuscitation
- When to start MTP
- Disability
- Finishing Up the Evaluation
- Bad Scene Responses
- OHCA from Trauma
- Blunt Trauma- No Signs of Life
- OHCA with CPR on Arrival
- Pediatric Trauma
- Questions
- References 1
- References 2
- References 3
- References 4
- References 5
- References 5
- XXXXBoston study ems peds trauma procedures- limited pediatric procedural exposure (but more adult experience)
- C-spine
Pediatric Trauma
bull Larger heads alter airway alignment bull Weaker necks increase c-spine injury risk
wwwebmedicinenet
Airway Differences
bull Smaller airway ndash Smaller oral opening ndash Larger tongue in proportion
bull Larynx ndash More cephalad and anterior ndash More acute angle to access the cords
bull Limited functional residual capacity bull Faster to desaturation
Pediatric-Adult Differences
bull Greater BSA more prone to hypothermia bull Higher risk with radiation exposure bull Weight-based interventions bull Greater success with conservative care
Pediatric Challenges
bull Parents bull Non-accidental trauma bull Neglect bull Medically complex kids bull Pediatric patient exposure bull Pediatric intervention experience
Prehospital Pediatric Challenges
bull Less pediatric exposure ndash Experience
bull Critical procedures ~1 of transports bull CPR BMV or advanced airway in 04 of patients bull ALS specific transports BMV 5 ETI 3
bull Less success in pediatric patients ndash IV access success- 86 adult vs 66 kids ndash Intubating problems- 69 peds vs 21 adults
Pediatric and Adult Trauma
bull Trimodal death distribution ndash 1st peak- seconds to minutes after
bull Impacted by prevention ndash 2nd peak- minutes to hours after
bull ldquoGolden Hourrdquo bull Rapid assessment and treatment
ndash 3rd peak- days to weeks bull Quality pediatric care limits morbidity and mortality bull Infection and multi-organ failure
Scene Response
bull 8 year old male in a rollover atv accident
bull Pt is unresponsive localizes pain wonrsquot open his eyes
bull HR 130 BP 10060 bull RR 10 O2 sat 93 bull What do you want to do
Prehospital Intervention
bull Pre-hospital interventions did not significantly worsen care ndash Similar transport times ndash Similar mortality length of stay
bull ETI vs BMV ndash No difference in survival ndash No difference in neurological outcome
Where do you take the patient
bull Pediatric trauma centers ndash Less surgery on solid organ injuries ndash Less radiation- of scans and dosage ndash Less comorbidities
bull Lower costs bull Shorter length of stay bull Lower infections bull Less multi-organ failure
Patient arrives at the EDhellip
bull Where do you start ndash Primary Survey
Primary Survey bull Your ABCrsquoshellip
bull Airway bull Breathing bull Circulation bull Disability (Neuro- GCS) bull Exposure
Order is critical
bull A before B or C bull Morbiditymortality will
occur much faster from airway compromise than from breathing or circulatory problems
bull Systematic approach is the cornerstone of ATLS success
httpwwwuptodatecomcontentsimageimageKey=EM2F64241amptopicKey=EM2F6571amprank=17E150ampsource=see_linkampsearch=traumaamputdPopup=true
httpwwwuptodatecomcontentsimageimageKey=EM2F64241amptopicKey=EM2F6571amprank=17E150ampsource=see_linkampsearch=traumaamputdPopup=true
Airway bull What are you assessing
ndash Airway patency bull What makes the airway not patent
ndash Foreign bodies ndash Vomitbloodsecretions ndash Edemahematoma ndash Impending obstruction
bull Interventions ndash Clearing foreign bodies ndash Suction secretionsvomit with yankauer ndash Repositioning- jaw thrust ndash Nasal trumpetoral airway ndash Intubation ndash Cricothyrotomy jet ventilation
Indications for Intubation
bull Respiratory arrest bull Impending respiratory failure bull Impending airway obstruction bull Inability to protect the airway bull GCS lt8 bull Declining GCS
Breathing bull What are you assessing
ndash ldquoGoodrdquo symmetric chest rise ndash Lung sounds ndash Aeration ndash Basic RR assessment (fast or minimalnone)
bull Interventions ndash Oxygen ndash Albuterolatrovent racemic epi ndash Positive pressure (CPAP BIPAP BMV) ndash Needle decompression ndash Chest tube thoracostomy ndash Intubation ndash Jet ventilation
ETT Intubation Basics bull Size
ndash Age4 + 4 or (Age +16)4 bull Depth
ndash ~ 3 x ETT size when over 1 year of age bull Blade size mac vs miller
ndash 0~ newborn ndash 1~ up to 2 years of life ndash 2~ 2-10 years ndash 3~ 10+ years
bull RSI medications ndash +-Sedation (Always before paralytic) ndash +-Paralytic (May not need it and never wo sedation)
Circulation
bull What do you assess ndash Central and peripheral pulses ndash Heart rate ndash Blood pressure systolic (age x2) +70 ndash Capillary refill ndash Cardiac activity on FAST ndash End organ perfusion
bull Mental status bull Urine output
Circulation Hemodynamic Changes
Percent Blood Volume Loss 0 15 25 35 45
Heart Rate
Blood Pressure
Cardiac Output
Circulation
ndash Access 2 large bore IVrsquos ndash IVFrsquos ndash pRBCrsquos
bull Hgb lt7gdl or ongoing blood losses
ndash Massive Transfusion Protocol
bull (111 ratio of PRBCS FFP Platelets)
ndash Vasopressors (epi norepi dopamine)
ndash Control of Hemorrhage bull Pelvic binders bull Direct pressure bull Indirectproximal pressure bull Tourniquet (only when
absolutely necessary)
ndash Chest Compressions ndash Pericardiocentesis ndash Delayed resuscitation
controlled hypotension (MAP 50 vs 65)
ndash Tranexamic acid in the near future
bull Interventions
Fluid Resuscitation Algorithm 20 mLkg isotonic crystalloid
Reassess
20 mLkg isotonic crystalloid
Reassess
20 mLkg isotonic crystalloid (31 rule)
or consider 10 to 20 mLkg packed red cells
Reconsidering Crystalloid Resuscitation
bull Less fluid ndash Permissive hypotension to
prevent clot rupture (select cases)
bull Too much fluid ndash Excessive Third Spacing ndash Secondary Compartment
Syndrome ndash Greater risk of ARDS ndash Dilutional Coagulopathy
When to start MTP
bull As soon as you believe you will need it ndash Institution specific guidelines
bull gt4 units or 40mlkg of PRBCrsquos expected bull Earlier use of Massive Transfusion Protocol
(pRBC FFP PLT) in ldquoDamage Controlrdquo resuscitations may improve outcome
bull 111 unit ratio bull Risk of TRALI ARDS etc
Disability bull GCS
ndash Range 3-15 ndash We should be 15 ndash Dead are still 3 ndash Less than 8 intubate ndash Eyes- 4 eyes ndash Verbal- most difficult ndash Motor- V6 engine ndash Intubated T
bull AVPU
Finishing Up the Evaluation
bull Airway bull Breathing bull Circulation bull Disability bull Exposure
ndash Expose and examine all parts ndash Cover quickly and keep warm
bull Secondary Survey
Bad Scene Responses
bull What are the outcomes of out-of-hospital cardiac arrest from blunt trauma
bull What are the outcomes of pediatric drowning patients
OHCA from Trauma
bull 2000-2003 bull 123 pts bull Mean age 73 yrs bull Most common
rhythms ndash Asystole 59 ndash PEA 29 ndash V-fib 35
bull 195 rosc in field ndash 98 survived for 24
hrs ndash 57 survived to
discharge ndash Drowning- 19
survival to discharge ndash Bystander CPR tripled
the survivor rate
Blunt Trauma- No Signs of Life
bull Review from 2002-2010 bull No signs of life- 025 of blunt trauma
ndash 25 resuscitated prior to hospital arrival bull 138 of these patients survived to discharge
bull 44 overall survived to hospital discharge
OHCA with CPR on Arrival
bull 169 children bull 141 deaths bull 69 required cpr on arrival- none survived bull 87 of patients requiring CPR on arrival
expired in the ED bull Of the 28 survivors
ndash 55 of survivors had full neurologic recovery
Pediatric Trauma
bull Fortunately these cases represent only a small fraction of EMS transports
bull Despite a few key differences pediatric trauma care overall is very similar to adult trauma care
Questions
References 1 bull NTDB 2013 pediatric Report bull Monkey bars httpsplaygroundchroniclesfileswordpresscom201307soccerjpg bull Screaming child httpblogsbabycentercomwp-contentuploads201409screaming-child-tantrum-fitjpg bull Pediatric airway image httpwwwcelebritydiagnosiscomwp-contentuploads201003pediatric-airwayjpg bull Child on backboard httpsencrypted-tbn2gstaticcomimagesq=tbnANd9GcQscrDVc8IH4MwkNGF6F1A9p7mSVzik5zrWyNvI-
qSwQT5S3GNyVg bull Elbow fracture httpwwwimageinterpretationcoukimageselbowSUPRACONDYLAR20LAT3jpg bull Bike riding httpsmile-per-daycomwp-contentuploads201412klr03jpg bull Dad and child pic httplaughingsquidcomwp-contentuploads471160jpg bull Weigth estimation inner city Am J Emerg Med 2015 Oct33(10)1364-7 doi 101016jajem201507040 Epub 2015 Jul 29 Weight
estimation in an inner-city pediatric ED the effect of obesity Chavez H1 Peterson RE2 Lo K3 Arel M4
bull Guess weight sign httpmedialiveauctiongroupneti963110572971_1jpgv=8CDDAAF8A5B9E20 bull Broselow tape httpsuploadwikimediaorgwikipediacommons994BTape1jpg bull Parent screaming httpmommyofamonstercomwp-contentuploads201301yellingjpg bull Prehospital pain management Am J Emerg Med 2015 Mar33(3)451-4 doi 101016jajem201412012 Epub 2014 Dec 18
Prehospital pain management of injured children a systematic review of current evidence Samuel N1 Steiner IP2 Shavit I3 bull Prehospital pain ped pain assessment Prehosp Emerg Care 2008 Apr-Jun12(2)182-6 doi 10108010903120801907471 Prehospital
pain assessment in pediatric trauma Izsak E1 Moore JL Stringfellow K Oswanski MF Lindstrom DA Stombaugh HA bull Ped pain management Prehosp Emerg Care 2005 Jan-Mar9(1)40-3 Prehospital pain management in children suffering traumatic
injury Swor R1 McEachin CM Seguin D Grall KH bull Prehospital intervention Allen CJ Teisch LF et al Prehospital care and transportation of pediatric trauma patients J Surg Res 2015
Aug197(2)240-6 JAMA 2000 Feb 9283(6)783-90 bull Effect of out-of-hospital pediatric endotracheal intubation on survival and neurological outcome a controlled clinical trial
Gausche M1 Lewis RJ Stratton SJ Haynes BE Gunter CS Goodrich SM Poore PD McCollough MD Henderson DP Pratt FD Seidel JS
bull Pediatric pain management survey Pediatr Emerg Care 2015 Sep 23 [Epub ahead of print] An Assessment of Newly Identified Barriers to and Enablers for Prehospital Pediatric Pain Management Whitley DE1 Li T Jones CM Cushman JT Williams DM Shah MN
References 2 bull httpwwwuptodatecomcontentsprehospital-pediatrics-and-emergency-medical-services-emsabstract6 bull httpwwwuptodatecomcontentsprehospital-pediatrics-and-emergency-medical-services-emsabstract7 bull Pediatr Crit Care Med 2011 Jul12(4)e166-70 doi 101097PCC0b013e3181f36f6e First responder
performance in pediatric trauma a comparison with an adult cohortBankole S1 Asuncion A Ross S Aghai Z Nollah L Echols H Da-Silva S
bull Drayna pc Browne LR et al Prehospital pediatric care Oppportunities for training treatment and research Prehosp Emerg Care 2015 Jul-Sep 19(3) Epub 2015 Feb 6
bull Pediatr Emerg Care 2001 Feb17(1) 5-9Pediatric pre-hospital advanced life support care in an urban setting Babl FE1 Vinci RJ Bauchner H Mottley L
bull Pediatr Crit Care Med 2015 Oct16(8)e260-7 doi 101097PCC0000000000000505Pediatric Out-of-Hospital Critical Procedures in the United States Carlson JN1 Gannon E Mann NC Jacobson KE Dai M Colleran C Wang HE
bull Pediatr Emerg Care 2009 Aug25(8)508-12 doi 101097PEC0b013e3181b0a0da The efficacy of pediatric advanced life support training in emergency medical service providers Baker TW1 King W Soto W Asher C Stolfi A Rowin ME
bull Sutton RM Case E et al ROC investigators A quantitative analysis of out-of-hospital pediatric and adolescent resuscitation quality A report from the ROC Epistry- Cardiac Arrest Resusciation 201593150-157
bull Resuscitation 2014 Aug85(8)1059-64 doi 101016jresuscitation201403307 Epub 2014 Apr 4 Neurocognitive long term follow-up study on drowned children Suominen PK1 Sutinen N2 Valle S3 Olkkola KT4 Loumlnnqvist T3
bull J Pediatr Surg 2010 Jul45(7)1413-9 doi 101016jjpedsurg200912020 Prehospital cardiopulmonary resuscitation in the pediatric trauma patient Murphy JT1 Jaiswal K Sabella J Vinson L Megison S Maxson RT
References 3 bull Pre atv accident
httpwwwctvnewscapolopoly_fs119871591409741949httpImageimagejpg_genderivativeslandscape_960imagejpg bull atv pic httpswwwutahadvocatescomwp-contentuploads201402atvAccidentLawyerjpg bull Blunt abdominal solid organ injury adult vs pediatric trauma center J Pediatr Surg 2015 Aug 28 pii S0022-3468(15)00526-6 doi
101016jjpedsurg201508012 [Epub ahead of print] Trauma center variation in the management of pediatric patients with blunt abdominal solid organ injury a national trauma data bank analysis Safavi A1 Skarsgard ED2 Rhee P1 Zangbar B1 Kulvatunyou N1 Tang A1 OKeeffe T1 Friese RS1 Joseph B3
bull Pediatric blunt abdominal injury Curr Opin Crit Care 2015 Sep 28 [Epub ahead of print] Pediatric blunt abdominal trauma current management Notrica DM1
bull Pediatric splenic injury management Am J Surg 2015 Jul 31 pii S0002-9610(15)00417-1 doi 101016jamjsurg201506009 [Epub ahead of print] Comparative effectiveness of treatment strategies for severe splenic trauma in the pediatric population Rialon KL1 Englum BR1 Gulack BC1 Guevara CJ2 Bhattacharya SD3 Shapiro ML4 Rice HE5 Scarborough JE4 Adibe OO6
bull Liver pic httpss-media-cache-ak0pinimgcom736x7da50e7da50eb2bb603c99ef6649ff897e26b5jpg bull Solid organ injury non op in peds J Trauma Acute Care Surg 2015 Oct79(4)683-93 doi 101097TA0000000000000808
Nonoperative management of blunt liver and spleen injury in children Evaluation of the ATOMAC guideline using GRADE Notrica DM1 Eubanks JW 3rd Tuggle DW Maxson RT Letton RW Garcia NM Alder AC Lawson KA St Peter SD Megison S Garcia Filion P
bull Pediaric vs nonped trauma ct use J Pediatr 2015 Oct167(4)897-904e3 doi 101016jjpeds201506052 Epub 2015 Jul 29 Variation in Computed Tomography Imaging for Pediatric Injury-Related Emergency Visits Marin JR1 Wang L2 Winger DG2 Mannix RC3
bull Solid organ management in ped population J Trauma Acute Care Surg 2015 Aug79(2)206-14quiz 332 doi 101097TA0000000000000731 Management of children with solid organ injuries after blunt torso trauma Wisner DH1 Kuppermann N Cooper A Menaker J Ehrlich P Kooistra J Mahajan P Lee L Cook LJ Yen K Lillis K Holmes JF
bull Triad of death image httpimageslidesharecdncomdamage-control-resuscitation-1304253390-phpapp0195damage-control-resuscitation-14-728jpgcb=1304235553
bull Tranexamic acid study Eckert MJ Wertin TM Tyner SD et al 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 77852
bull Image care accident httpsuploadwikimediaorgwikipediacommonsthumbee1Car_crash_1jpg1280px-Car_crash_1jpg
References 4 bull httpwwwsurgeryvcuedudivisionsacutesurghtml bull Trauma management Approach to the unstable child
httpwwwuptodatecomcontentstrauma-management-approach-to-the-unstable-childsource=search_resultampsearch=pediatric+trauma+childrenampselectedTitle=17E150
bull Trauma management Unique pediatric considerations httpwwwuptodatecomcontentstrauma-management-unique-pediatric-considerationssource=search_resultampsearch=pediatric+trauma+childrenampselectedTitle=37E150
References 5 bull httpwwwetiquettehellcomsmfindexphptopic=8666360 bull httpwwwstlouischildrensorghealth-care-professionalsems-providers bull httpwwwuchicagokidshospitalorgspecialtiesemergency-medicinespecialhtml bull httpwwwsimsacademyinfoFXpatienthtm bull httptheemtspotcomwp-contentuploads200902another-burn-patient-by-annette-larsonjpg bull httplastangryfancomwp-contentuploads200910Clint-Malarchukjpg bull httpwwwtraumaorgarchiveresusmassivehtml bull httpwwwuptodatecomcontentsimageimageKey=PEDS68694amptopicKey=EM2F6389ampsourc
e=previewampsearch=pediatric+hemorrhagic+shockampselectedTitle=17E150amprank=undefined bull httptheemtspotcomwp-contentuploads200902gcsgif bull httpwwwuptodatecomcontentsimageimageKey=EM2F60409amptopicKey=EM2F6571amprank
=17E150ampsource=see_linkampsearch=traumaamputdPopup=true bull httpwwwuptodatecomcontentsimageimageKey=EM2F80874amptopicKey=EM2F6571amprank
=17E150ampsource=see_linkampsearch=traumaamputdPopup=true bull httpempracticenewswordpresscomcategorynexus-criteria bull httpswwwgooglecomsearchq=pediatric+glasgow+coma+scaleamptbm=ischamptbo=uampsource=uni
vampsa=Xampei=8TiOU7TNC5WuyATp5YG4BQampsqi=2ampved=0CDYQsAQampbiw=1426ampbih=883q=canadian+c-spine+rulesamptbm=ischampfacrc=_ampimgdii=_ampimgrc=WI94QMHgMLTQmM253A3BP5nbsFhNCXK0FM3Bhttp253A252F252Fwwwbmjcom252Fhighwire252Ffilestream252F436003252Ffield_highwire_fragment_image_l252F0jpg3Bhttp253A252F252Fwwwbmjcom252Fcontent252F339252Fbmjb41463B12803B1253
References 5 bull httpwwwuptodatecomcontentsimageimageKey=EM2F76777amptopicKey=EM2F6571amprank
=17E150ampsource=see_linkampsearch=traumaamputdPopup=true bull httpwwwdocumentingrealitycomforumattachmentsf14964898d1246625322-firework-injury-
m80injury1jpg bull httpwwwpediatriceducationorg20050620 bull httpwwwarmstrongmedicalcomindexcfmgoproductdetailsec3ssec19cat61fam515 bull httpwwwuptodatecomcontentsimageimageKey=PEDS61087amptopicKey=ID2F7661ampsource
=outline_linkampsearch=tetanus+prophylaxisamputdPopup=true bull httpwwwafsecafmilsharedmediaphotodbweb110609-F-MJ378-009jpg bull httpwwwuptodatecomcontentsimageimageKey=EM75765amptopicKey= bull EM2F6389ampsource=outline_linkampsearch=massive+transfusion+protocolamputdPopup=true bull httpwwwmotifakecomimagedemotivational-postersmall0910whats-the-question-ignorance-
calvin-and-hobbes-demotivational-poster-1255020127jpg
XXXXBoston study ems peds trauma procedures- limited pediatric procedural exposure (but more adult experience) bull Catchment area 590000
over 1 year bull 555 pediatric ALS
transport ndash 19 blunt trauma ndash 10 penetrating trauma
bull IV 33 bull BMV 5 bull Intubation 3 bull 50 ALS providers average
year ndash IV- 37 ndash Intubation- 03 ndash IO- 006
bull 7 ped ems ndash 13 trauma
bull Critical procedures ndash 101000 peds cases ndash Intubation 671000 ndash IO 51000 ndash 81 successful
Pediatr Emerg Care 2001 Feb17(1)5-9 Pediatric pre-hospital advanced life support care in an urban setting
Babl FE1 Vinci RJ Bauchner H Mottley L
Pediatr Crit Care Med 2015 Oct16(8)e260-7 doi 101097PCC0000000000000505 Pediatric Out-of-Hospital Critical Procedures in the United States
Carlson JN1 Gannon E Mann NC Jacobson KE Dai M Colleran C Wang HE
C-spine bull C-spine injuries rare bull Take pt to closest hospital if over injuries
call for it (ie resuscitation altered mental status) primary guide
bull Mechanism ndash Altered mental status focal neuro change
torticollis substantial torso injury diving high speed auto neck pain underlying predisposing condition Acad Emerg Med 2014 Jan21(1)55-64 doi 101111acem12288
Comparison of outcomes for children with cervical spine injury based on destination hospital from scene of injury Anders JF1 Adelgais K Hoyle JD Jr Olsen C Jaffe DM Leonard JC Pediatric Emergency Care Applied Research Network
(PECARN)
Ann Emerg Med 2011 Aug58(2)145-55 doi 101016jannemergmed201008038 Epub 2010 Oct 29 Factors associated with cervical spine injury in children after blunt trauma
Leonard JC Kuppermann N Olsen C Babcock-Cimpello L Brown K Mahajan P Adelgais KM Anders J Borgialli D Donoghue A Hoyle JD Jr Kim E Leonard JR Lillis KA Nigrovic LE Powell EC Rebella
G Reeves SD Rogers AJ Stankovic C Teshome G Jaffe DM Pediatric Emergency Care Applied Research Network
- Itrsquos Hard to Put a Band-Aid on a Broken Spleen Pediatric Trauma
- Disclosures
- Objectives
- Pediatric Prehospital Care
- Mechanism
- Traumatic Pain Management
- Pediatric Trauma
- Deaths by Mechanism of Injury
- Pediatric Trauma
- Pediatric Trauma
- Airway Differences
- Pediatric-Adult Differences
- Pediatric Challenges
- Prehospital Pediatric Challenges
- Pediatric and Adult Trauma
- Scene Response
- Prehospital Intervention
- Where do you take the patient
- Patient arrives at the EDhellip
- Primary Survey
- Order is critical
- Slide Number 22
- Slide Number 23
- Airway
- Indications for Intubation
- Breathing
- ETT Intubation Basics
- Circulation
- Slide Number 29
- CirculationHemodynamic Changes
- Circulation
- Fluid Resuscitation Algorithm
- Reconsidering Crystalloid Resuscitation
- When to start MTP
- Disability
- Finishing Up the Evaluation
- Bad Scene Responses
- OHCA from Trauma
- Blunt Trauma- No Signs of Life
- OHCA with CPR on Arrival
- Pediatric Trauma
- Questions
- References 1
- References 2
- References 3
- References 4
- References 5
- References 5
- XXXXBoston study ems peds trauma procedures- limited pediatric procedural exposure (but more adult experience)
- C-spine
Airway Differences
bull Smaller airway ndash Smaller oral opening ndash Larger tongue in proportion
bull Larynx ndash More cephalad and anterior ndash More acute angle to access the cords
bull Limited functional residual capacity bull Faster to desaturation
Pediatric-Adult Differences
bull Greater BSA more prone to hypothermia bull Higher risk with radiation exposure bull Weight-based interventions bull Greater success with conservative care
Pediatric Challenges
bull Parents bull Non-accidental trauma bull Neglect bull Medically complex kids bull Pediatric patient exposure bull Pediatric intervention experience
Prehospital Pediatric Challenges
bull Less pediatric exposure ndash Experience
bull Critical procedures ~1 of transports bull CPR BMV or advanced airway in 04 of patients bull ALS specific transports BMV 5 ETI 3
bull Less success in pediatric patients ndash IV access success- 86 adult vs 66 kids ndash Intubating problems- 69 peds vs 21 adults
Pediatric and Adult Trauma
bull Trimodal death distribution ndash 1st peak- seconds to minutes after
bull Impacted by prevention ndash 2nd peak- minutes to hours after
bull ldquoGolden Hourrdquo bull Rapid assessment and treatment
ndash 3rd peak- days to weeks bull Quality pediatric care limits morbidity and mortality bull Infection and multi-organ failure
Scene Response
bull 8 year old male in a rollover atv accident
bull Pt is unresponsive localizes pain wonrsquot open his eyes
bull HR 130 BP 10060 bull RR 10 O2 sat 93 bull What do you want to do
Prehospital Intervention
bull Pre-hospital interventions did not significantly worsen care ndash Similar transport times ndash Similar mortality length of stay
bull ETI vs BMV ndash No difference in survival ndash No difference in neurological outcome
Where do you take the patient
bull Pediatric trauma centers ndash Less surgery on solid organ injuries ndash Less radiation- of scans and dosage ndash Less comorbidities
bull Lower costs bull Shorter length of stay bull Lower infections bull Less multi-organ failure
Patient arrives at the EDhellip
bull Where do you start ndash Primary Survey
Primary Survey bull Your ABCrsquoshellip
bull Airway bull Breathing bull Circulation bull Disability (Neuro- GCS) bull Exposure
Order is critical
bull A before B or C bull Morbiditymortality will
occur much faster from airway compromise than from breathing or circulatory problems
bull Systematic approach is the cornerstone of ATLS success
httpwwwuptodatecomcontentsimageimageKey=EM2F64241amptopicKey=EM2F6571amprank=17E150ampsource=see_linkampsearch=traumaamputdPopup=true
httpwwwuptodatecomcontentsimageimageKey=EM2F64241amptopicKey=EM2F6571amprank=17E150ampsource=see_linkampsearch=traumaamputdPopup=true
Airway bull What are you assessing
ndash Airway patency bull What makes the airway not patent
ndash Foreign bodies ndash Vomitbloodsecretions ndash Edemahematoma ndash Impending obstruction
bull Interventions ndash Clearing foreign bodies ndash Suction secretionsvomit with yankauer ndash Repositioning- jaw thrust ndash Nasal trumpetoral airway ndash Intubation ndash Cricothyrotomy jet ventilation
Indications for Intubation
bull Respiratory arrest bull Impending respiratory failure bull Impending airway obstruction bull Inability to protect the airway bull GCS lt8 bull Declining GCS
Breathing bull What are you assessing
ndash ldquoGoodrdquo symmetric chest rise ndash Lung sounds ndash Aeration ndash Basic RR assessment (fast or minimalnone)
bull Interventions ndash Oxygen ndash Albuterolatrovent racemic epi ndash Positive pressure (CPAP BIPAP BMV) ndash Needle decompression ndash Chest tube thoracostomy ndash Intubation ndash Jet ventilation
ETT Intubation Basics bull Size
ndash Age4 + 4 or (Age +16)4 bull Depth
ndash ~ 3 x ETT size when over 1 year of age bull Blade size mac vs miller
ndash 0~ newborn ndash 1~ up to 2 years of life ndash 2~ 2-10 years ndash 3~ 10+ years
bull RSI medications ndash +-Sedation (Always before paralytic) ndash +-Paralytic (May not need it and never wo sedation)
Circulation
bull What do you assess ndash Central and peripheral pulses ndash Heart rate ndash Blood pressure systolic (age x2) +70 ndash Capillary refill ndash Cardiac activity on FAST ndash End organ perfusion
bull Mental status bull Urine output
Circulation Hemodynamic Changes
Percent Blood Volume Loss 0 15 25 35 45
Heart Rate
Blood Pressure
Cardiac Output
Circulation
ndash Access 2 large bore IVrsquos ndash IVFrsquos ndash pRBCrsquos
bull Hgb lt7gdl or ongoing blood losses
ndash Massive Transfusion Protocol
bull (111 ratio of PRBCS FFP Platelets)
ndash Vasopressors (epi norepi dopamine)
ndash Control of Hemorrhage bull Pelvic binders bull Direct pressure bull Indirectproximal pressure bull Tourniquet (only when
absolutely necessary)
ndash Chest Compressions ndash Pericardiocentesis ndash Delayed resuscitation
controlled hypotension (MAP 50 vs 65)
ndash Tranexamic acid in the near future
bull Interventions
Fluid Resuscitation Algorithm 20 mLkg isotonic crystalloid
Reassess
20 mLkg isotonic crystalloid
Reassess
20 mLkg isotonic crystalloid (31 rule)
or consider 10 to 20 mLkg packed red cells
Reconsidering Crystalloid Resuscitation
bull Less fluid ndash Permissive hypotension to
prevent clot rupture (select cases)
bull Too much fluid ndash Excessive Third Spacing ndash Secondary Compartment
Syndrome ndash Greater risk of ARDS ndash Dilutional Coagulopathy
When to start MTP
bull As soon as you believe you will need it ndash Institution specific guidelines
bull gt4 units or 40mlkg of PRBCrsquos expected bull Earlier use of Massive Transfusion Protocol
(pRBC FFP PLT) in ldquoDamage Controlrdquo resuscitations may improve outcome
bull 111 unit ratio bull Risk of TRALI ARDS etc
Disability bull GCS
ndash Range 3-15 ndash We should be 15 ndash Dead are still 3 ndash Less than 8 intubate ndash Eyes- 4 eyes ndash Verbal- most difficult ndash Motor- V6 engine ndash Intubated T
bull AVPU
Finishing Up the Evaluation
bull Airway bull Breathing bull Circulation bull Disability bull Exposure
ndash Expose and examine all parts ndash Cover quickly and keep warm
bull Secondary Survey
Bad Scene Responses
bull What are the outcomes of out-of-hospital cardiac arrest from blunt trauma
bull What are the outcomes of pediatric drowning patients
OHCA from Trauma
bull 2000-2003 bull 123 pts bull Mean age 73 yrs bull Most common
rhythms ndash Asystole 59 ndash PEA 29 ndash V-fib 35
bull 195 rosc in field ndash 98 survived for 24
hrs ndash 57 survived to
discharge ndash Drowning- 19
survival to discharge ndash Bystander CPR tripled
the survivor rate
Blunt Trauma- No Signs of Life
bull Review from 2002-2010 bull No signs of life- 025 of blunt trauma
ndash 25 resuscitated prior to hospital arrival bull 138 of these patients survived to discharge
bull 44 overall survived to hospital discharge
OHCA with CPR on Arrival
bull 169 children bull 141 deaths bull 69 required cpr on arrival- none survived bull 87 of patients requiring CPR on arrival
expired in the ED bull Of the 28 survivors
ndash 55 of survivors had full neurologic recovery
Pediatric Trauma
bull Fortunately these cases represent only a small fraction of EMS transports
bull Despite a few key differences pediatric trauma care overall is very similar to adult trauma care
Questions
References 1 bull NTDB 2013 pediatric Report bull Monkey bars httpsplaygroundchroniclesfileswordpresscom201307soccerjpg bull Screaming child httpblogsbabycentercomwp-contentuploads201409screaming-child-tantrum-fitjpg bull Pediatric airway image httpwwwcelebritydiagnosiscomwp-contentuploads201003pediatric-airwayjpg bull Child on backboard httpsencrypted-tbn2gstaticcomimagesq=tbnANd9GcQscrDVc8IH4MwkNGF6F1A9p7mSVzik5zrWyNvI-
qSwQT5S3GNyVg bull Elbow fracture httpwwwimageinterpretationcoukimageselbowSUPRACONDYLAR20LAT3jpg bull Bike riding httpsmile-per-daycomwp-contentuploads201412klr03jpg bull Dad and child pic httplaughingsquidcomwp-contentuploads471160jpg bull Weigth estimation inner city Am J Emerg Med 2015 Oct33(10)1364-7 doi 101016jajem201507040 Epub 2015 Jul 29 Weight
estimation in an inner-city pediatric ED the effect of obesity Chavez H1 Peterson RE2 Lo K3 Arel M4
bull Guess weight sign httpmedialiveauctiongroupneti963110572971_1jpgv=8CDDAAF8A5B9E20 bull Broselow tape httpsuploadwikimediaorgwikipediacommons994BTape1jpg bull Parent screaming httpmommyofamonstercomwp-contentuploads201301yellingjpg bull Prehospital pain management Am J Emerg Med 2015 Mar33(3)451-4 doi 101016jajem201412012 Epub 2014 Dec 18
Prehospital pain management of injured children a systematic review of current evidence Samuel N1 Steiner IP2 Shavit I3 bull Prehospital pain ped pain assessment Prehosp Emerg Care 2008 Apr-Jun12(2)182-6 doi 10108010903120801907471 Prehospital
pain assessment in pediatric trauma Izsak E1 Moore JL Stringfellow K Oswanski MF Lindstrom DA Stombaugh HA bull Ped pain management Prehosp Emerg Care 2005 Jan-Mar9(1)40-3 Prehospital pain management in children suffering traumatic
injury Swor R1 McEachin CM Seguin D Grall KH bull Prehospital intervention Allen CJ Teisch LF et al Prehospital care and transportation of pediatric trauma patients J Surg Res 2015
Aug197(2)240-6 JAMA 2000 Feb 9283(6)783-90 bull Effect of out-of-hospital pediatric endotracheal intubation on survival and neurological outcome a controlled clinical trial
Gausche M1 Lewis RJ Stratton SJ Haynes BE Gunter CS Goodrich SM Poore PD McCollough MD Henderson DP Pratt FD Seidel JS
bull Pediatric pain management survey Pediatr Emerg Care 2015 Sep 23 [Epub ahead of print] An Assessment of Newly Identified Barriers to and Enablers for Prehospital Pediatric Pain Management Whitley DE1 Li T Jones CM Cushman JT Williams DM Shah MN
References 2 bull httpwwwuptodatecomcontentsprehospital-pediatrics-and-emergency-medical-services-emsabstract6 bull httpwwwuptodatecomcontentsprehospital-pediatrics-and-emergency-medical-services-emsabstract7 bull Pediatr Crit Care Med 2011 Jul12(4)e166-70 doi 101097PCC0b013e3181f36f6e First responder
performance in pediatric trauma a comparison with an adult cohortBankole S1 Asuncion A Ross S Aghai Z Nollah L Echols H Da-Silva S
bull Drayna pc Browne LR et al Prehospital pediatric care Oppportunities for training treatment and research Prehosp Emerg Care 2015 Jul-Sep 19(3) Epub 2015 Feb 6
bull Pediatr Emerg Care 2001 Feb17(1) 5-9Pediatric pre-hospital advanced life support care in an urban setting Babl FE1 Vinci RJ Bauchner H Mottley L
bull Pediatr Crit Care Med 2015 Oct16(8)e260-7 doi 101097PCC0000000000000505Pediatric Out-of-Hospital Critical Procedures in the United States Carlson JN1 Gannon E Mann NC Jacobson KE Dai M Colleran C Wang HE
bull Pediatr Emerg Care 2009 Aug25(8)508-12 doi 101097PEC0b013e3181b0a0da The efficacy of pediatric advanced life support training in emergency medical service providers Baker TW1 King W Soto W Asher C Stolfi A Rowin ME
bull Sutton RM Case E et al ROC investigators A quantitative analysis of out-of-hospital pediatric and adolescent resuscitation quality A report from the ROC Epistry- Cardiac Arrest Resusciation 201593150-157
bull Resuscitation 2014 Aug85(8)1059-64 doi 101016jresuscitation201403307 Epub 2014 Apr 4 Neurocognitive long term follow-up study on drowned children Suominen PK1 Sutinen N2 Valle S3 Olkkola KT4 Loumlnnqvist T3
bull J Pediatr Surg 2010 Jul45(7)1413-9 doi 101016jjpedsurg200912020 Prehospital cardiopulmonary resuscitation in the pediatric trauma patient Murphy JT1 Jaiswal K Sabella J Vinson L Megison S Maxson RT
References 3 bull Pre atv accident
httpwwwctvnewscapolopoly_fs119871591409741949httpImageimagejpg_genderivativeslandscape_960imagejpg bull atv pic httpswwwutahadvocatescomwp-contentuploads201402atvAccidentLawyerjpg bull Blunt abdominal solid organ injury adult vs pediatric trauma center J Pediatr Surg 2015 Aug 28 pii S0022-3468(15)00526-6 doi
101016jjpedsurg201508012 [Epub ahead of print] Trauma center variation in the management of pediatric patients with blunt abdominal solid organ injury a national trauma data bank analysis Safavi A1 Skarsgard ED2 Rhee P1 Zangbar B1 Kulvatunyou N1 Tang A1 OKeeffe T1 Friese RS1 Joseph B3
bull Pediatric blunt abdominal injury Curr Opin Crit Care 2015 Sep 28 [Epub ahead of print] Pediatric blunt abdominal trauma current management Notrica DM1
bull Pediatric splenic injury management Am J Surg 2015 Jul 31 pii S0002-9610(15)00417-1 doi 101016jamjsurg201506009 [Epub ahead of print] Comparative effectiveness of treatment strategies for severe splenic trauma in the pediatric population Rialon KL1 Englum BR1 Gulack BC1 Guevara CJ2 Bhattacharya SD3 Shapiro ML4 Rice HE5 Scarborough JE4 Adibe OO6
bull Liver pic httpss-media-cache-ak0pinimgcom736x7da50e7da50eb2bb603c99ef6649ff897e26b5jpg bull Solid organ injury non op in peds J Trauma Acute Care Surg 2015 Oct79(4)683-93 doi 101097TA0000000000000808
Nonoperative management of blunt liver and spleen injury in children Evaluation of the ATOMAC guideline using GRADE Notrica DM1 Eubanks JW 3rd Tuggle DW Maxson RT Letton RW Garcia NM Alder AC Lawson KA St Peter SD Megison S Garcia Filion P
bull Pediaric vs nonped trauma ct use J Pediatr 2015 Oct167(4)897-904e3 doi 101016jjpeds201506052 Epub 2015 Jul 29 Variation in Computed Tomography Imaging for Pediatric Injury-Related Emergency Visits Marin JR1 Wang L2 Winger DG2 Mannix RC3
bull Solid organ management in ped population J Trauma Acute Care Surg 2015 Aug79(2)206-14quiz 332 doi 101097TA0000000000000731 Management of children with solid organ injuries after blunt torso trauma Wisner DH1 Kuppermann N Cooper A Menaker J Ehrlich P Kooistra J Mahajan P Lee L Cook LJ Yen K Lillis K Holmes JF
bull Triad of death image httpimageslidesharecdncomdamage-control-resuscitation-1304253390-phpapp0195damage-control-resuscitation-14-728jpgcb=1304235553
bull Tranexamic acid study Eckert MJ Wertin TM Tyner SD et al 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 77852
bull Image care accident httpsuploadwikimediaorgwikipediacommonsthumbee1Car_crash_1jpg1280px-Car_crash_1jpg
References 4 bull httpwwwsurgeryvcuedudivisionsacutesurghtml bull Trauma management Approach to the unstable child
httpwwwuptodatecomcontentstrauma-management-approach-to-the-unstable-childsource=search_resultampsearch=pediatric+trauma+childrenampselectedTitle=17E150
bull Trauma management Unique pediatric considerations httpwwwuptodatecomcontentstrauma-management-unique-pediatric-considerationssource=search_resultampsearch=pediatric+trauma+childrenampselectedTitle=37E150
References 5 bull httpwwwetiquettehellcomsmfindexphptopic=8666360 bull httpwwwstlouischildrensorghealth-care-professionalsems-providers bull httpwwwuchicagokidshospitalorgspecialtiesemergency-medicinespecialhtml bull httpwwwsimsacademyinfoFXpatienthtm bull httptheemtspotcomwp-contentuploads200902another-burn-patient-by-annette-larsonjpg bull httplastangryfancomwp-contentuploads200910Clint-Malarchukjpg bull httpwwwtraumaorgarchiveresusmassivehtml bull httpwwwuptodatecomcontentsimageimageKey=PEDS68694amptopicKey=EM2F6389ampsourc
e=previewampsearch=pediatric+hemorrhagic+shockampselectedTitle=17E150amprank=undefined bull httptheemtspotcomwp-contentuploads200902gcsgif bull httpwwwuptodatecomcontentsimageimageKey=EM2F60409amptopicKey=EM2F6571amprank
=17E150ampsource=see_linkampsearch=traumaamputdPopup=true bull httpwwwuptodatecomcontentsimageimageKey=EM2F80874amptopicKey=EM2F6571amprank
=17E150ampsource=see_linkampsearch=traumaamputdPopup=true bull httpempracticenewswordpresscomcategorynexus-criteria bull httpswwwgooglecomsearchq=pediatric+glasgow+coma+scaleamptbm=ischamptbo=uampsource=uni
vampsa=Xampei=8TiOU7TNC5WuyATp5YG4BQampsqi=2ampved=0CDYQsAQampbiw=1426ampbih=883q=canadian+c-spine+rulesamptbm=ischampfacrc=_ampimgdii=_ampimgrc=WI94QMHgMLTQmM253A3BP5nbsFhNCXK0FM3Bhttp253A252F252Fwwwbmjcom252Fhighwire252Ffilestream252F436003252Ffield_highwire_fragment_image_l252F0jpg3Bhttp253A252F252Fwwwbmjcom252Fcontent252F339252Fbmjb41463B12803B1253
References 5 bull httpwwwuptodatecomcontentsimageimageKey=EM2F76777amptopicKey=EM2F6571amprank
=17E150ampsource=see_linkampsearch=traumaamputdPopup=true bull httpwwwdocumentingrealitycomforumattachmentsf14964898d1246625322-firework-injury-
m80injury1jpg bull httpwwwpediatriceducationorg20050620 bull httpwwwarmstrongmedicalcomindexcfmgoproductdetailsec3ssec19cat61fam515 bull httpwwwuptodatecomcontentsimageimageKey=PEDS61087amptopicKey=ID2F7661ampsource
=outline_linkampsearch=tetanus+prophylaxisamputdPopup=true bull httpwwwafsecafmilsharedmediaphotodbweb110609-F-MJ378-009jpg bull httpwwwuptodatecomcontentsimageimageKey=EM75765amptopicKey= bull EM2F6389ampsource=outline_linkampsearch=massive+transfusion+protocolamputdPopup=true bull httpwwwmotifakecomimagedemotivational-postersmall0910whats-the-question-ignorance-
calvin-and-hobbes-demotivational-poster-1255020127jpg
XXXXBoston study ems peds trauma procedures- limited pediatric procedural exposure (but more adult experience) bull Catchment area 590000
over 1 year bull 555 pediatric ALS
transport ndash 19 blunt trauma ndash 10 penetrating trauma
bull IV 33 bull BMV 5 bull Intubation 3 bull 50 ALS providers average
year ndash IV- 37 ndash Intubation- 03 ndash IO- 006
bull 7 ped ems ndash 13 trauma
bull Critical procedures ndash 101000 peds cases ndash Intubation 671000 ndash IO 51000 ndash 81 successful
Pediatr Emerg Care 2001 Feb17(1)5-9 Pediatric pre-hospital advanced life support care in an urban setting
Babl FE1 Vinci RJ Bauchner H Mottley L
Pediatr Crit Care Med 2015 Oct16(8)e260-7 doi 101097PCC0000000000000505 Pediatric Out-of-Hospital Critical Procedures in the United States
Carlson JN1 Gannon E Mann NC Jacobson KE Dai M Colleran C Wang HE
C-spine bull C-spine injuries rare bull Take pt to closest hospital if over injuries
call for it (ie resuscitation altered mental status) primary guide
bull Mechanism ndash Altered mental status focal neuro change
torticollis substantial torso injury diving high speed auto neck pain underlying predisposing condition Acad Emerg Med 2014 Jan21(1)55-64 doi 101111acem12288
Comparison of outcomes for children with cervical spine injury based on destination hospital from scene of injury Anders JF1 Adelgais K Hoyle JD Jr Olsen C Jaffe DM Leonard JC Pediatric Emergency Care Applied Research Network
(PECARN)
Ann Emerg Med 2011 Aug58(2)145-55 doi 101016jannemergmed201008038 Epub 2010 Oct 29 Factors associated with cervical spine injury in children after blunt trauma
Leonard JC Kuppermann N Olsen C Babcock-Cimpello L Brown K Mahajan P Adelgais KM Anders J Borgialli D Donoghue A Hoyle JD Jr Kim E Leonard JR Lillis KA Nigrovic LE Powell EC Rebella
G Reeves SD Rogers AJ Stankovic C Teshome G Jaffe DM Pediatric Emergency Care Applied Research Network
- Itrsquos Hard to Put a Band-Aid on a Broken Spleen Pediatric Trauma
- Disclosures
- Objectives
- Pediatric Prehospital Care
- Mechanism
- Traumatic Pain Management
- Pediatric Trauma
- Deaths by Mechanism of Injury
- Pediatric Trauma
- Pediatric Trauma
- Airway Differences
- Pediatric-Adult Differences
- Pediatric Challenges
- Prehospital Pediatric Challenges
- Pediatric and Adult Trauma
- Scene Response
- Prehospital Intervention
- Where do you take the patient
- Patient arrives at the EDhellip
- Primary Survey
- Order is critical
- Slide Number 22
- Slide Number 23
- Airway
- Indications for Intubation
- Breathing
- ETT Intubation Basics
- Circulation
- Slide Number 29
- CirculationHemodynamic Changes
- Circulation
- Fluid Resuscitation Algorithm
- Reconsidering Crystalloid Resuscitation
- When to start MTP
- Disability
- Finishing Up the Evaluation
- Bad Scene Responses
- OHCA from Trauma
- Blunt Trauma- No Signs of Life
- OHCA with CPR on Arrival
- Pediatric Trauma
- Questions
- References 1
- References 2
- References 3
- References 4
- References 5
- References 5
- XXXXBoston study ems peds trauma procedures- limited pediatric procedural exposure (but more adult experience)
- C-spine
Pediatric-Adult Differences
bull Greater BSA more prone to hypothermia bull Higher risk with radiation exposure bull Weight-based interventions bull Greater success with conservative care
Pediatric Challenges
bull Parents bull Non-accidental trauma bull Neglect bull Medically complex kids bull Pediatric patient exposure bull Pediatric intervention experience
Prehospital Pediatric Challenges
bull Less pediatric exposure ndash Experience
bull Critical procedures ~1 of transports bull CPR BMV or advanced airway in 04 of patients bull ALS specific transports BMV 5 ETI 3
bull Less success in pediatric patients ndash IV access success- 86 adult vs 66 kids ndash Intubating problems- 69 peds vs 21 adults
Pediatric and Adult Trauma
bull Trimodal death distribution ndash 1st peak- seconds to minutes after
bull Impacted by prevention ndash 2nd peak- minutes to hours after
bull ldquoGolden Hourrdquo bull Rapid assessment and treatment
ndash 3rd peak- days to weeks bull Quality pediatric care limits morbidity and mortality bull Infection and multi-organ failure
Scene Response
bull 8 year old male in a rollover atv accident
bull Pt is unresponsive localizes pain wonrsquot open his eyes
bull HR 130 BP 10060 bull RR 10 O2 sat 93 bull What do you want to do
Prehospital Intervention
bull Pre-hospital interventions did not significantly worsen care ndash Similar transport times ndash Similar mortality length of stay
bull ETI vs BMV ndash No difference in survival ndash No difference in neurological outcome
Where do you take the patient
bull Pediatric trauma centers ndash Less surgery on solid organ injuries ndash Less radiation- of scans and dosage ndash Less comorbidities
bull Lower costs bull Shorter length of stay bull Lower infections bull Less multi-organ failure
Patient arrives at the EDhellip
bull Where do you start ndash Primary Survey
Primary Survey bull Your ABCrsquoshellip
bull Airway bull Breathing bull Circulation bull Disability (Neuro- GCS) bull Exposure
Order is critical
bull A before B or C bull Morbiditymortality will
occur much faster from airway compromise than from breathing or circulatory problems
bull Systematic approach is the cornerstone of ATLS success
httpwwwuptodatecomcontentsimageimageKey=EM2F64241amptopicKey=EM2F6571amprank=17E150ampsource=see_linkampsearch=traumaamputdPopup=true
httpwwwuptodatecomcontentsimageimageKey=EM2F64241amptopicKey=EM2F6571amprank=17E150ampsource=see_linkampsearch=traumaamputdPopup=true
Airway bull What are you assessing
ndash Airway patency bull What makes the airway not patent
ndash Foreign bodies ndash Vomitbloodsecretions ndash Edemahematoma ndash Impending obstruction
bull Interventions ndash Clearing foreign bodies ndash Suction secretionsvomit with yankauer ndash Repositioning- jaw thrust ndash Nasal trumpetoral airway ndash Intubation ndash Cricothyrotomy jet ventilation
Indications for Intubation
bull Respiratory arrest bull Impending respiratory failure bull Impending airway obstruction bull Inability to protect the airway bull GCS lt8 bull Declining GCS
Breathing bull What are you assessing
ndash ldquoGoodrdquo symmetric chest rise ndash Lung sounds ndash Aeration ndash Basic RR assessment (fast or minimalnone)
bull Interventions ndash Oxygen ndash Albuterolatrovent racemic epi ndash Positive pressure (CPAP BIPAP BMV) ndash Needle decompression ndash Chest tube thoracostomy ndash Intubation ndash Jet ventilation
ETT Intubation Basics bull Size
ndash Age4 + 4 or (Age +16)4 bull Depth
ndash ~ 3 x ETT size when over 1 year of age bull Blade size mac vs miller
ndash 0~ newborn ndash 1~ up to 2 years of life ndash 2~ 2-10 years ndash 3~ 10+ years
bull RSI medications ndash +-Sedation (Always before paralytic) ndash +-Paralytic (May not need it and never wo sedation)
Circulation
bull What do you assess ndash Central and peripheral pulses ndash Heart rate ndash Blood pressure systolic (age x2) +70 ndash Capillary refill ndash Cardiac activity on FAST ndash End organ perfusion
bull Mental status bull Urine output
Circulation Hemodynamic Changes
Percent Blood Volume Loss 0 15 25 35 45
Heart Rate
Blood Pressure
Cardiac Output
Circulation
ndash Access 2 large bore IVrsquos ndash IVFrsquos ndash pRBCrsquos
bull Hgb lt7gdl or ongoing blood losses
ndash Massive Transfusion Protocol
bull (111 ratio of PRBCS FFP Platelets)
ndash Vasopressors (epi norepi dopamine)
ndash Control of Hemorrhage bull Pelvic binders bull Direct pressure bull Indirectproximal pressure bull Tourniquet (only when
absolutely necessary)
ndash Chest Compressions ndash Pericardiocentesis ndash Delayed resuscitation
controlled hypotension (MAP 50 vs 65)
ndash Tranexamic acid in the near future
bull Interventions
Fluid Resuscitation Algorithm 20 mLkg isotonic crystalloid
Reassess
20 mLkg isotonic crystalloid
Reassess
20 mLkg isotonic crystalloid (31 rule)
or consider 10 to 20 mLkg packed red cells
Reconsidering Crystalloid Resuscitation
bull Less fluid ndash Permissive hypotension to
prevent clot rupture (select cases)
bull Too much fluid ndash Excessive Third Spacing ndash Secondary Compartment
Syndrome ndash Greater risk of ARDS ndash Dilutional Coagulopathy
When to start MTP
bull As soon as you believe you will need it ndash Institution specific guidelines
bull gt4 units or 40mlkg of PRBCrsquos expected bull Earlier use of Massive Transfusion Protocol
(pRBC FFP PLT) in ldquoDamage Controlrdquo resuscitations may improve outcome
bull 111 unit ratio bull Risk of TRALI ARDS etc
Disability bull GCS
ndash Range 3-15 ndash We should be 15 ndash Dead are still 3 ndash Less than 8 intubate ndash Eyes- 4 eyes ndash Verbal- most difficult ndash Motor- V6 engine ndash Intubated T
bull AVPU
Finishing Up the Evaluation
bull Airway bull Breathing bull Circulation bull Disability bull Exposure
ndash Expose and examine all parts ndash Cover quickly and keep warm
bull Secondary Survey
Bad Scene Responses
bull What are the outcomes of out-of-hospital cardiac arrest from blunt trauma
bull What are the outcomes of pediatric drowning patients
OHCA from Trauma
bull 2000-2003 bull 123 pts bull Mean age 73 yrs bull Most common
rhythms ndash Asystole 59 ndash PEA 29 ndash V-fib 35
bull 195 rosc in field ndash 98 survived for 24
hrs ndash 57 survived to
discharge ndash Drowning- 19
survival to discharge ndash Bystander CPR tripled
the survivor rate
Blunt Trauma- No Signs of Life
bull Review from 2002-2010 bull No signs of life- 025 of blunt trauma
ndash 25 resuscitated prior to hospital arrival bull 138 of these patients survived to discharge
bull 44 overall survived to hospital discharge
OHCA with CPR on Arrival
bull 169 children bull 141 deaths bull 69 required cpr on arrival- none survived bull 87 of patients requiring CPR on arrival
expired in the ED bull Of the 28 survivors
ndash 55 of survivors had full neurologic recovery
Pediatric Trauma
bull Fortunately these cases represent only a small fraction of EMS transports
bull Despite a few key differences pediatric trauma care overall is very similar to adult trauma care
Questions
References 1 bull NTDB 2013 pediatric Report bull Monkey bars httpsplaygroundchroniclesfileswordpresscom201307soccerjpg bull Screaming child httpblogsbabycentercomwp-contentuploads201409screaming-child-tantrum-fitjpg bull Pediatric airway image httpwwwcelebritydiagnosiscomwp-contentuploads201003pediatric-airwayjpg bull Child on backboard httpsencrypted-tbn2gstaticcomimagesq=tbnANd9GcQscrDVc8IH4MwkNGF6F1A9p7mSVzik5zrWyNvI-
qSwQT5S3GNyVg bull Elbow fracture httpwwwimageinterpretationcoukimageselbowSUPRACONDYLAR20LAT3jpg bull Bike riding httpsmile-per-daycomwp-contentuploads201412klr03jpg bull Dad and child pic httplaughingsquidcomwp-contentuploads471160jpg bull Weigth estimation inner city Am J Emerg Med 2015 Oct33(10)1364-7 doi 101016jajem201507040 Epub 2015 Jul 29 Weight
estimation in an inner-city pediatric ED the effect of obesity Chavez H1 Peterson RE2 Lo K3 Arel M4
bull Guess weight sign httpmedialiveauctiongroupneti963110572971_1jpgv=8CDDAAF8A5B9E20 bull Broselow tape httpsuploadwikimediaorgwikipediacommons994BTape1jpg bull Parent screaming httpmommyofamonstercomwp-contentuploads201301yellingjpg bull Prehospital pain management Am J Emerg Med 2015 Mar33(3)451-4 doi 101016jajem201412012 Epub 2014 Dec 18
Prehospital pain management of injured children a systematic review of current evidence Samuel N1 Steiner IP2 Shavit I3 bull Prehospital pain ped pain assessment Prehosp Emerg Care 2008 Apr-Jun12(2)182-6 doi 10108010903120801907471 Prehospital
pain assessment in pediatric trauma Izsak E1 Moore JL Stringfellow K Oswanski MF Lindstrom DA Stombaugh HA bull Ped pain management Prehosp Emerg Care 2005 Jan-Mar9(1)40-3 Prehospital pain management in children suffering traumatic
injury Swor R1 McEachin CM Seguin D Grall KH bull Prehospital intervention Allen CJ Teisch LF et al Prehospital care and transportation of pediatric trauma patients J Surg Res 2015
Aug197(2)240-6 JAMA 2000 Feb 9283(6)783-90 bull Effect of out-of-hospital pediatric endotracheal intubation on survival and neurological outcome a controlled clinical trial
Gausche M1 Lewis RJ Stratton SJ Haynes BE Gunter CS Goodrich SM Poore PD McCollough MD Henderson DP Pratt FD Seidel JS
bull Pediatric pain management survey Pediatr Emerg Care 2015 Sep 23 [Epub ahead of print] An Assessment of Newly Identified Barriers to and Enablers for Prehospital Pediatric Pain Management Whitley DE1 Li T Jones CM Cushman JT Williams DM Shah MN
References 2 bull httpwwwuptodatecomcontentsprehospital-pediatrics-and-emergency-medical-services-emsabstract6 bull httpwwwuptodatecomcontentsprehospital-pediatrics-and-emergency-medical-services-emsabstract7 bull Pediatr Crit Care Med 2011 Jul12(4)e166-70 doi 101097PCC0b013e3181f36f6e First responder
performance in pediatric trauma a comparison with an adult cohortBankole S1 Asuncion A Ross S Aghai Z Nollah L Echols H Da-Silva S
bull Drayna pc Browne LR et al Prehospital pediatric care Oppportunities for training treatment and research Prehosp Emerg Care 2015 Jul-Sep 19(3) Epub 2015 Feb 6
bull Pediatr Emerg Care 2001 Feb17(1) 5-9Pediatric pre-hospital advanced life support care in an urban setting Babl FE1 Vinci RJ Bauchner H Mottley L
bull Pediatr Crit Care Med 2015 Oct16(8)e260-7 doi 101097PCC0000000000000505Pediatric Out-of-Hospital Critical Procedures in the United States Carlson JN1 Gannon E Mann NC Jacobson KE Dai M Colleran C Wang HE
bull Pediatr Emerg Care 2009 Aug25(8)508-12 doi 101097PEC0b013e3181b0a0da The efficacy of pediatric advanced life support training in emergency medical service providers Baker TW1 King W Soto W Asher C Stolfi A Rowin ME
bull Sutton RM Case E et al ROC investigators A quantitative analysis of out-of-hospital pediatric and adolescent resuscitation quality A report from the ROC Epistry- Cardiac Arrest Resusciation 201593150-157
bull Resuscitation 2014 Aug85(8)1059-64 doi 101016jresuscitation201403307 Epub 2014 Apr 4 Neurocognitive long term follow-up study on drowned children Suominen PK1 Sutinen N2 Valle S3 Olkkola KT4 Loumlnnqvist T3
bull J Pediatr Surg 2010 Jul45(7)1413-9 doi 101016jjpedsurg200912020 Prehospital cardiopulmonary resuscitation in the pediatric trauma patient Murphy JT1 Jaiswal K Sabella J Vinson L Megison S Maxson RT
References 3 bull Pre atv accident
httpwwwctvnewscapolopoly_fs119871591409741949httpImageimagejpg_genderivativeslandscape_960imagejpg bull atv pic httpswwwutahadvocatescomwp-contentuploads201402atvAccidentLawyerjpg bull Blunt abdominal solid organ injury adult vs pediatric trauma center J Pediatr Surg 2015 Aug 28 pii S0022-3468(15)00526-6 doi
101016jjpedsurg201508012 [Epub ahead of print] Trauma center variation in the management of pediatric patients with blunt abdominal solid organ injury a national trauma data bank analysis Safavi A1 Skarsgard ED2 Rhee P1 Zangbar B1 Kulvatunyou N1 Tang A1 OKeeffe T1 Friese RS1 Joseph B3
bull Pediatric blunt abdominal injury Curr Opin Crit Care 2015 Sep 28 [Epub ahead of print] Pediatric blunt abdominal trauma current management Notrica DM1
bull Pediatric splenic injury management Am J Surg 2015 Jul 31 pii S0002-9610(15)00417-1 doi 101016jamjsurg201506009 [Epub ahead of print] Comparative effectiveness of treatment strategies for severe splenic trauma in the pediatric population Rialon KL1 Englum BR1 Gulack BC1 Guevara CJ2 Bhattacharya SD3 Shapiro ML4 Rice HE5 Scarborough JE4 Adibe OO6
bull Liver pic httpss-media-cache-ak0pinimgcom736x7da50e7da50eb2bb603c99ef6649ff897e26b5jpg bull Solid organ injury non op in peds J Trauma Acute Care Surg 2015 Oct79(4)683-93 doi 101097TA0000000000000808
Nonoperative management of blunt liver and spleen injury in children Evaluation of the ATOMAC guideline using GRADE Notrica DM1 Eubanks JW 3rd Tuggle DW Maxson RT Letton RW Garcia NM Alder AC Lawson KA St Peter SD Megison S Garcia Filion P
bull Pediaric vs nonped trauma ct use J Pediatr 2015 Oct167(4)897-904e3 doi 101016jjpeds201506052 Epub 2015 Jul 29 Variation in Computed Tomography Imaging for Pediatric Injury-Related Emergency Visits Marin JR1 Wang L2 Winger DG2 Mannix RC3
bull Solid organ management in ped population J Trauma Acute Care Surg 2015 Aug79(2)206-14quiz 332 doi 101097TA0000000000000731 Management of children with solid organ injuries after blunt torso trauma Wisner DH1 Kuppermann N Cooper A Menaker J Ehrlich P Kooistra J Mahajan P Lee L Cook LJ Yen K Lillis K Holmes JF
bull Triad of death image httpimageslidesharecdncomdamage-control-resuscitation-1304253390-phpapp0195damage-control-resuscitation-14-728jpgcb=1304235553
bull Tranexamic acid study Eckert MJ Wertin TM Tyner SD et al 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 77852
bull Image care accident httpsuploadwikimediaorgwikipediacommonsthumbee1Car_crash_1jpg1280px-Car_crash_1jpg
References 4 bull httpwwwsurgeryvcuedudivisionsacutesurghtml bull Trauma management Approach to the unstable child
httpwwwuptodatecomcontentstrauma-management-approach-to-the-unstable-childsource=search_resultampsearch=pediatric+trauma+childrenampselectedTitle=17E150
bull Trauma management Unique pediatric considerations httpwwwuptodatecomcontentstrauma-management-unique-pediatric-considerationssource=search_resultampsearch=pediatric+trauma+childrenampselectedTitle=37E150
References 5 bull httpwwwetiquettehellcomsmfindexphptopic=8666360 bull httpwwwstlouischildrensorghealth-care-professionalsems-providers bull httpwwwuchicagokidshospitalorgspecialtiesemergency-medicinespecialhtml bull httpwwwsimsacademyinfoFXpatienthtm bull httptheemtspotcomwp-contentuploads200902another-burn-patient-by-annette-larsonjpg bull httplastangryfancomwp-contentuploads200910Clint-Malarchukjpg bull httpwwwtraumaorgarchiveresusmassivehtml bull httpwwwuptodatecomcontentsimageimageKey=PEDS68694amptopicKey=EM2F6389ampsourc
e=previewampsearch=pediatric+hemorrhagic+shockampselectedTitle=17E150amprank=undefined bull httptheemtspotcomwp-contentuploads200902gcsgif bull httpwwwuptodatecomcontentsimageimageKey=EM2F60409amptopicKey=EM2F6571amprank
=17E150ampsource=see_linkampsearch=traumaamputdPopup=true bull httpwwwuptodatecomcontentsimageimageKey=EM2F80874amptopicKey=EM2F6571amprank
=17E150ampsource=see_linkampsearch=traumaamputdPopup=true bull httpempracticenewswordpresscomcategorynexus-criteria bull httpswwwgooglecomsearchq=pediatric+glasgow+coma+scaleamptbm=ischamptbo=uampsource=uni
vampsa=Xampei=8TiOU7TNC5WuyATp5YG4BQampsqi=2ampved=0CDYQsAQampbiw=1426ampbih=883q=canadian+c-spine+rulesamptbm=ischampfacrc=_ampimgdii=_ampimgrc=WI94QMHgMLTQmM253A3BP5nbsFhNCXK0FM3Bhttp253A252F252Fwwwbmjcom252Fhighwire252Ffilestream252F436003252Ffield_highwire_fragment_image_l252F0jpg3Bhttp253A252F252Fwwwbmjcom252Fcontent252F339252Fbmjb41463B12803B1253
References 5 bull httpwwwuptodatecomcontentsimageimageKey=EM2F76777amptopicKey=EM2F6571amprank
=17E150ampsource=see_linkampsearch=traumaamputdPopup=true bull httpwwwdocumentingrealitycomforumattachmentsf14964898d1246625322-firework-injury-
m80injury1jpg bull httpwwwpediatriceducationorg20050620 bull httpwwwarmstrongmedicalcomindexcfmgoproductdetailsec3ssec19cat61fam515 bull httpwwwuptodatecomcontentsimageimageKey=PEDS61087amptopicKey=ID2F7661ampsource
=outline_linkampsearch=tetanus+prophylaxisamputdPopup=true bull httpwwwafsecafmilsharedmediaphotodbweb110609-F-MJ378-009jpg bull httpwwwuptodatecomcontentsimageimageKey=EM75765amptopicKey= bull EM2F6389ampsource=outline_linkampsearch=massive+transfusion+protocolamputdPopup=true bull httpwwwmotifakecomimagedemotivational-postersmall0910whats-the-question-ignorance-
calvin-and-hobbes-demotivational-poster-1255020127jpg
XXXXBoston study ems peds trauma procedures- limited pediatric procedural exposure (but more adult experience) bull Catchment area 590000
over 1 year bull 555 pediatric ALS
transport ndash 19 blunt trauma ndash 10 penetrating trauma
bull IV 33 bull BMV 5 bull Intubation 3 bull 50 ALS providers average
year ndash IV- 37 ndash Intubation- 03 ndash IO- 006
bull 7 ped ems ndash 13 trauma
bull Critical procedures ndash 101000 peds cases ndash Intubation 671000 ndash IO 51000 ndash 81 successful
Pediatr Emerg Care 2001 Feb17(1)5-9 Pediatric pre-hospital advanced life support care in an urban setting
Babl FE1 Vinci RJ Bauchner H Mottley L
Pediatr Crit Care Med 2015 Oct16(8)e260-7 doi 101097PCC0000000000000505 Pediatric Out-of-Hospital Critical Procedures in the United States
Carlson JN1 Gannon E Mann NC Jacobson KE Dai M Colleran C Wang HE
C-spine bull C-spine injuries rare bull Take pt to closest hospital if over injuries
call for it (ie resuscitation altered mental status) primary guide
bull Mechanism ndash Altered mental status focal neuro change
torticollis substantial torso injury diving high speed auto neck pain underlying predisposing condition Acad Emerg Med 2014 Jan21(1)55-64 doi 101111acem12288
Comparison of outcomes for children with cervical spine injury based on destination hospital from scene of injury Anders JF1 Adelgais K Hoyle JD Jr Olsen C Jaffe DM Leonard JC Pediatric Emergency Care Applied Research Network
(PECARN)
Ann Emerg Med 2011 Aug58(2)145-55 doi 101016jannemergmed201008038 Epub 2010 Oct 29 Factors associated with cervical spine injury in children after blunt trauma
Leonard JC Kuppermann N Olsen C Babcock-Cimpello L Brown K Mahajan P Adelgais KM Anders J Borgialli D Donoghue A Hoyle JD Jr Kim E Leonard JR Lillis KA Nigrovic LE Powell EC Rebella
G Reeves SD Rogers AJ Stankovic C Teshome G Jaffe DM Pediatric Emergency Care Applied Research Network
- Itrsquos Hard to Put a Band-Aid on a Broken Spleen Pediatric Trauma
- Disclosures
- Objectives
- Pediatric Prehospital Care
- Mechanism
- Traumatic Pain Management
- Pediatric Trauma
- Deaths by Mechanism of Injury
- Pediatric Trauma
- Pediatric Trauma
- Airway Differences
- Pediatric-Adult Differences
- Pediatric Challenges
- Prehospital Pediatric Challenges
- Pediatric and Adult Trauma
- Scene Response
- Prehospital Intervention
- Where do you take the patient
- Patient arrives at the EDhellip
- Primary Survey
- Order is critical
- Slide Number 22
- Slide Number 23
- Airway
- Indications for Intubation
- Breathing
- ETT Intubation Basics
- Circulation
- Slide Number 29
- CirculationHemodynamic Changes
- Circulation
- Fluid Resuscitation Algorithm
- Reconsidering Crystalloid Resuscitation
- When to start MTP
- Disability
- Finishing Up the Evaluation
- Bad Scene Responses
- OHCA from Trauma
- Blunt Trauma- No Signs of Life
- OHCA with CPR on Arrival
- Pediatric Trauma
- Questions
- References 1
- References 2
- References 3
- References 4
- References 5
- References 5
- XXXXBoston study ems peds trauma procedures- limited pediatric procedural exposure (but more adult experience)
- C-spine
Pediatric Challenges
bull Parents bull Non-accidental trauma bull Neglect bull Medically complex kids bull Pediatric patient exposure bull Pediatric intervention experience
Prehospital Pediatric Challenges
bull Less pediatric exposure ndash Experience
bull Critical procedures ~1 of transports bull CPR BMV or advanced airway in 04 of patients bull ALS specific transports BMV 5 ETI 3
bull Less success in pediatric patients ndash IV access success- 86 adult vs 66 kids ndash Intubating problems- 69 peds vs 21 adults
Pediatric and Adult Trauma
bull Trimodal death distribution ndash 1st peak- seconds to minutes after
bull Impacted by prevention ndash 2nd peak- minutes to hours after
bull ldquoGolden Hourrdquo bull Rapid assessment and treatment
ndash 3rd peak- days to weeks bull Quality pediatric care limits morbidity and mortality bull Infection and multi-organ failure
Scene Response
bull 8 year old male in a rollover atv accident
bull Pt is unresponsive localizes pain wonrsquot open his eyes
bull HR 130 BP 10060 bull RR 10 O2 sat 93 bull What do you want to do
Prehospital Intervention
bull Pre-hospital interventions did not significantly worsen care ndash Similar transport times ndash Similar mortality length of stay
bull ETI vs BMV ndash No difference in survival ndash No difference in neurological outcome
Where do you take the patient
bull Pediatric trauma centers ndash Less surgery on solid organ injuries ndash Less radiation- of scans and dosage ndash Less comorbidities
bull Lower costs bull Shorter length of stay bull Lower infections bull Less multi-organ failure
Patient arrives at the EDhellip
bull Where do you start ndash Primary Survey
Primary Survey bull Your ABCrsquoshellip
bull Airway bull Breathing bull Circulation bull Disability (Neuro- GCS) bull Exposure
Order is critical
bull A before B or C bull Morbiditymortality will
occur much faster from airway compromise than from breathing or circulatory problems
bull Systematic approach is the cornerstone of ATLS success
httpwwwuptodatecomcontentsimageimageKey=EM2F64241amptopicKey=EM2F6571amprank=17E150ampsource=see_linkampsearch=traumaamputdPopup=true
httpwwwuptodatecomcontentsimageimageKey=EM2F64241amptopicKey=EM2F6571amprank=17E150ampsource=see_linkampsearch=traumaamputdPopup=true
Airway bull What are you assessing
ndash Airway patency bull What makes the airway not patent
ndash Foreign bodies ndash Vomitbloodsecretions ndash Edemahematoma ndash Impending obstruction
bull Interventions ndash Clearing foreign bodies ndash Suction secretionsvomit with yankauer ndash Repositioning- jaw thrust ndash Nasal trumpetoral airway ndash Intubation ndash Cricothyrotomy jet ventilation
Indications for Intubation
bull Respiratory arrest bull Impending respiratory failure bull Impending airway obstruction bull Inability to protect the airway bull GCS lt8 bull Declining GCS
Breathing bull What are you assessing
ndash ldquoGoodrdquo symmetric chest rise ndash Lung sounds ndash Aeration ndash Basic RR assessment (fast or minimalnone)
bull Interventions ndash Oxygen ndash Albuterolatrovent racemic epi ndash Positive pressure (CPAP BIPAP BMV) ndash Needle decompression ndash Chest tube thoracostomy ndash Intubation ndash Jet ventilation
ETT Intubation Basics bull Size
ndash Age4 + 4 or (Age +16)4 bull Depth
ndash ~ 3 x ETT size when over 1 year of age bull Blade size mac vs miller
ndash 0~ newborn ndash 1~ up to 2 years of life ndash 2~ 2-10 years ndash 3~ 10+ years
bull RSI medications ndash +-Sedation (Always before paralytic) ndash +-Paralytic (May not need it and never wo sedation)
Circulation
bull What do you assess ndash Central and peripheral pulses ndash Heart rate ndash Blood pressure systolic (age x2) +70 ndash Capillary refill ndash Cardiac activity on FAST ndash End organ perfusion
bull Mental status bull Urine output
Circulation Hemodynamic Changes
Percent Blood Volume Loss 0 15 25 35 45
Heart Rate
Blood Pressure
Cardiac Output
Circulation
ndash Access 2 large bore IVrsquos ndash IVFrsquos ndash pRBCrsquos
bull Hgb lt7gdl or ongoing blood losses
ndash Massive Transfusion Protocol
bull (111 ratio of PRBCS FFP Platelets)
ndash Vasopressors (epi norepi dopamine)
ndash Control of Hemorrhage bull Pelvic binders bull Direct pressure bull Indirectproximal pressure bull Tourniquet (only when
absolutely necessary)
ndash Chest Compressions ndash Pericardiocentesis ndash Delayed resuscitation
controlled hypotension (MAP 50 vs 65)
ndash Tranexamic acid in the near future
bull Interventions
Fluid Resuscitation Algorithm 20 mLkg isotonic crystalloid
Reassess
20 mLkg isotonic crystalloid
Reassess
20 mLkg isotonic crystalloid (31 rule)
or consider 10 to 20 mLkg packed red cells
Reconsidering Crystalloid Resuscitation
bull Less fluid ndash Permissive hypotension to
prevent clot rupture (select cases)
bull Too much fluid ndash Excessive Third Spacing ndash Secondary Compartment
Syndrome ndash Greater risk of ARDS ndash Dilutional Coagulopathy
When to start MTP
bull As soon as you believe you will need it ndash Institution specific guidelines
bull gt4 units or 40mlkg of PRBCrsquos expected bull Earlier use of Massive Transfusion Protocol
(pRBC FFP PLT) in ldquoDamage Controlrdquo resuscitations may improve outcome
bull 111 unit ratio bull Risk of TRALI ARDS etc
Disability bull GCS
ndash Range 3-15 ndash We should be 15 ndash Dead are still 3 ndash Less than 8 intubate ndash Eyes- 4 eyes ndash Verbal- most difficult ndash Motor- V6 engine ndash Intubated T
bull AVPU
Finishing Up the Evaluation
bull Airway bull Breathing bull Circulation bull Disability bull Exposure
ndash Expose and examine all parts ndash Cover quickly and keep warm
bull Secondary Survey
Bad Scene Responses
bull What are the outcomes of out-of-hospital cardiac arrest from blunt trauma
bull What are the outcomes of pediatric drowning patients
OHCA from Trauma
bull 2000-2003 bull 123 pts bull Mean age 73 yrs bull Most common
rhythms ndash Asystole 59 ndash PEA 29 ndash V-fib 35
bull 195 rosc in field ndash 98 survived for 24
hrs ndash 57 survived to
discharge ndash Drowning- 19
survival to discharge ndash Bystander CPR tripled
the survivor rate
Blunt Trauma- No Signs of Life
bull Review from 2002-2010 bull No signs of life- 025 of blunt trauma
ndash 25 resuscitated prior to hospital arrival bull 138 of these patients survived to discharge
bull 44 overall survived to hospital discharge
OHCA with CPR on Arrival
bull 169 children bull 141 deaths bull 69 required cpr on arrival- none survived bull 87 of patients requiring CPR on arrival
expired in the ED bull Of the 28 survivors
ndash 55 of survivors had full neurologic recovery
Pediatric Trauma
bull Fortunately these cases represent only a small fraction of EMS transports
bull Despite a few key differences pediatric trauma care overall is very similar to adult trauma care
Questions
References 1 bull NTDB 2013 pediatric Report bull Monkey bars httpsplaygroundchroniclesfileswordpresscom201307soccerjpg bull Screaming child httpblogsbabycentercomwp-contentuploads201409screaming-child-tantrum-fitjpg bull Pediatric airway image httpwwwcelebritydiagnosiscomwp-contentuploads201003pediatric-airwayjpg bull Child on backboard httpsencrypted-tbn2gstaticcomimagesq=tbnANd9GcQscrDVc8IH4MwkNGF6F1A9p7mSVzik5zrWyNvI-
qSwQT5S3GNyVg bull Elbow fracture httpwwwimageinterpretationcoukimageselbowSUPRACONDYLAR20LAT3jpg bull Bike riding httpsmile-per-daycomwp-contentuploads201412klr03jpg bull Dad and child pic httplaughingsquidcomwp-contentuploads471160jpg bull Weigth estimation inner city Am J Emerg Med 2015 Oct33(10)1364-7 doi 101016jajem201507040 Epub 2015 Jul 29 Weight
estimation in an inner-city pediatric ED the effect of obesity Chavez H1 Peterson RE2 Lo K3 Arel M4
bull Guess weight sign httpmedialiveauctiongroupneti963110572971_1jpgv=8CDDAAF8A5B9E20 bull Broselow tape httpsuploadwikimediaorgwikipediacommons994BTape1jpg bull Parent screaming httpmommyofamonstercomwp-contentuploads201301yellingjpg bull Prehospital pain management Am J Emerg Med 2015 Mar33(3)451-4 doi 101016jajem201412012 Epub 2014 Dec 18
Prehospital pain management of injured children a systematic review of current evidence Samuel N1 Steiner IP2 Shavit I3 bull Prehospital pain ped pain assessment Prehosp Emerg Care 2008 Apr-Jun12(2)182-6 doi 10108010903120801907471 Prehospital
pain assessment in pediatric trauma Izsak E1 Moore JL Stringfellow K Oswanski MF Lindstrom DA Stombaugh HA bull Ped pain management Prehosp Emerg Care 2005 Jan-Mar9(1)40-3 Prehospital pain management in children suffering traumatic
injury Swor R1 McEachin CM Seguin D Grall KH bull Prehospital intervention Allen CJ Teisch LF et al Prehospital care and transportation of pediatric trauma patients J Surg Res 2015
Aug197(2)240-6 JAMA 2000 Feb 9283(6)783-90 bull Effect of out-of-hospital pediatric endotracheal intubation on survival and neurological outcome a controlled clinical trial
Gausche M1 Lewis RJ Stratton SJ Haynes BE Gunter CS Goodrich SM Poore PD McCollough MD Henderson DP Pratt FD Seidel JS
bull Pediatric pain management survey Pediatr Emerg Care 2015 Sep 23 [Epub ahead of print] An Assessment of Newly Identified Barriers to and Enablers for Prehospital Pediatric Pain Management Whitley DE1 Li T Jones CM Cushman JT Williams DM Shah MN
References 2 bull httpwwwuptodatecomcontentsprehospital-pediatrics-and-emergency-medical-services-emsabstract6 bull httpwwwuptodatecomcontentsprehospital-pediatrics-and-emergency-medical-services-emsabstract7 bull Pediatr Crit Care Med 2011 Jul12(4)e166-70 doi 101097PCC0b013e3181f36f6e First responder
performance in pediatric trauma a comparison with an adult cohortBankole S1 Asuncion A Ross S Aghai Z Nollah L Echols H Da-Silva S
bull Drayna pc Browne LR et al Prehospital pediatric care Oppportunities for training treatment and research Prehosp Emerg Care 2015 Jul-Sep 19(3) Epub 2015 Feb 6
bull Pediatr Emerg Care 2001 Feb17(1) 5-9Pediatric pre-hospital advanced life support care in an urban setting Babl FE1 Vinci RJ Bauchner H Mottley L
bull Pediatr Crit Care Med 2015 Oct16(8)e260-7 doi 101097PCC0000000000000505Pediatric Out-of-Hospital Critical Procedures in the United States Carlson JN1 Gannon E Mann NC Jacobson KE Dai M Colleran C Wang HE
bull Pediatr Emerg Care 2009 Aug25(8)508-12 doi 101097PEC0b013e3181b0a0da The efficacy of pediatric advanced life support training in emergency medical service providers Baker TW1 King W Soto W Asher C Stolfi A Rowin ME
bull Sutton RM Case E et al ROC investigators A quantitative analysis of out-of-hospital pediatric and adolescent resuscitation quality A report from the ROC Epistry- Cardiac Arrest Resusciation 201593150-157
bull Resuscitation 2014 Aug85(8)1059-64 doi 101016jresuscitation201403307 Epub 2014 Apr 4 Neurocognitive long term follow-up study on drowned children Suominen PK1 Sutinen N2 Valle S3 Olkkola KT4 Loumlnnqvist T3
bull J Pediatr Surg 2010 Jul45(7)1413-9 doi 101016jjpedsurg200912020 Prehospital cardiopulmonary resuscitation in the pediatric trauma patient Murphy JT1 Jaiswal K Sabella J Vinson L Megison S Maxson RT
References 3 bull Pre atv accident
httpwwwctvnewscapolopoly_fs119871591409741949httpImageimagejpg_genderivativeslandscape_960imagejpg bull atv pic httpswwwutahadvocatescomwp-contentuploads201402atvAccidentLawyerjpg bull Blunt abdominal solid organ injury adult vs pediatric trauma center J Pediatr Surg 2015 Aug 28 pii S0022-3468(15)00526-6 doi
101016jjpedsurg201508012 [Epub ahead of print] Trauma center variation in the management of pediatric patients with blunt abdominal solid organ injury a national trauma data bank analysis Safavi A1 Skarsgard ED2 Rhee P1 Zangbar B1 Kulvatunyou N1 Tang A1 OKeeffe T1 Friese RS1 Joseph B3
bull Pediatric blunt abdominal injury Curr Opin Crit Care 2015 Sep 28 [Epub ahead of print] Pediatric blunt abdominal trauma current management Notrica DM1
bull Pediatric splenic injury management Am J Surg 2015 Jul 31 pii S0002-9610(15)00417-1 doi 101016jamjsurg201506009 [Epub ahead of print] Comparative effectiveness of treatment strategies for severe splenic trauma in the pediatric population Rialon KL1 Englum BR1 Gulack BC1 Guevara CJ2 Bhattacharya SD3 Shapiro ML4 Rice HE5 Scarborough JE4 Adibe OO6
bull Liver pic httpss-media-cache-ak0pinimgcom736x7da50e7da50eb2bb603c99ef6649ff897e26b5jpg bull Solid organ injury non op in peds J Trauma Acute Care Surg 2015 Oct79(4)683-93 doi 101097TA0000000000000808
Nonoperative management of blunt liver and spleen injury in children Evaluation of the ATOMAC guideline using GRADE Notrica DM1 Eubanks JW 3rd Tuggle DW Maxson RT Letton RW Garcia NM Alder AC Lawson KA St Peter SD Megison S Garcia Filion P
bull Pediaric vs nonped trauma ct use J Pediatr 2015 Oct167(4)897-904e3 doi 101016jjpeds201506052 Epub 2015 Jul 29 Variation in Computed Tomography Imaging for Pediatric Injury-Related Emergency Visits Marin JR1 Wang L2 Winger DG2 Mannix RC3
bull Solid organ management in ped population J Trauma Acute Care Surg 2015 Aug79(2)206-14quiz 332 doi 101097TA0000000000000731 Management of children with solid organ injuries after blunt torso trauma Wisner DH1 Kuppermann N Cooper A Menaker J Ehrlich P Kooistra J Mahajan P Lee L Cook LJ Yen K Lillis K Holmes JF
bull Triad of death image httpimageslidesharecdncomdamage-control-resuscitation-1304253390-phpapp0195damage-control-resuscitation-14-728jpgcb=1304235553
bull Tranexamic acid study Eckert MJ Wertin TM Tyner SD et al 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 77852
bull Image care accident httpsuploadwikimediaorgwikipediacommonsthumbee1Car_crash_1jpg1280px-Car_crash_1jpg
References 4 bull httpwwwsurgeryvcuedudivisionsacutesurghtml bull Trauma management Approach to the unstable child
httpwwwuptodatecomcontentstrauma-management-approach-to-the-unstable-childsource=search_resultampsearch=pediatric+trauma+childrenampselectedTitle=17E150
bull Trauma management Unique pediatric considerations httpwwwuptodatecomcontentstrauma-management-unique-pediatric-considerationssource=search_resultampsearch=pediatric+trauma+childrenampselectedTitle=37E150
References 5 bull httpwwwetiquettehellcomsmfindexphptopic=8666360 bull httpwwwstlouischildrensorghealth-care-professionalsems-providers bull httpwwwuchicagokidshospitalorgspecialtiesemergency-medicinespecialhtml bull httpwwwsimsacademyinfoFXpatienthtm bull httptheemtspotcomwp-contentuploads200902another-burn-patient-by-annette-larsonjpg bull httplastangryfancomwp-contentuploads200910Clint-Malarchukjpg bull httpwwwtraumaorgarchiveresusmassivehtml bull httpwwwuptodatecomcontentsimageimageKey=PEDS68694amptopicKey=EM2F6389ampsourc
e=previewampsearch=pediatric+hemorrhagic+shockampselectedTitle=17E150amprank=undefined bull httptheemtspotcomwp-contentuploads200902gcsgif bull httpwwwuptodatecomcontentsimageimageKey=EM2F60409amptopicKey=EM2F6571amprank
=17E150ampsource=see_linkampsearch=traumaamputdPopup=true bull httpwwwuptodatecomcontentsimageimageKey=EM2F80874amptopicKey=EM2F6571amprank
=17E150ampsource=see_linkampsearch=traumaamputdPopup=true bull httpempracticenewswordpresscomcategorynexus-criteria bull httpswwwgooglecomsearchq=pediatric+glasgow+coma+scaleamptbm=ischamptbo=uampsource=uni
vampsa=Xampei=8TiOU7TNC5WuyATp5YG4BQampsqi=2ampved=0CDYQsAQampbiw=1426ampbih=883q=canadian+c-spine+rulesamptbm=ischampfacrc=_ampimgdii=_ampimgrc=WI94QMHgMLTQmM253A3BP5nbsFhNCXK0FM3Bhttp253A252F252Fwwwbmjcom252Fhighwire252Ffilestream252F436003252Ffield_highwire_fragment_image_l252F0jpg3Bhttp253A252F252Fwwwbmjcom252Fcontent252F339252Fbmjb41463B12803B1253
References 5 bull httpwwwuptodatecomcontentsimageimageKey=EM2F76777amptopicKey=EM2F6571amprank
=17E150ampsource=see_linkampsearch=traumaamputdPopup=true bull httpwwwdocumentingrealitycomforumattachmentsf14964898d1246625322-firework-injury-
m80injury1jpg bull httpwwwpediatriceducationorg20050620 bull httpwwwarmstrongmedicalcomindexcfmgoproductdetailsec3ssec19cat61fam515 bull httpwwwuptodatecomcontentsimageimageKey=PEDS61087amptopicKey=ID2F7661ampsource
=outline_linkampsearch=tetanus+prophylaxisamputdPopup=true bull httpwwwafsecafmilsharedmediaphotodbweb110609-F-MJ378-009jpg bull httpwwwuptodatecomcontentsimageimageKey=EM75765amptopicKey= bull EM2F6389ampsource=outline_linkampsearch=massive+transfusion+protocolamputdPopup=true bull httpwwwmotifakecomimagedemotivational-postersmall0910whats-the-question-ignorance-
calvin-and-hobbes-demotivational-poster-1255020127jpg
XXXXBoston study ems peds trauma procedures- limited pediatric procedural exposure (but more adult experience) bull Catchment area 590000
over 1 year bull 555 pediatric ALS
transport ndash 19 blunt trauma ndash 10 penetrating trauma
bull IV 33 bull BMV 5 bull Intubation 3 bull 50 ALS providers average
year ndash IV- 37 ndash Intubation- 03 ndash IO- 006
bull 7 ped ems ndash 13 trauma
bull Critical procedures ndash 101000 peds cases ndash Intubation 671000 ndash IO 51000 ndash 81 successful
Pediatr Emerg Care 2001 Feb17(1)5-9 Pediatric pre-hospital advanced life support care in an urban setting
Babl FE1 Vinci RJ Bauchner H Mottley L
Pediatr Crit Care Med 2015 Oct16(8)e260-7 doi 101097PCC0000000000000505 Pediatric Out-of-Hospital Critical Procedures in the United States
Carlson JN1 Gannon E Mann NC Jacobson KE Dai M Colleran C Wang HE
C-spine bull C-spine injuries rare bull Take pt to closest hospital if over injuries
call for it (ie resuscitation altered mental status) primary guide
bull Mechanism ndash Altered mental status focal neuro change
torticollis substantial torso injury diving high speed auto neck pain underlying predisposing condition Acad Emerg Med 2014 Jan21(1)55-64 doi 101111acem12288
Comparison of outcomes for children with cervical spine injury based on destination hospital from scene of injury Anders JF1 Adelgais K Hoyle JD Jr Olsen C Jaffe DM Leonard JC Pediatric Emergency Care Applied Research Network
(PECARN)
Ann Emerg Med 2011 Aug58(2)145-55 doi 101016jannemergmed201008038 Epub 2010 Oct 29 Factors associated with cervical spine injury in children after blunt trauma
Leonard JC Kuppermann N Olsen C Babcock-Cimpello L Brown K Mahajan P Adelgais KM Anders J Borgialli D Donoghue A Hoyle JD Jr Kim E Leonard JR Lillis KA Nigrovic LE Powell EC Rebella
G Reeves SD Rogers AJ Stankovic C Teshome G Jaffe DM Pediatric Emergency Care Applied Research Network
- Itrsquos Hard to Put a Band-Aid on a Broken Spleen Pediatric Trauma
- Disclosures
- Objectives
- Pediatric Prehospital Care
- Mechanism
- Traumatic Pain Management
- Pediatric Trauma
- Deaths by Mechanism of Injury
- Pediatric Trauma
- Pediatric Trauma
- Airway Differences
- Pediatric-Adult Differences
- Pediatric Challenges
- Prehospital Pediatric Challenges
- Pediatric and Adult Trauma
- Scene Response
- Prehospital Intervention
- Where do you take the patient
- Patient arrives at the EDhellip
- Primary Survey
- Order is critical
- Slide Number 22
- Slide Number 23
- Airway
- Indications for Intubation
- Breathing
- ETT Intubation Basics
- Circulation
- Slide Number 29
- CirculationHemodynamic Changes
- Circulation
- Fluid Resuscitation Algorithm
- Reconsidering Crystalloid Resuscitation
- When to start MTP
- Disability
- Finishing Up the Evaluation
- Bad Scene Responses
- OHCA from Trauma
- Blunt Trauma- No Signs of Life
- OHCA with CPR on Arrival
- Pediatric Trauma
- Questions
- References 1
- References 2
- References 3
- References 4
- References 5
- References 5
- XXXXBoston study ems peds trauma procedures- limited pediatric procedural exposure (but more adult experience)
- C-spine
Prehospital Pediatric Challenges
bull Less pediatric exposure ndash Experience
bull Critical procedures ~1 of transports bull CPR BMV or advanced airway in 04 of patients bull ALS specific transports BMV 5 ETI 3
bull Less success in pediatric patients ndash IV access success- 86 adult vs 66 kids ndash Intubating problems- 69 peds vs 21 adults
Pediatric and Adult Trauma
bull Trimodal death distribution ndash 1st peak- seconds to minutes after
bull Impacted by prevention ndash 2nd peak- minutes to hours after
bull ldquoGolden Hourrdquo bull Rapid assessment and treatment
ndash 3rd peak- days to weeks bull Quality pediatric care limits morbidity and mortality bull Infection and multi-organ failure
Scene Response
bull 8 year old male in a rollover atv accident
bull Pt is unresponsive localizes pain wonrsquot open his eyes
bull HR 130 BP 10060 bull RR 10 O2 sat 93 bull What do you want to do
Prehospital Intervention
bull Pre-hospital interventions did not significantly worsen care ndash Similar transport times ndash Similar mortality length of stay
bull ETI vs BMV ndash No difference in survival ndash No difference in neurological outcome
Where do you take the patient
bull Pediatric trauma centers ndash Less surgery on solid organ injuries ndash Less radiation- of scans and dosage ndash Less comorbidities
bull Lower costs bull Shorter length of stay bull Lower infections bull Less multi-organ failure
Patient arrives at the EDhellip
bull Where do you start ndash Primary Survey
Primary Survey bull Your ABCrsquoshellip
bull Airway bull Breathing bull Circulation bull Disability (Neuro- GCS) bull Exposure
Order is critical
bull A before B or C bull Morbiditymortality will
occur much faster from airway compromise than from breathing or circulatory problems
bull Systematic approach is the cornerstone of ATLS success
httpwwwuptodatecomcontentsimageimageKey=EM2F64241amptopicKey=EM2F6571amprank=17E150ampsource=see_linkampsearch=traumaamputdPopup=true
httpwwwuptodatecomcontentsimageimageKey=EM2F64241amptopicKey=EM2F6571amprank=17E150ampsource=see_linkampsearch=traumaamputdPopup=true
Airway bull What are you assessing
ndash Airway patency bull What makes the airway not patent
ndash Foreign bodies ndash Vomitbloodsecretions ndash Edemahematoma ndash Impending obstruction
bull Interventions ndash Clearing foreign bodies ndash Suction secretionsvomit with yankauer ndash Repositioning- jaw thrust ndash Nasal trumpetoral airway ndash Intubation ndash Cricothyrotomy jet ventilation
Indications for Intubation
bull Respiratory arrest bull Impending respiratory failure bull Impending airway obstruction bull Inability to protect the airway bull GCS lt8 bull Declining GCS
Breathing bull What are you assessing
ndash ldquoGoodrdquo symmetric chest rise ndash Lung sounds ndash Aeration ndash Basic RR assessment (fast or minimalnone)
bull Interventions ndash Oxygen ndash Albuterolatrovent racemic epi ndash Positive pressure (CPAP BIPAP BMV) ndash Needle decompression ndash Chest tube thoracostomy ndash Intubation ndash Jet ventilation
ETT Intubation Basics bull Size
ndash Age4 + 4 or (Age +16)4 bull Depth
ndash ~ 3 x ETT size when over 1 year of age bull Blade size mac vs miller
ndash 0~ newborn ndash 1~ up to 2 years of life ndash 2~ 2-10 years ndash 3~ 10+ years
bull RSI medications ndash +-Sedation (Always before paralytic) ndash +-Paralytic (May not need it and never wo sedation)
Circulation
bull What do you assess ndash Central and peripheral pulses ndash Heart rate ndash Blood pressure systolic (age x2) +70 ndash Capillary refill ndash Cardiac activity on FAST ndash End organ perfusion
bull Mental status bull Urine output
Circulation Hemodynamic Changes
Percent Blood Volume Loss 0 15 25 35 45
Heart Rate
Blood Pressure
Cardiac Output
Circulation
ndash Access 2 large bore IVrsquos ndash IVFrsquos ndash pRBCrsquos
bull Hgb lt7gdl or ongoing blood losses
ndash Massive Transfusion Protocol
bull (111 ratio of PRBCS FFP Platelets)
ndash Vasopressors (epi norepi dopamine)
ndash Control of Hemorrhage bull Pelvic binders bull Direct pressure bull Indirectproximal pressure bull Tourniquet (only when
absolutely necessary)
ndash Chest Compressions ndash Pericardiocentesis ndash Delayed resuscitation
controlled hypotension (MAP 50 vs 65)
ndash Tranexamic acid in the near future
bull Interventions
Fluid Resuscitation Algorithm 20 mLkg isotonic crystalloid
Reassess
20 mLkg isotonic crystalloid
Reassess
20 mLkg isotonic crystalloid (31 rule)
or consider 10 to 20 mLkg packed red cells
Reconsidering Crystalloid Resuscitation
bull Less fluid ndash Permissive hypotension to
prevent clot rupture (select cases)
bull Too much fluid ndash Excessive Third Spacing ndash Secondary Compartment
Syndrome ndash Greater risk of ARDS ndash Dilutional Coagulopathy
When to start MTP
bull As soon as you believe you will need it ndash Institution specific guidelines
bull gt4 units or 40mlkg of PRBCrsquos expected bull Earlier use of Massive Transfusion Protocol
(pRBC FFP PLT) in ldquoDamage Controlrdquo resuscitations may improve outcome
bull 111 unit ratio bull Risk of TRALI ARDS etc
Disability bull GCS
ndash Range 3-15 ndash We should be 15 ndash Dead are still 3 ndash Less than 8 intubate ndash Eyes- 4 eyes ndash Verbal- most difficult ndash Motor- V6 engine ndash Intubated T
bull AVPU
Finishing Up the Evaluation
bull Airway bull Breathing bull Circulation bull Disability bull Exposure
ndash Expose and examine all parts ndash Cover quickly and keep warm
bull Secondary Survey
Bad Scene Responses
bull What are the outcomes of out-of-hospital cardiac arrest from blunt trauma
bull What are the outcomes of pediatric drowning patients
OHCA from Trauma
bull 2000-2003 bull 123 pts bull Mean age 73 yrs bull Most common
rhythms ndash Asystole 59 ndash PEA 29 ndash V-fib 35
bull 195 rosc in field ndash 98 survived for 24
hrs ndash 57 survived to
discharge ndash Drowning- 19
survival to discharge ndash Bystander CPR tripled
the survivor rate
Blunt Trauma- No Signs of Life
bull Review from 2002-2010 bull No signs of life- 025 of blunt trauma
ndash 25 resuscitated prior to hospital arrival bull 138 of these patients survived to discharge
bull 44 overall survived to hospital discharge
OHCA with CPR on Arrival
bull 169 children bull 141 deaths bull 69 required cpr on arrival- none survived bull 87 of patients requiring CPR on arrival
expired in the ED bull Of the 28 survivors
ndash 55 of survivors had full neurologic recovery
Pediatric Trauma
bull Fortunately these cases represent only a small fraction of EMS transports
bull Despite a few key differences pediatric trauma care overall is very similar to adult trauma care
Questions
References 1 bull NTDB 2013 pediatric Report bull Monkey bars httpsplaygroundchroniclesfileswordpresscom201307soccerjpg bull Screaming child httpblogsbabycentercomwp-contentuploads201409screaming-child-tantrum-fitjpg bull Pediatric airway image httpwwwcelebritydiagnosiscomwp-contentuploads201003pediatric-airwayjpg bull Child on backboard httpsencrypted-tbn2gstaticcomimagesq=tbnANd9GcQscrDVc8IH4MwkNGF6F1A9p7mSVzik5zrWyNvI-
qSwQT5S3GNyVg bull Elbow fracture httpwwwimageinterpretationcoukimageselbowSUPRACONDYLAR20LAT3jpg bull Bike riding httpsmile-per-daycomwp-contentuploads201412klr03jpg bull Dad and child pic httplaughingsquidcomwp-contentuploads471160jpg bull Weigth estimation inner city Am J Emerg Med 2015 Oct33(10)1364-7 doi 101016jajem201507040 Epub 2015 Jul 29 Weight
estimation in an inner-city pediatric ED the effect of obesity Chavez H1 Peterson RE2 Lo K3 Arel M4
bull Guess weight sign httpmedialiveauctiongroupneti963110572971_1jpgv=8CDDAAF8A5B9E20 bull Broselow tape httpsuploadwikimediaorgwikipediacommons994BTape1jpg bull Parent screaming httpmommyofamonstercomwp-contentuploads201301yellingjpg bull Prehospital pain management Am J Emerg Med 2015 Mar33(3)451-4 doi 101016jajem201412012 Epub 2014 Dec 18
Prehospital pain management of injured children a systematic review of current evidence Samuel N1 Steiner IP2 Shavit I3 bull Prehospital pain ped pain assessment Prehosp Emerg Care 2008 Apr-Jun12(2)182-6 doi 10108010903120801907471 Prehospital
pain assessment in pediatric trauma Izsak E1 Moore JL Stringfellow K Oswanski MF Lindstrom DA Stombaugh HA bull Ped pain management Prehosp Emerg Care 2005 Jan-Mar9(1)40-3 Prehospital pain management in children suffering traumatic
injury Swor R1 McEachin CM Seguin D Grall KH bull Prehospital intervention Allen CJ Teisch LF et al Prehospital care and transportation of pediatric trauma patients J Surg Res 2015
Aug197(2)240-6 JAMA 2000 Feb 9283(6)783-90 bull Effect of out-of-hospital pediatric endotracheal intubation on survival and neurological outcome a controlled clinical trial
Gausche M1 Lewis RJ Stratton SJ Haynes BE Gunter CS Goodrich SM Poore PD McCollough MD Henderson DP Pratt FD Seidel JS
bull Pediatric pain management survey Pediatr Emerg Care 2015 Sep 23 [Epub ahead of print] An Assessment of Newly Identified Barriers to and Enablers for Prehospital Pediatric Pain Management Whitley DE1 Li T Jones CM Cushman JT Williams DM Shah MN
References 2 bull httpwwwuptodatecomcontentsprehospital-pediatrics-and-emergency-medical-services-emsabstract6 bull httpwwwuptodatecomcontentsprehospital-pediatrics-and-emergency-medical-services-emsabstract7 bull Pediatr Crit Care Med 2011 Jul12(4)e166-70 doi 101097PCC0b013e3181f36f6e First responder
performance in pediatric trauma a comparison with an adult cohortBankole S1 Asuncion A Ross S Aghai Z Nollah L Echols H Da-Silva S
bull Drayna pc Browne LR et al Prehospital pediatric care Oppportunities for training treatment and research Prehosp Emerg Care 2015 Jul-Sep 19(3) Epub 2015 Feb 6
bull Pediatr Emerg Care 2001 Feb17(1) 5-9Pediatric pre-hospital advanced life support care in an urban setting Babl FE1 Vinci RJ Bauchner H Mottley L
bull Pediatr Crit Care Med 2015 Oct16(8)e260-7 doi 101097PCC0000000000000505Pediatric Out-of-Hospital Critical Procedures in the United States Carlson JN1 Gannon E Mann NC Jacobson KE Dai M Colleran C Wang HE
bull Pediatr Emerg Care 2009 Aug25(8)508-12 doi 101097PEC0b013e3181b0a0da The efficacy of pediatric advanced life support training in emergency medical service providers Baker TW1 King W Soto W Asher C Stolfi A Rowin ME
bull Sutton RM Case E et al ROC investigators A quantitative analysis of out-of-hospital pediatric and adolescent resuscitation quality A report from the ROC Epistry- Cardiac Arrest Resusciation 201593150-157
bull Resuscitation 2014 Aug85(8)1059-64 doi 101016jresuscitation201403307 Epub 2014 Apr 4 Neurocognitive long term follow-up study on drowned children Suominen PK1 Sutinen N2 Valle S3 Olkkola KT4 Loumlnnqvist T3
bull J Pediatr Surg 2010 Jul45(7)1413-9 doi 101016jjpedsurg200912020 Prehospital cardiopulmonary resuscitation in the pediatric trauma patient Murphy JT1 Jaiswal K Sabella J Vinson L Megison S Maxson RT
References 3 bull Pre atv accident
httpwwwctvnewscapolopoly_fs119871591409741949httpImageimagejpg_genderivativeslandscape_960imagejpg bull atv pic httpswwwutahadvocatescomwp-contentuploads201402atvAccidentLawyerjpg bull Blunt abdominal solid organ injury adult vs pediatric trauma center J Pediatr Surg 2015 Aug 28 pii S0022-3468(15)00526-6 doi
101016jjpedsurg201508012 [Epub ahead of print] Trauma center variation in the management of pediatric patients with blunt abdominal solid organ injury a national trauma data bank analysis Safavi A1 Skarsgard ED2 Rhee P1 Zangbar B1 Kulvatunyou N1 Tang A1 OKeeffe T1 Friese RS1 Joseph B3
bull Pediatric blunt abdominal injury Curr Opin Crit Care 2015 Sep 28 [Epub ahead of print] Pediatric blunt abdominal trauma current management Notrica DM1
bull Pediatric splenic injury management Am J Surg 2015 Jul 31 pii S0002-9610(15)00417-1 doi 101016jamjsurg201506009 [Epub ahead of print] Comparative effectiveness of treatment strategies for severe splenic trauma in the pediatric population Rialon KL1 Englum BR1 Gulack BC1 Guevara CJ2 Bhattacharya SD3 Shapiro ML4 Rice HE5 Scarborough JE4 Adibe OO6
bull Liver pic httpss-media-cache-ak0pinimgcom736x7da50e7da50eb2bb603c99ef6649ff897e26b5jpg bull Solid organ injury non op in peds J Trauma Acute Care Surg 2015 Oct79(4)683-93 doi 101097TA0000000000000808
Nonoperative management of blunt liver and spleen injury in children Evaluation of the ATOMAC guideline using GRADE Notrica DM1 Eubanks JW 3rd Tuggle DW Maxson RT Letton RW Garcia NM Alder AC Lawson KA St Peter SD Megison S Garcia Filion P
bull Pediaric vs nonped trauma ct use J Pediatr 2015 Oct167(4)897-904e3 doi 101016jjpeds201506052 Epub 2015 Jul 29 Variation in Computed Tomography Imaging for Pediatric Injury-Related Emergency Visits Marin JR1 Wang L2 Winger DG2 Mannix RC3
bull Solid organ management in ped population J Trauma Acute Care Surg 2015 Aug79(2)206-14quiz 332 doi 101097TA0000000000000731 Management of children with solid organ injuries after blunt torso trauma Wisner DH1 Kuppermann N Cooper A Menaker J Ehrlich P Kooistra J Mahajan P Lee L Cook LJ Yen K Lillis K Holmes JF
bull Triad of death image httpimageslidesharecdncomdamage-control-resuscitation-1304253390-phpapp0195damage-control-resuscitation-14-728jpgcb=1304235553
bull Tranexamic acid study Eckert MJ Wertin TM Tyner SD et al 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 77852
bull Image care accident httpsuploadwikimediaorgwikipediacommonsthumbee1Car_crash_1jpg1280px-Car_crash_1jpg
References 4 bull httpwwwsurgeryvcuedudivisionsacutesurghtml bull Trauma management Approach to the unstable child
httpwwwuptodatecomcontentstrauma-management-approach-to-the-unstable-childsource=search_resultampsearch=pediatric+trauma+childrenampselectedTitle=17E150
bull Trauma management Unique pediatric considerations httpwwwuptodatecomcontentstrauma-management-unique-pediatric-considerationssource=search_resultampsearch=pediatric+trauma+childrenampselectedTitle=37E150
References 5 bull httpwwwetiquettehellcomsmfindexphptopic=8666360 bull httpwwwstlouischildrensorghealth-care-professionalsems-providers bull httpwwwuchicagokidshospitalorgspecialtiesemergency-medicinespecialhtml bull httpwwwsimsacademyinfoFXpatienthtm bull httptheemtspotcomwp-contentuploads200902another-burn-patient-by-annette-larsonjpg bull httplastangryfancomwp-contentuploads200910Clint-Malarchukjpg bull httpwwwtraumaorgarchiveresusmassivehtml bull httpwwwuptodatecomcontentsimageimageKey=PEDS68694amptopicKey=EM2F6389ampsourc
e=previewampsearch=pediatric+hemorrhagic+shockampselectedTitle=17E150amprank=undefined bull httptheemtspotcomwp-contentuploads200902gcsgif bull httpwwwuptodatecomcontentsimageimageKey=EM2F60409amptopicKey=EM2F6571amprank
=17E150ampsource=see_linkampsearch=traumaamputdPopup=true bull httpwwwuptodatecomcontentsimageimageKey=EM2F80874amptopicKey=EM2F6571amprank
=17E150ampsource=see_linkampsearch=traumaamputdPopup=true bull httpempracticenewswordpresscomcategorynexus-criteria bull httpswwwgooglecomsearchq=pediatric+glasgow+coma+scaleamptbm=ischamptbo=uampsource=uni
vampsa=Xampei=8TiOU7TNC5WuyATp5YG4BQampsqi=2ampved=0CDYQsAQampbiw=1426ampbih=883q=canadian+c-spine+rulesamptbm=ischampfacrc=_ampimgdii=_ampimgrc=WI94QMHgMLTQmM253A3BP5nbsFhNCXK0FM3Bhttp253A252F252Fwwwbmjcom252Fhighwire252Ffilestream252F436003252Ffield_highwire_fragment_image_l252F0jpg3Bhttp253A252F252Fwwwbmjcom252Fcontent252F339252Fbmjb41463B12803B1253
References 5 bull httpwwwuptodatecomcontentsimageimageKey=EM2F76777amptopicKey=EM2F6571amprank
=17E150ampsource=see_linkampsearch=traumaamputdPopup=true bull httpwwwdocumentingrealitycomforumattachmentsf14964898d1246625322-firework-injury-
m80injury1jpg bull httpwwwpediatriceducationorg20050620 bull httpwwwarmstrongmedicalcomindexcfmgoproductdetailsec3ssec19cat61fam515 bull httpwwwuptodatecomcontentsimageimageKey=PEDS61087amptopicKey=ID2F7661ampsource
=outline_linkampsearch=tetanus+prophylaxisamputdPopup=true bull httpwwwafsecafmilsharedmediaphotodbweb110609-F-MJ378-009jpg bull httpwwwuptodatecomcontentsimageimageKey=EM75765amptopicKey= bull EM2F6389ampsource=outline_linkampsearch=massive+transfusion+protocolamputdPopup=true bull httpwwwmotifakecomimagedemotivational-postersmall0910whats-the-question-ignorance-
calvin-and-hobbes-demotivational-poster-1255020127jpg
XXXXBoston study ems peds trauma procedures- limited pediatric procedural exposure (but more adult experience) bull Catchment area 590000
over 1 year bull 555 pediatric ALS
transport ndash 19 blunt trauma ndash 10 penetrating trauma
bull IV 33 bull BMV 5 bull Intubation 3 bull 50 ALS providers average
year ndash IV- 37 ndash Intubation- 03 ndash IO- 006
bull 7 ped ems ndash 13 trauma
bull Critical procedures ndash 101000 peds cases ndash Intubation 671000 ndash IO 51000 ndash 81 successful
Pediatr Emerg Care 2001 Feb17(1)5-9 Pediatric pre-hospital advanced life support care in an urban setting
Babl FE1 Vinci RJ Bauchner H Mottley L
Pediatr Crit Care Med 2015 Oct16(8)e260-7 doi 101097PCC0000000000000505 Pediatric Out-of-Hospital Critical Procedures in the United States
Carlson JN1 Gannon E Mann NC Jacobson KE Dai M Colleran C Wang HE
C-spine bull C-spine injuries rare bull Take pt to closest hospital if over injuries
call for it (ie resuscitation altered mental status) primary guide
bull Mechanism ndash Altered mental status focal neuro change
torticollis substantial torso injury diving high speed auto neck pain underlying predisposing condition Acad Emerg Med 2014 Jan21(1)55-64 doi 101111acem12288
Comparison of outcomes for children with cervical spine injury based on destination hospital from scene of injury Anders JF1 Adelgais K Hoyle JD Jr Olsen C Jaffe DM Leonard JC Pediatric Emergency Care Applied Research Network
(PECARN)
Ann Emerg Med 2011 Aug58(2)145-55 doi 101016jannemergmed201008038 Epub 2010 Oct 29 Factors associated with cervical spine injury in children after blunt trauma
Leonard JC Kuppermann N Olsen C Babcock-Cimpello L Brown K Mahajan P Adelgais KM Anders J Borgialli D Donoghue A Hoyle JD Jr Kim E Leonard JR Lillis KA Nigrovic LE Powell EC Rebella
G Reeves SD Rogers AJ Stankovic C Teshome G Jaffe DM Pediatric Emergency Care Applied Research Network
- Itrsquos Hard to Put a Band-Aid on a Broken Spleen Pediatric Trauma
- Disclosures
- Objectives
- Pediatric Prehospital Care
- Mechanism
- Traumatic Pain Management
- Pediatric Trauma
- Deaths by Mechanism of Injury
- Pediatric Trauma
- Pediatric Trauma
- Airway Differences
- Pediatric-Adult Differences
- Pediatric Challenges
- Prehospital Pediatric Challenges
- Pediatric and Adult Trauma
- Scene Response
- Prehospital Intervention
- Where do you take the patient
- Patient arrives at the EDhellip
- Primary Survey
- Order is critical
- Slide Number 22
- Slide Number 23
- Airway
- Indications for Intubation
- Breathing
- ETT Intubation Basics
- Circulation
- Slide Number 29
- CirculationHemodynamic Changes
- Circulation
- Fluid Resuscitation Algorithm
- Reconsidering Crystalloid Resuscitation
- When to start MTP
- Disability
- Finishing Up the Evaluation
- Bad Scene Responses
- OHCA from Trauma
- Blunt Trauma- No Signs of Life
- OHCA with CPR on Arrival
- Pediatric Trauma
- Questions
- References 1
- References 2
- References 3
- References 4
- References 5
- References 5
- XXXXBoston study ems peds trauma procedures- limited pediatric procedural exposure (but more adult experience)
- C-spine
Pediatric and Adult Trauma
bull Trimodal death distribution ndash 1st peak- seconds to minutes after
bull Impacted by prevention ndash 2nd peak- minutes to hours after
bull ldquoGolden Hourrdquo bull Rapid assessment and treatment
ndash 3rd peak- days to weeks bull Quality pediatric care limits morbidity and mortality bull Infection and multi-organ failure
Scene Response
bull 8 year old male in a rollover atv accident
bull Pt is unresponsive localizes pain wonrsquot open his eyes
bull HR 130 BP 10060 bull RR 10 O2 sat 93 bull What do you want to do
Prehospital Intervention
bull Pre-hospital interventions did not significantly worsen care ndash Similar transport times ndash Similar mortality length of stay
bull ETI vs BMV ndash No difference in survival ndash No difference in neurological outcome
Where do you take the patient
bull Pediatric trauma centers ndash Less surgery on solid organ injuries ndash Less radiation- of scans and dosage ndash Less comorbidities
bull Lower costs bull Shorter length of stay bull Lower infections bull Less multi-organ failure
Patient arrives at the EDhellip
bull Where do you start ndash Primary Survey
Primary Survey bull Your ABCrsquoshellip
bull Airway bull Breathing bull Circulation bull Disability (Neuro- GCS) bull Exposure
Order is critical
bull A before B or C bull Morbiditymortality will
occur much faster from airway compromise than from breathing or circulatory problems
bull Systematic approach is the cornerstone of ATLS success
httpwwwuptodatecomcontentsimageimageKey=EM2F64241amptopicKey=EM2F6571amprank=17E150ampsource=see_linkampsearch=traumaamputdPopup=true
httpwwwuptodatecomcontentsimageimageKey=EM2F64241amptopicKey=EM2F6571amprank=17E150ampsource=see_linkampsearch=traumaamputdPopup=true
Airway bull What are you assessing
ndash Airway patency bull What makes the airway not patent
ndash Foreign bodies ndash Vomitbloodsecretions ndash Edemahematoma ndash Impending obstruction
bull Interventions ndash Clearing foreign bodies ndash Suction secretionsvomit with yankauer ndash Repositioning- jaw thrust ndash Nasal trumpetoral airway ndash Intubation ndash Cricothyrotomy jet ventilation
Indications for Intubation
bull Respiratory arrest bull Impending respiratory failure bull Impending airway obstruction bull Inability to protect the airway bull GCS lt8 bull Declining GCS
Breathing bull What are you assessing
ndash ldquoGoodrdquo symmetric chest rise ndash Lung sounds ndash Aeration ndash Basic RR assessment (fast or minimalnone)
bull Interventions ndash Oxygen ndash Albuterolatrovent racemic epi ndash Positive pressure (CPAP BIPAP BMV) ndash Needle decompression ndash Chest tube thoracostomy ndash Intubation ndash Jet ventilation
ETT Intubation Basics bull Size
ndash Age4 + 4 or (Age +16)4 bull Depth
ndash ~ 3 x ETT size when over 1 year of age bull Blade size mac vs miller
ndash 0~ newborn ndash 1~ up to 2 years of life ndash 2~ 2-10 years ndash 3~ 10+ years
bull RSI medications ndash +-Sedation (Always before paralytic) ndash +-Paralytic (May not need it and never wo sedation)
Circulation
bull What do you assess ndash Central and peripheral pulses ndash Heart rate ndash Blood pressure systolic (age x2) +70 ndash Capillary refill ndash Cardiac activity on FAST ndash End organ perfusion
bull Mental status bull Urine output
Circulation Hemodynamic Changes
Percent Blood Volume Loss 0 15 25 35 45
Heart Rate
Blood Pressure
Cardiac Output
Circulation
ndash Access 2 large bore IVrsquos ndash IVFrsquos ndash pRBCrsquos
bull Hgb lt7gdl or ongoing blood losses
ndash Massive Transfusion Protocol
bull (111 ratio of PRBCS FFP Platelets)
ndash Vasopressors (epi norepi dopamine)
ndash Control of Hemorrhage bull Pelvic binders bull Direct pressure bull Indirectproximal pressure bull Tourniquet (only when
absolutely necessary)
ndash Chest Compressions ndash Pericardiocentesis ndash Delayed resuscitation
controlled hypotension (MAP 50 vs 65)
ndash Tranexamic acid in the near future
bull Interventions
Fluid Resuscitation Algorithm 20 mLkg isotonic crystalloid
Reassess
20 mLkg isotonic crystalloid
Reassess
20 mLkg isotonic crystalloid (31 rule)
or consider 10 to 20 mLkg packed red cells
Reconsidering Crystalloid Resuscitation
bull Less fluid ndash Permissive hypotension to
prevent clot rupture (select cases)
bull Too much fluid ndash Excessive Third Spacing ndash Secondary Compartment
Syndrome ndash Greater risk of ARDS ndash Dilutional Coagulopathy
When to start MTP
bull As soon as you believe you will need it ndash Institution specific guidelines
bull gt4 units or 40mlkg of PRBCrsquos expected bull Earlier use of Massive Transfusion Protocol
(pRBC FFP PLT) in ldquoDamage Controlrdquo resuscitations may improve outcome
bull 111 unit ratio bull Risk of TRALI ARDS etc
Disability bull GCS
ndash Range 3-15 ndash We should be 15 ndash Dead are still 3 ndash Less than 8 intubate ndash Eyes- 4 eyes ndash Verbal- most difficult ndash Motor- V6 engine ndash Intubated T
bull AVPU
Finishing Up the Evaluation
bull Airway bull Breathing bull Circulation bull Disability bull Exposure
ndash Expose and examine all parts ndash Cover quickly and keep warm
bull Secondary Survey
Bad Scene Responses
bull What are the outcomes of out-of-hospital cardiac arrest from blunt trauma
bull What are the outcomes of pediatric drowning patients
OHCA from Trauma
bull 2000-2003 bull 123 pts bull Mean age 73 yrs bull Most common
rhythms ndash Asystole 59 ndash PEA 29 ndash V-fib 35
bull 195 rosc in field ndash 98 survived for 24
hrs ndash 57 survived to
discharge ndash Drowning- 19
survival to discharge ndash Bystander CPR tripled
the survivor rate
Blunt Trauma- No Signs of Life
bull Review from 2002-2010 bull No signs of life- 025 of blunt trauma
ndash 25 resuscitated prior to hospital arrival bull 138 of these patients survived to discharge
bull 44 overall survived to hospital discharge
OHCA with CPR on Arrival
bull 169 children bull 141 deaths bull 69 required cpr on arrival- none survived bull 87 of patients requiring CPR on arrival
expired in the ED bull Of the 28 survivors
ndash 55 of survivors had full neurologic recovery
Pediatric Trauma
bull Fortunately these cases represent only a small fraction of EMS transports
bull Despite a few key differences pediatric trauma care overall is very similar to adult trauma care
Questions
References 1 bull NTDB 2013 pediatric Report bull Monkey bars httpsplaygroundchroniclesfileswordpresscom201307soccerjpg bull Screaming child httpblogsbabycentercomwp-contentuploads201409screaming-child-tantrum-fitjpg bull Pediatric airway image httpwwwcelebritydiagnosiscomwp-contentuploads201003pediatric-airwayjpg bull Child on backboard httpsencrypted-tbn2gstaticcomimagesq=tbnANd9GcQscrDVc8IH4MwkNGF6F1A9p7mSVzik5zrWyNvI-
qSwQT5S3GNyVg bull Elbow fracture httpwwwimageinterpretationcoukimageselbowSUPRACONDYLAR20LAT3jpg bull Bike riding httpsmile-per-daycomwp-contentuploads201412klr03jpg bull Dad and child pic httplaughingsquidcomwp-contentuploads471160jpg bull Weigth estimation inner city Am J Emerg Med 2015 Oct33(10)1364-7 doi 101016jajem201507040 Epub 2015 Jul 29 Weight
estimation in an inner-city pediatric ED the effect of obesity Chavez H1 Peterson RE2 Lo K3 Arel M4
bull Guess weight sign httpmedialiveauctiongroupneti963110572971_1jpgv=8CDDAAF8A5B9E20 bull Broselow tape httpsuploadwikimediaorgwikipediacommons994BTape1jpg bull Parent screaming httpmommyofamonstercomwp-contentuploads201301yellingjpg bull Prehospital pain management Am J Emerg Med 2015 Mar33(3)451-4 doi 101016jajem201412012 Epub 2014 Dec 18
Prehospital pain management of injured children a systematic review of current evidence Samuel N1 Steiner IP2 Shavit I3 bull Prehospital pain ped pain assessment Prehosp Emerg Care 2008 Apr-Jun12(2)182-6 doi 10108010903120801907471 Prehospital
pain assessment in pediatric trauma Izsak E1 Moore JL Stringfellow K Oswanski MF Lindstrom DA Stombaugh HA bull Ped pain management Prehosp Emerg Care 2005 Jan-Mar9(1)40-3 Prehospital pain management in children suffering traumatic
injury Swor R1 McEachin CM Seguin D Grall KH bull Prehospital intervention Allen CJ Teisch LF et al Prehospital care and transportation of pediatric trauma patients J Surg Res 2015
Aug197(2)240-6 JAMA 2000 Feb 9283(6)783-90 bull Effect of out-of-hospital pediatric endotracheal intubation on survival and neurological outcome a controlled clinical trial
Gausche M1 Lewis RJ Stratton SJ Haynes BE Gunter CS Goodrich SM Poore PD McCollough MD Henderson DP Pratt FD Seidel JS
bull Pediatric pain management survey Pediatr Emerg Care 2015 Sep 23 [Epub ahead of print] An Assessment of Newly Identified Barriers to and Enablers for Prehospital Pediatric Pain Management Whitley DE1 Li T Jones CM Cushman JT Williams DM Shah MN
References 2 bull httpwwwuptodatecomcontentsprehospital-pediatrics-and-emergency-medical-services-emsabstract6 bull httpwwwuptodatecomcontentsprehospital-pediatrics-and-emergency-medical-services-emsabstract7 bull Pediatr Crit Care Med 2011 Jul12(4)e166-70 doi 101097PCC0b013e3181f36f6e First responder
performance in pediatric trauma a comparison with an adult cohortBankole S1 Asuncion A Ross S Aghai Z Nollah L Echols H Da-Silva S
bull Drayna pc Browne LR et al Prehospital pediatric care Oppportunities for training treatment and research Prehosp Emerg Care 2015 Jul-Sep 19(3) Epub 2015 Feb 6
bull Pediatr Emerg Care 2001 Feb17(1) 5-9Pediatric pre-hospital advanced life support care in an urban setting Babl FE1 Vinci RJ Bauchner H Mottley L
bull Pediatr Crit Care Med 2015 Oct16(8)e260-7 doi 101097PCC0000000000000505Pediatric Out-of-Hospital Critical Procedures in the United States Carlson JN1 Gannon E Mann NC Jacobson KE Dai M Colleran C Wang HE
bull Pediatr Emerg Care 2009 Aug25(8)508-12 doi 101097PEC0b013e3181b0a0da The efficacy of pediatric advanced life support training in emergency medical service providers Baker TW1 King W Soto W Asher C Stolfi A Rowin ME
bull Sutton RM Case E et al ROC investigators A quantitative analysis of out-of-hospital pediatric and adolescent resuscitation quality A report from the ROC Epistry- Cardiac Arrest Resusciation 201593150-157
bull Resuscitation 2014 Aug85(8)1059-64 doi 101016jresuscitation201403307 Epub 2014 Apr 4 Neurocognitive long term follow-up study on drowned children Suominen PK1 Sutinen N2 Valle S3 Olkkola KT4 Loumlnnqvist T3
bull J Pediatr Surg 2010 Jul45(7)1413-9 doi 101016jjpedsurg200912020 Prehospital cardiopulmonary resuscitation in the pediatric trauma patient Murphy JT1 Jaiswal K Sabella J Vinson L Megison S Maxson RT
References 3 bull Pre atv accident
httpwwwctvnewscapolopoly_fs119871591409741949httpImageimagejpg_genderivativeslandscape_960imagejpg bull atv pic httpswwwutahadvocatescomwp-contentuploads201402atvAccidentLawyerjpg bull Blunt abdominal solid organ injury adult vs pediatric trauma center J Pediatr Surg 2015 Aug 28 pii S0022-3468(15)00526-6 doi
101016jjpedsurg201508012 [Epub ahead of print] Trauma center variation in the management of pediatric patients with blunt abdominal solid organ injury a national trauma data bank analysis Safavi A1 Skarsgard ED2 Rhee P1 Zangbar B1 Kulvatunyou N1 Tang A1 OKeeffe T1 Friese RS1 Joseph B3
bull Pediatric blunt abdominal injury Curr Opin Crit Care 2015 Sep 28 [Epub ahead of print] Pediatric blunt abdominal trauma current management Notrica DM1
bull Pediatric splenic injury management Am J Surg 2015 Jul 31 pii S0002-9610(15)00417-1 doi 101016jamjsurg201506009 [Epub ahead of print] Comparative effectiveness of treatment strategies for severe splenic trauma in the pediatric population Rialon KL1 Englum BR1 Gulack BC1 Guevara CJ2 Bhattacharya SD3 Shapiro ML4 Rice HE5 Scarborough JE4 Adibe OO6
bull Liver pic httpss-media-cache-ak0pinimgcom736x7da50e7da50eb2bb603c99ef6649ff897e26b5jpg bull Solid organ injury non op in peds J Trauma Acute Care Surg 2015 Oct79(4)683-93 doi 101097TA0000000000000808
Nonoperative management of blunt liver and spleen injury in children Evaluation of the ATOMAC guideline using GRADE Notrica DM1 Eubanks JW 3rd Tuggle DW Maxson RT Letton RW Garcia NM Alder AC Lawson KA St Peter SD Megison S Garcia Filion P
bull Pediaric vs nonped trauma ct use J Pediatr 2015 Oct167(4)897-904e3 doi 101016jjpeds201506052 Epub 2015 Jul 29 Variation in Computed Tomography Imaging for Pediatric Injury-Related Emergency Visits Marin JR1 Wang L2 Winger DG2 Mannix RC3
bull Solid organ management in ped population J Trauma Acute Care Surg 2015 Aug79(2)206-14quiz 332 doi 101097TA0000000000000731 Management of children with solid organ injuries after blunt torso trauma Wisner DH1 Kuppermann N Cooper A Menaker J Ehrlich P Kooistra J Mahajan P Lee L Cook LJ Yen K Lillis K Holmes JF
bull Triad of death image httpimageslidesharecdncomdamage-control-resuscitation-1304253390-phpapp0195damage-control-resuscitation-14-728jpgcb=1304235553
bull Tranexamic acid study Eckert MJ Wertin TM Tyner SD et al 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 77852
bull Image care accident httpsuploadwikimediaorgwikipediacommonsthumbee1Car_crash_1jpg1280px-Car_crash_1jpg
References 4 bull httpwwwsurgeryvcuedudivisionsacutesurghtml bull Trauma management Approach to the unstable child
httpwwwuptodatecomcontentstrauma-management-approach-to-the-unstable-childsource=search_resultampsearch=pediatric+trauma+childrenampselectedTitle=17E150
bull Trauma management Unique pediatric considerations httpwwwuptodatecomcontentstrauma-management-unique-pediatric-considerationssource=search_resultampsearch=pediatric+trauma+childrenampselectedTitle=37E150
References 5 bull httpwwwetiquettehellcomsmfindexphptopic=8666360 bull httpwwwstlouischildrensorghealth-care-professionalsems-providers bull httpwwwuchicagokidshospitalorgspecialtiesemergency-medicinespecialhtml bull httpwwwsimsacademyinfoFXpatienthtm bull httptheemtspotcomwp-contentuploads200902another-burn-patient-by-annette-larsonjpg bull httplastangryfancomwp-contentuploads200910Clint-Malarchukjpg bull httpwwwtraumaorgarchiveresusmassivehtml bull httpwwwuptodatecomcontentsimageimageKey=PEDS68694amptopicKey=EM2F6389ampsourc
e=previewampsearch=pediatric+hemorrhagic+shockampselectedTitle=17E150amprank=undefined bull httptheemtspotcomwp-contentuploads200902gcsgif bull httpwwwuptodatecomcontentsimageimageKey=EM2F60409amptopicKey=EM2F6571amprank
=17E150ampsource=see_linkampsearch=traumaamputdPopup=true bull httpwwwuptodatecomcontentsimageimageKey=EM2F80874amptopicKey=EM2F6571amprank
=17E150ampsource=see_linkampsearch=traumaamputdPopup=true bull httpempracticenewswordpresscomcategorynexus-criteria bull httpswwwgooglecomsearchq=pediatric+glasgow+coma+scaleamptbm=ischamptbo=uampsource=uni
vampsa=Xampei=8TiOU7TNC5WuyATp5YG4BQampsqi=2ampved=0CDYQsAQampbiw=1426ampbih=883q=canadian+c-spine+rulesamptbm=ischampfacrc=_ampimgdii=_ampimgrc=WI94QMHgMLTQmM253A3BP5nbsFhNCXK0FM3Bhttp253A252F252Fwwwbmjcom252Fhighwire252Ffilestream252F436003252Ffield_highwire_fragment_image_l252F0jpg3Bhttp253A252F252Fwwwbmjcom252Fcontent252F339252Fbmjb41463B12803B1253
References 5 bull httpwwwuptodatecomcontentsimageimageKey=EM2F76777amptopicKey=EM2F6571amprank
=17E150ampsource=see_linkampsearch=traumaamputdPopup=true bull httpwwwdocumentingrealitycomforumattachmentsf14964898d1246625322-firework-injury-
m80injury1jpg bull httpwwwpediatriceducationorg20050620 bull httpwwwarmstrongmedicalcomindexcfmgoproductdetailsec3ssec19cat61fam515 bull httpwwwuptodatecomcontentsimageimageKey=PEDS61087amptopicKey=ID2F7661ampsource
=outline_linkampsearch=tetanus+prophylaxisamputdPopup=true bull httpwwwafsecafmilsharedmediaphotodbweb110609-F-MJ378-009jpg bull httpwwwuptodatecomcontentsimageimageKey=EM75765amptopicKey= bull EM2F6389ampsource=outline_linkampsearch=massive+transfusion+protocolamputdPopup=true bull httpwwwmotifakecomimagedemotivational-postersmall0910whats-the-question-ignorance-
calvin-and-hobbes-demotivational-poster-1255020127jpg
XXXXBoston study ems peds trauma procedures- limited pediatric procedural exposure (but more adult experience) bull Catchment area 590000
over 1 year bull 555 pediatric ALS
transport ndash 19 blunt trauma ndash 10 penetrating trauma
bull IV 33 bull BMV 5 bull Intubation 3 bull 50 ALS providers average
year ndash IV- 37 ndash Intubation- 03 ndash IO- 006
bull 7 ped ems ndash 13 trauma
bull Critical procedures ndash 101000 peds cases ndash Intubation 671000 ndash IO 51000 ndash 81 successful
Pediatr Emerg Care 2001 Feb17(1)5-9 Pediatric pre-hospital advanced life support care in an urban setting
Babl FE1 Vinci RJ Bauchner H Mottley L
Pediatr Crit Care Med 2015 Oct16(8)e260-7 doi 101097PCC0000000000000505 Pediatric Out-of-Hospital Critical Procedures in the United States
Carlson JN1 Gannon E Mann NC Jacobson KE Dai M Colleran C Wang HE
C-spine bull C-spine injuries rare bull Take pt to closest hospital if over injuries
call for it (ie resuscitation altered mental status) primary guide
bull Mechanism ndash Altered mental status focal neuro change
torticollis substantial torso injury diving high speed auto neck pain underlying predisposing condition Acad Emerg Med 2014 Jan21(1)55-64 doi 101111acem12288
Comparison of outcomes for children with cervical spine injury based on destination hospital from scene of injury Anders JF1 Adelgais K Hoyle JD Jr Olsen C Jaffe DM Leonard JC Pediatric Emergency Care Applied Research Network
(PECARN)
Ann Emerg Med 2011 Aug58(2)145-55 doi 101016jannemergmed201008038 Epub 2010 Oct 29 Factors associated with cervical spine injury in children after blunt trauma
Leonard JC Kuppermann N Olsen C Babcock-Cimpello L Brown K Mahajan P Adelgais KM Anders J Borgialli D Donoghue A Hoyle JD Jr Kim E Leonard JR Lillis KA Nigrovic LE Powell EC Rebella
G Reeves SD Rogers AJ Stankovic C Teshome G Jaffe DM Pediatric Emergency Care Applied Research Network
- Itrsquos Hard to Put a Band-Aid on a Broken Spleen Pediatric Trauma
- Disclosures
- Objectives
- Pediatric Prehospital Care
- Mechanism
- Traumatic Pain Management
- Pediatric Trauma
- Deaths by Mechanism of Injury
- Pediatric Trauma
- Pediatric Trauma
- Airway Differences
- Pediatric-Adult Differences
- Pediatric Challenges
- Prehospital Pediatric Challenges
- Pediatric and Adult Trauma
- Scene Response
- Prehospital Intervention
- Where do you take the patient
- Patient arrives at the EDhellip
- Primary Survey
- Order is critical
- Slide Number 22
- Slide Number 23
- Airway
- Indications for Intubation
- Breathing
- ETT Intubation Basics
- Circulation
- Slide Number 29
- CirculationHemodynamic Changes
- Circulation
- Fluid Resuscitation Algorithm
- Reconsidering Crystalloid Resuscitation
- When to start MTP
- Disability
- Finishing Up the Evaluation
- Bad Scene Responses
- OHCA from Trauma
- Blunt Trauma- No Signs of Life
- OHCA with CPR on Arrival
- Pediatric Trauma
- Questions
- References 1
- References 2
- References 3
- References 4
- References 5
- References 5
- XXXXBoston study ems peds trauma procedures- limited pediatric procedural exposure (but more adult experience)
- C-spine
Scene Response
bull 8 year old male in a rollover atv accident
bull Pt is unresponsive localizes pain wonrsquot open his eyes
bull HR 130 BP 10060 bull RR 10 O2 sat 93 bull What do you want to do
Prehospital Intervention
bull Pre-hospital interventions did not significantly worsen care ndash Similar transport times ndash Similar mortality length of stay
bull ETI vs BMV ndash No difference in survival ndash No difference in neurological outcome
Where do you take the patient
bull Pediatric trauma centers ndash Less surgery on solid organ injuries ndash Less radiation- of scans and dosage ndash Less comorbidities
bull Lower costs bull Shorter length of stay bull Lower infections bull Less multi-organ failure
Patient arrives at the EDhellip
bull Where do you start ndash Primary Survey
Primary Survey bull Your ABCrsquoshellip
bull Airway bull Breathing bull Circulation bull Disability (Neuro- GCS) bull Exposure
Order is critical
bull A before B or C bull Morbiditymortality will
occur much faster from airway compromise than from breathing or circulatory problems
bull Systematic approach is the cornerstone of ATLS success
httpwwwuptodatecomcontentsimageimageKey=EM2F64241amptopicKey=EM2F6571amprank=17E150ampsource=see_linkampsearch=traumaamputdPopup=true
httpwwwuptodatecomcontentsimageimageKey=EM2F64241amptopicKey=EM2F6571amprank=17E150ampsource=see_linkampsearch=traumaamputdPopup=true
Airway bull What are you assessing
ndash Airway patency bull What makes the airway not patent
ndash Foreign bodies ndash Vomitbloodsecretions ndash Edemahematoma ndash Impending obstruction
bull Interventions ndash Clearing foreign bodies ndash Suction secretionsvomit with yankauer ndash Repositioning- jaw thrust ndash Nasal trumpetoral airway ndash Intubation ndash Cricothyrotomy jet ventilation
Indications for Intubation
bull Respiratory arrest bull Impending respiratory failure bull Impending airway obstruction bull Inability to protect the airway bull GCS lt8 bull Declining GCS
Breathing bull What are you assessing
ndash ldquoGoodrdquo symmetric chest rise ndash Lung sounds ndash Aeration ndash Basic RR assessment (fast or minimalnone)
bull Interventions ndash Oxygen ndash Albuterolatrovent racemic epi ndash Positive pressure (CPAP BIPAP BMV) ndash Needle decompression ndash Chest tube thoracostomy ndash Intubation ndash Jet ventilation
ETT Intubation Basics bull Size
ndash Age4 + 4 or (Age +16)4 bull Depth
ndash ~ 3 x ETT size when over 1 year of age bull Blade size mac vs miller
ndash 0~ newborn ndash 1~ up to 2 years of life ndash 2~ 2-10 years ndash 3~ 10+ years
bull RSI medications ndash +-Sedation (Always before paralytic) ndash +-Paralytic (May not need it and never wo sedation)
Circulation
bull What do you assess ndash Central and peripheral pulses ndash Heart rate ndash Blood pressure systolic (age x2) +70 ndash Capillary refill ndash Cardiac activity on FAST ndash End organ perfusion
bull Mental status bull Urine output
Circulation Hemodynamic Changes
Percent Blood Volume Loss 0 15 25 35 45
Heart Rate
Blood Pressure
Cardiac Output
Circulation
ndash Access 2 large bore IVrsquos ndash IVFrsquos ndash pRBCrsquos
bull Hgb lt7gdl or ongoing blood losses
ndash Massive Transfusion Protocol
bull (111 ratio of PRBCS FFP Platelets)
ndash Vasopressors (epi norepi dopamine)
ndash Control of Hemorrhage bull Pelvic binders bull Direct pressure bull Indirectproximal pressure bull Tourniquet (only when
absolutely necessary)
ndash Chest Compressions ndash Pericardiocentesis ndash Delayed resuscitation
controlled hypotension (MAP 50 vs 65)
ndash Tranexamic acid in the near future
bull Interventions
Fluid Resuscitation Algorithm 20 mLkg isotonic crystalloid
Reassess
20 mLkg isotonic crystalloid
Reassess
20 mLkg isotonic crystalloid (31 rule)
or consider 10 to 20 mLkg packed red cells
Reconsidering Crystalloid Resuscitation
bull Less fluid ndash Permissive hypotension to
prevent clot rupture (select cases)
bull Too much fluid ndash Excessive Third Spacing ndash Secondary Compartment
Syndrome ndash Greater risk of ARDS ndash Dilutional Coagulopathy
When to start MTP
bull As soon as you believe you will need it ndash Institution specific guidelines
bull gt4 units or 40mlkg of PRBCrsquos expected bull Earlier use of Massive Transfusion Protocol
(pRBC FFP PLT) in ldquoDamage Controlrdquo resuscitations may improve outcome
bull 111 unit ratio bull Risk of TRALI ARDS etc
Disability bull GCS
ndash Range 3-15 ndash We should be 15 ndash Dead are still 3 ndash Less than 8 intubate ndash Eyes- 4 eyes ndash Verbal- most difficult ndash Motor- V6 engine ndash Intubated T
bull AVPU
Finishing Up the Evaluation
bull Airway bull Breathing bull Circulation bull Disability bull Exposure
ndash Expose and examine all parts ndash Cover quickly and keep warm
bull Secondary Survey
Bad Scene Responses
bull What are the outcomes of out-of-hospital cardiac arrest from blunt trauma
bull What are the outcomes of pediatric drowning patients
OHCA from Trauma
bull 2000-2003 bull 123 pts bull Mean age 73 yrs bull Most common
rhythms ndash Asystole 59 ndash PEA 29 ndash V-fib 35
bull 195 rosc in field ndash 98 survived for 24
hrs ndash 57 survived to
discharge ndash Drowning- 19
survival to discharge ndash Bystander CPR tripled
the survivor rate
Blunt Trauma- No Signs of Life
bull Review from 2002-2010 bull No signs of life- 025 of blunt trauma
ndash 25 resuscitated prior to hospital arrival bull 138 of these patients survived to discharge
bull 44 overall survived to hospital discharge
OHCA with CPR on Arrival
bull 169 children bull 141 deaths bull 69 required cpr on arrival- none survived bull 87 of patients requiring CPR on arrival
expired in the ED bull Of the 28 survivors
ndash 55 of survivors had full neurologic recovery
Pediatric Trauma
bull Fortunately these cases represent only a small fraction of EMS transports
bull Despite a few key differences pediatric trauma care overall is very similar to adult trauma care
Questions
References 1 bull NTDB 2013 pediatric Report bull Monkey bars httpsplaygroundchroniclesfileswordpresscom201307soccerjpg bull Screaming child httpblogsbabycentercomwp-contentuploads201409screaming-child-tantrum-fitjpg bull Pediatric airway image httpwwwcelebritydiagnosiscomwp-contentuploads201003pediatric-airwayjpg bull Child on backboard httpsencrypted-tbn2gstaticcomimagesq=tbnANd9GcQscrDVc8IH4MwkNGF6F1A9p7mSVzik5zrWyNvI-
qSwQT5S3GNyVg bull Elbow fracture httpwwwimageinterpretationcoukimageselbowSUPRACONDYLAR20LAT3jpg bull Bike riding httpsmile-per-daycomwp-contentuploads201412klr03jpg bull Dad and child pic httplaughingsquidcomwp-contentuploads471160jpg bull Weigth estimation inner city Am J Emerg Med 2015 Oct33(10)1364-7 doi 101016jajem201507040 Epub 2015 Jul 29 Weight
estimation in an inner-city pediatric ED the effect of obesity Chavez H1 Peterson RE2 Lo K3 Arel M4
bull Guess weight sign httpmedialiveauctiongroupneti963110572971_1jpgv=8CDDAAF8A5B9E20 bull Broselow tape httpsuploadwikimediaorgwikipediacommons994BTape1jpg bull Parent screaming httpmommyofamonstercomwp-contentuploads201301yellingjpg bull Prehospital pain management Am J Emerg Med 2015 Mar33(3)451-4 doi 101016jajem201412012 Epub 2014 Dec 18
Prehospital pain management of injured children a systematic review of current evidence Samuel N1 Steiner IP2 Shavit I3 bull Prehospital pain ped pain assessment Prehosp Emerg Care 2008 Apr-Jun12(2)182-6 doi 10108010903120801907471 Prehospital
pain assessment in pediatric trauma Izsak E1 Moore JL Stringfellow K Oswanski MF Lindstrom DA Stombaugh HA bull Ped pain management Prehosp Emerg Care 2005 Jan-Mar9(1)40-3 Prehospital pain management in children suffering traumatic
injury Swor R1 McEachin CM Seguin D Grall KH bull Prehospital intervention Allen CJ Teisch LF et al Prehospital care and transportation of pediatric trauma patients J Surg Res 2015
Aug197(2)240-6 JAMA 2000 Feb 9283(6)783-90 bull Effect of out-of-hospital pediatric endotracheal intubation on survival and neurological outcome a controlled clinical trial
Gausche M1 Lewis RJ Stratton SJ Haynes BE Gunter CS Goodrich SM Poore PD McCollough MD Henderson DP Pratt FD Seidel JS
bull Pediatric pain management survey Pediatr Emerg Care 2015 Sep 23 [Epub ahead of print] An Assessment of Newly Identified Barriers to and Enablers for Prehospital Pediatric Pain Management Whitley DE1 Li T Jones CM Cushman JT Williams DM Shah MN
References 2 bull httpwwwuptodatecomcontentsprehospital-pediatrics-and-emergency-medical-services-emsabstract6 bull httpwwwuptodatecomcontentsprehospital-pediatrics-and-emergency-medical-services-emsabstract7 bull Pediatr Crit Care Med 2011 Jul12(4)e166-70 doi 101097PCC0b013e3181f36f6e First responder
performance in pediatric trauma a comparison with an adult cohortBankole S1 Asuncion A Ross S Aghai Z Nollah L Echols H Da-Silva S
bull Drayna pc Browne LR et al Prehospital pediatric care Oppportunities for training treatment and research Prehosp Emerg Care 2015 Jul-Sep 19(3) Epub 2015 Feb 6
bull Pediatr Emerg Care 2001 Feb17(1) 5-9Pediatric pre-hospital advanced life support care in an urban setting Babl FE1 Vinci RJ Bauchner H Mottley L
bull Pediatr Crit Care Med 2015 Oct16(8)e260-7 doi 101097PCC0000000000000505Pediatric Out-of-Hospital Critical Procedures in the United States Carlson JN1 Gannon E Mann NC Jacobson KE Dai M Colleran C Wang HE
bull Pediatr Emerg Care 2009 Aug25(8)508-12 doi 101097PEC0b013e3181b0a0da The efficacy of pediatric advanced life support training in emergency medical service providers Baker TW1 King W Soto W Asher C Stolfi A Rowin ME
bull Sutton RM Case E et al ROC investigators A quantitative analysis of out-of-hospital pediatric and adolescent resuscitation quality A report from the ROC Epistry- Cardiac Arrest Resusciation 201593150-157
bull Resuscitation 2014 Aug85(8)1059-64 doi 101016jresuscitation201403307 Epub 2014 Apr 4 Neurocognitive long term follow-up study on drowned children Suominen PK1 Sutinen N2 Valle S3 Olkkola KT4 Loumlnnqvist T3
bull J Pediatr Surg 2010 Jul45(7)1413-9 doi 101016jjpedsurg200912020 Prehospital cardiopulmonary resuscitation in the pediatric trauma patient Murphy JT1 Jaiswal K Sabella J Vinson L Megison S Maxson RT
References 3 bull Pre atv accident
httpwwwctvnewscapolopoly_fs119871591409741949httpImageimagejpg_genderivativeslandscape_960imagejpg bull atv pic httpswwwutahadvocatescomwp-contentuploads201402atvAccidentLawyerjpg bull Blunt abdominal solid organ injury adult vs pediatric trauma center J Pediatr Surg 2015 Aug 28 pii S0022-3468(15)00526-6 doi
101016jjpedsurg201508012 [Epub ahead of print] Trauma center variation in the management of pediatric patients with blunt abdominal solid organ injury a national trauma data bank analysis Safavi A1 Skarsgard ED2 Rhee P1 Zangbar B1 Kulvatunyou N1 Tang A1 OKeeffe T1 Friese RS1 Joseph B3
bull Pediatric blunt abdominal injury Curr Opin Crit Care 2015 Sep 28 [Epub ahead of print] Pediatric blunt abdominal trauma current management Notrica DM1
bull Pediatric splenic injury management Am J Surg 2015 Jul 31 pii S0002-9610(15)00417-1 doi 101016jamjsurg201506009 [Epub ahead of print] Comparative effectiveness of treatment strategies for severe splenic trauma in the pediatric population Rialon KL1 Englum BR1 Gulack BC1 Guevara CJ2 Bhattacharya SD3 Shapiro ML4 Rice HE5 Scarborough JE4 Adibe OO6
bull Liver pic httpss-media-cache-ak0pinimgcom736x7da50e7da50eb2bb603c99ef6649ff897e26b5jpg bull Solid organ injury non op in peds J Trauma Acute Care Surg 2015 Oct79(4)683-93 doi 101097TA0000000000000808
Nonoperative management of blunt liver and spleen injury in children Evaluation of the ATOMAC guideline using GRADE Notrica DM1 Eubanks JW 3rd Tuggle DW Maxson RT Letton RW Garcia NM Alder AC Lawson KA St Peter SD Megison S Garcia Filion P
bull Pediaric vs nonped trauma ct use J Pediatr 2015 Oct167(4)897-904e3 doi 101016jjpeds201506052 Epub 2015 Jul 29 Variation in Computed Tomography Imaging for Pediatric Injury-Related Emergency Visits Marin JR1 Wang L2 Winger DG2 Mannix RC3
bull Solid organ management in ped population J Trauma Acute Care Surg 2015 Aug79(2)206-14quiz 332 doi 101097TA0000000000000731 Management of children with solid organ injuries after blunt torso trauma Wisner DH1 Kuppermann N Cooper A Menaker J Ehrlich P Kooistra J Mahajan P Lee L Cook LJ Yen K Lillis K Holmes JF
bull Triad of death image httpimageslidesharecdncomdamage-control-resuscitation-1304253390-phpapp0195damage-control-resuscitation-14-728jpgcb=1304235553
bull Tranexamic acid study Eckert MJ Wertin TM Tyner SD et al 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 77852
bull Image care accident httpsuploadwikimediaorgwikipediacommonsthumbee1Car_crash_1jpg1280px-Car_crash_1jpg
References 4 bull httpwwwsurgeryvcuedudivisionsacutesurghtml bull Trauma management Approach to the unstable child
httpwwwuptodatecomcontentstrauma-management-approach-to-the-unstable-childsource=search_resultampsearch=pediatric+trauma+childrenampselectedTitle=17E150
bull Trauma management Unique pediatric considerations httpwwwuptodatecomcontentstrauma-management-unique-pediatric-considerationssource=search_resultampsearch=pediatric+trauma+childrenampselectedTitle=37E150
References 5 bull httpwwwetiquettehellcomsmfindexphptopic=8666360 bull httpwwwstlouischildrensorghealth-care-professionalsems-providers bull httpwwwuchicagokidshospitalorgspecialtiesemergency-medicinespecialhtml bull httpwwwsimsacademyinfoFXpatienthtm bull httptheemtspotcomwp-contentuploads200902another-burn-patient-by-annette-larsonjpg bull httplastangryfancomwp-contentuploads200910Clint-Malarchukjpg bull httpwwwtraumaorgarchiveresusmassivehtml bull httpwwwuptodatecomcontentsimageimageKey=PEDS68694amptopicKey=EM2F6389ampsourc
e=previewampsearch=pediatric+hemorrhagic+shockampselectedTitle=17E150amprank=undefined bull httptheemtspotcomwp-contentuploads200902gcsgif bull httpwwwuptodatecomcontentsimageimageKey=EM2F60409amptopicKey=EM2F6571amprank
=17E150ampsource=see_linkampsearch=traumaamputdPopup=true bull httpwwwuptodatecomcontentsimageimageKey=EM2F80874amptopicKey=EM2F6571amprank
=17E150ampsource=see_linkampsearch=traumaamputdPopup=true bull httpempracticenewswordpresscomcategorynexus-criteria bull httpswwwgooglecomsearchq=pediatric+glasgow+coma+scaleamptbm=ischamptbo=uampsource=uni
vampsa=Xampei=8TiOU7TNC5WuyATp5YG4BQampsqi=2ampved=0CDYQsAQampbiw=1426ampbih=883q=canadian+c-spine+rulesamptbm=ischampfacrc=_ampimgdii=_ampimgrc=WI94QMHgMLTQmM253A3BP5nbsFhNCXK0FM3Bhttp253A252F252Fwwwbmjcom252Fhighwire252Ffilestream252F436003252Ffield_highwire_fragment_image_l252F0jpg3Bhttp253A252F252Fwwwbmjcom252Fcontent252F339252Fbmjb41463B12803B1253
References 5 bull httpwwwuptodatecomcontentsimageimageKey=EM2F76777amptopicKey=EM2F6571amprank
=17E150ampsource=see_linkampsearch=traumaamputdPopup=true bull httpwwwdocumentingrealitycomforumattachmentsf14964898d1246625322-firework-injury-
m80injury1jpg bull httpwwwpediatriceducationorg20050620 bull httpwwwarmstrongmedicalcomindexcfmgoproductdetailsec3ssec19cat61fam515 bull httpwwwuptodatecomcontentsimageimageKey=PEDS61087amptopicKey=ID2F7661ampsource
=outline_linkampsearch=tetanus+prophylaxisamputdPopup=true bull httpwwwafsecafmilsharedmediaphotodbweb110609-F-MJ378-009jpg bull httpwwwuptodatecomcontentsimageimageKey=EM75765amptopicKey= bull EM2F6389ampsource=outline_linkampsearch=massive+transfusion+protocolamputdPopup=true bull httpwwwmotifakecomimagedemotivational-postersmall0910whats-the-question-ignorance-
calvin-and-hobbes-demotivational-poster-1255020127jpg
XXXXBoston study ems peds trauma procedures- limited pediatric procedural exposure (but more adult experience) bull Catchment area 590000
over 1 year bull 555 pediatric ALS
transport ndash 19 blunt trauma ndash 10 penetrating trauma
bull IV 33 bull BMV 5 bull Intubation 3 bull 50 ALS providers average
year ndash IV- 37 ndash Intubation- 03 ndash IO- 006
bull 7 ped ems ndash 13 trauma
bull Critical procedures ndash 101000 peds cases ndash Intubation 671000 ndash IO 51000 ndash 81 successful
Pediatr Emerg Care 2001 Feb17(1)5-9 Pediatric pre-hospital advanced life support care in an urban setting
Babl FE1 Vinci RJ Bauchner H Mottley L
Pediatr Crit Care Med 2015 Oct16(8)e260-7 doi 101097PCC0000000000000505 Pediatric Out-of-Hospital Critical Procedures in the United States
Carlson JN1 Gannon E Mann NC Jacobson KE Dai M Colleran C Wang HE
C-spine bull C-spine injuries rare bull Take pt to closest hospital if over injuries
call for it (ie resuscitation altered mental status) primary guide
bull Mechanism ndash Altered mental status focal neuro change
torticollis substantial torso injury diving high speed auto neck pain underlying predisposing condition Acad Emerg Med 2014 Jan21(1)55-64 doi 101111acem12288
Comparison of outcomes for children with cervical spine injury based on destination hospital from scene of injury Anders JF1 Adelgais K Hoyle JD Jr Olsen C Jaffe DM Leonard JC Pediatric Emergency Care Applied Research Network
(PECARN)
Ann Emerg Med 2011 Aug58(2)145-55 doi 101016jannemergmed201008038 Epub 2010 Oct 29 Factors associated with cervical spine injury in children after blunt trauma
Leonard JC Kuppermann N Olsen C Babcock-Cimpello L Brown K Mahajan P Adelgais KM Anders J Borgialli D Donoghue A Hoyle JD Jr Kim E Leonard JR Lillis KA Nigrovic LE Powell EC Rebella
G Reeves SD Rogers AJ Stankovic C Teshome G Jaffe DM Pediatric Emergency Care Applied Research Network
- Itrsquos Hard to Put a Band-Aid on a Broken Spleen Pediatric Trauma
- Disclosures
- Objectives
- Pediatric Prehospital Care
- Mechanism
- Traumatic Pain Management
- Pediatric Trauma
- Deaths by Mechanism of Injury
- Pediatric Trauma
- Pediatric Trauma
- Airway Differences
- Pediatric-Adult Differences
- Pediatric Challenges
- Prehospital Pediatric Challenges
- Pediatric and Adult Trauma
- Scene Response
- Prehospital Intervention
- Where do you take the patient
- Patient arrives at the EDhellip
- Primary Survey
- Order is critical
- Slide Number 22
- Slide Number 23
- Airway
- Indications for Intubation
- Breathing
- ETT Intubation Basics
- Circulation
- Slide Number 29
- CirculationHemodynamic Changes
- Circulation
- Fluid Resuscitation Algorithm
- Reconsidering Crystalloid Resuscitation
- When to start MTP
- Disability
- Finishing Up the Evaluation
- Bad Scene Responses
- OHCA from Trauma
- Blunt Trauma- No Signs of Life
- OHCA with CPR on Arrival
- Pediatric Trauma
- Questions
- References 1
- References 2
- References 3
- References 4
- References 5
- References 5
- XXXXBoston study ems peds trauma procedures- limited pediatric procedural exposure (but more adult experience)
- C-spine
Prehospital Intervention
bull Pre-hospital interventions did not significantly worsen care ndash Similar transport times ndash Similar mortality length of stay
bull ETI vs BMV ndash No difference in survival ndash No difference in neurological outcome
Where do you take the patient
bull Pediatric trauma centers ndash Less surgery on solid organ injuries ndash Less radiation- of scans and dosage ndash Less comorbidities
bull Lower costs bull Shorter length of stay bull Lower infections bull Less multi-organ failure
Patient arrives at the EDhellip
bull Where do you start ndash Primary Survey
Primary Survey bull Your ABCrsquoshellip
bull Airway bull Breathing bull Circulation bull Disability (Neuro- GCS) bull Exposure
Order is critical
bull A before B or C bull Morbiditymortality will
occur much faster from airway compromise than from breathing or circulatory problems
bull Systematic approach is the cornerstone of ATLS success
httpwwwuptodatecomcontentsimageimageKey=EM2F64241amptopicKey=EM2F6571amprank=17E150ampsource=see_linkampsearch=traumaamputdPopup=true
httpwwwuptodatecomcontentsimageimageKey=EM2F64241amptopicKey=EM2F6571amprank=17E150ampsource=see_linkampsearch=traumaamputdPopup=true
Airway bull What are you assessing
ndash Airway patency bull What makes the airway not patent
ndash Foreign bodies ndash Vomitbloodsecretions ndash Edemahematoma ndash Impending obstruction
bull Interventions ndash Clearing foreign bodies ndash Suction secretionsvomit with yankauer ndash Repositioning- jaw thrust ndash Nasal trumpetoral airway ndash Intubation ndash Cricothyrotomy jet ventilation
Indications for Intubation
bull Respiratory arrest bull Impending respiratory failure bull Impending airway obstruction bull Inability to protect the airway bull GCS lt8 bull Declining GCS
Breathing bull What are you assessing
ndash ldquoGoodrdquo symmetric chest rise ndash Lung sounds ndash Aeration ndash Basic RR assessment (fast or minimalnone)
bull Interventions ndash Oxygen ndash Albuterolatrovent racemic epi ndash Positive pressure (CPAP BIPAP BMV) ndash Needle decompression ndash Chest tube thoracostomy ndash Intubation ndash Jet ventilation
ETT Intubation Basics bull Size
ndash Age4 + 4 or (Age +16)4 bull Depth
ndash ~ 3 x ETT size when over 1 year of age bull Blade size mac vs miller
ndash 0~ newborn ndash 1~ up to 2 years of life ndash 2~ 2-10 years ndash 3~ 10+ years
bull RSI medications ndash +-Sedation (Always before paralytic) ndash +-Paralytic (May not need it and never wo sedation)
Circulation
bull What do you assess ndash Central and peripheral pulses ndash Heart rate ndash Blood pressure systolic (age x2) +70 ndash Capillary refill ndash Cardiac activity on FAST ndash End organ perfusion
bull Mental status bull Urine output
Circulation Hemodynamic Changes
Percent Blood Volume Loss 0 15 25 35 45
Heart Rate
Blood Pressure
Cardiac Output
Circulation
ndash Access 2 large bore IVrsquos ndash IVFrsquos ndash pRBCrsquos
bull Hgb lt7gdl or ongoing blood losses
ndash Massive Transfusion Protocol
bull (111 ratio of PRBCS FFP Platelets)
ndash Vasopressors (epi norepi dopamine)
ndash Control of Hemorrhage bull Pelvic binders bull Direct pressure bull Indirectproximal pressure bull Tourniquet (only when
absolutely necessary)
ndash Chest Compressions ndash Pericardiocentesis ndash Delayed resuscitation
controlled hypotension (MAP 50 vs 65)
ndash Tranexamic acid in the near future
bull Interventions
Fluid Resuscitation Algorithm 20 mLkg isotonic crystalloid
Reassess
20 mLkg isotonic crystalloid
Reassess
20 mLkg isotonic crystalloid (31 rule)
or consider 10 to 20 mLkg packed red cells
Reconsidering Crystalloid Resuscitation
bull Less fluid ndash Permissive hypotension to
prevent clot rupture (select cases)
bull Too much fluid ndash Excessive Third Spacing ndash Secondary Compartment
Syndrome ndash Greater risk of ARDS ndash Dilutional Coagulopathy
When to start MTP
bull As soon as you believe you will need it ndash Institution specific guidelines
bull gt4 units or 40mlkg of PRBCrsquos expected bull Earlier use of Massive Transfusion Protocol
(pRBC FFP PLT) in ldquoDamage Controlrdquo resuscitations may improve outcome
bull 111 unit ratio bull Risk of TRALI ARDS etc
Disability bull GCS
ndash Range 3-15 ndash We should be 15 ndash Dead are still 3 ndash Less than 8 intubate ndash Eyes- 4 eyes ndash Verbal- most difficult ndash Motor- V6 engine ndash Intubated T
bull AVPU
Finishing Up the Evaluation
bull Airway bull Breathing bull Circulation bull Disability bull Exposure
ndash Expose and examine all parts ndash Cover quickly and keep warm
bull Secondary Survey
Bad Scene Responses
bull What are the outcomes of out-of-hospital cardiac arrest from blunt trauma
bull What are the outcomes of pediatric drowning patients
OHCA from Trauma
bull 2000-2003 bull 123 pts bull Mean age 73 yrs bull Most common
rhythms ndash Asystole 59 ndash PEA 29 ndash V-fib 35
bull 195 rosc in field ndash 98 survived for 24
hrs ndash 57 survived to
discharge ndash Drowning- 19
survival to discharge ndash Bystander CPR tripled
the survivor rate
Blunt Trauma- No Signs of Life
bull Review from 2002-2010 bull No signs of life- 025 of blunt trauma
ndash 25 resuscitated prior to hospital arrival bull 138 of these patients survived to discharge
bull 44 overall survived to hospital discharge
OHCA with CPR on Arrival
bull 169 children bull 141 deaths bull 69 required cpr on arrival- none survived bull 87 of patients requiring CPR on arrival
expired in the ED bull Of the 28 survivors
ndash 55 of survivors had full neurologic recovery
Pediatric Trauma
bull Fortunately these cases represent only a small fraction of EMS transports
bull Despite a few key differences pediatric trauma care overall is very similar to adult trauma care
Questions
References 1 bull NTDB 2013 pediatric Report bull Monkey bars httpsplaygroundchroniclesfileswordpresscom201307soccerjpg bull Screaming child httpblogsbabycentercomwp-contentuploads201409screaming-child-tantrum-fitjpg bull Pediatric airway image httpwwwcelebritydiagnosiscomwp-contentuploads201003pediatric-airwayjpg bull Child on backboard httpsencrypted-tbn2gstaticcomimagesq=tbnANd9GcQscrDVc8IH4MwkNGF6F1A9p7mSVzik5zrWyNvI-
qSwQT5S3GNyVg bull Elbow fracture httpwwwimageinterpretationcoukimageselbowSUPRACONDYLAR20LAT3jpg bull Bike riding httpsmile-per-daycomwp-contentuploads201412klr03jpg bull Dad and child pic httplaughingsquidcomwp-contentuploads471160jpg bull Weigth estimation inner city Am J Emerg Med 2015 Oct33(10)1364-7 doi 101016jajem201507040 Epub 2015 Jul 29 Weight
estimation in an inner-city pediatric ED the effect of obesity Chavez H1 Peterson RE2 Lo K3 Arel M4
bull Guess weight sign httpmedialiveauctiongroupneti963110572971_1jpgv=8CDDAAF8A5B9E20 bull Broselow tape httpsuploadwikimediaorgwikipediacommons994BTape1jpg bull Parent screaming httpmommyofamonstercomwp-contentuploads201301yellingjpg bull Prehospital pain management Am J Emerg Med 2015 Mar33(3)451-4 doi 101016jajem201412012 Epub 2014 Dec 18
Prehospital pain management of injured children a systematic review of current evidence Samuel N1 Steiner IP2 Shavit I3 bull Prehospital pain ped pain assessment Prehosp Emerg Care 2008 Apr-Jun12(2)182-6 doi 10108010903120801907471 Prehospital
pain assessment in pediatric trauma Izsak E1 Moore JL Stringfellow K Oswanski MF Lindstrom DA Stombaugh HA bull Ped pain management Prehosp Emerg Care 2005 Jan-Mar9(1)40-3 Prehospital pain management in children suffering traumatic
injury Swor R1 McEachin CM Seguin D Grall KH bull Prehospital intervention Allen CJ Teisch LF et al Prehospital care and transportation of pediatric trauma patients J Surg Res 2015
Aug197(2)240-6 JAMA 2000 Feb 9283(6)783-90 bull Effect of out-of-hospital pediatric endotracheal intubation on survival and neurological outcome a controlled clinical trial
Gausche M1 Lewis RJ Stratton SJ Haynes BE Gunter CS Goodrich SM Poore PD McCollough MD Henderson DP Pratt FD Seidel JS
bull Pediatric pain management survey Pediatr Emerg Care 2015 Sep 23 [Epub ahead of print] An Assessment of Newly Identified Barriers to and Enablers for Prehospital Pediatric Pain Management Whitley DE1 Li T Jones CM Cushman JT Williams DM Shah MN
References 2 bull httpwwwuptodatecomcontentsprehospital-pediatrics-and-emergency-medical-services-emsabstract6 bull httpwwwuptodatecomcontentsprehospital-pediatrics-and-emergency-medical-services-emsabstract7 bull Pediatr Crit Care Med 2011 Jul12(4)e166-70 doi 101097PCC0b013e3181f36f6e First responder
performance in pediatric trauma a comparison with an adult cohortBankole S1 Asuncion A Ross S Aghai Z Nollah L Echols H Da-Silva S
bull Drayna pc Browne LR et al Prehospital pediatric care Oppportunities for training treatment and research Prehosp Emerg Care 2015 Jul-Sep 19(3) Epub 2015 Feb 6
bull Pediatr Emerg Care 2001 Feb17(1) 5-9Pediatric pre-hospital advanced life support care in an urban setting Babl FE1 Vinci RJ Bauchner H Mottley L
bull Pediatr Crit Care Med 2015 Oct16(8)e260-7 doi 101097PCC0000000000000505Pediatric Out-of-Hospital Critical Procedures in the United States Carlson JN1 Gannon E Mann NC Jacobson KE Dai M Colleran C Wang HE
bull Pediatr Emerg Care 2009 Aug25(8)508-12 doi 101097PEC0b013e3181b0a0da The efficacy of pediatric advanced life support training in emergency medical service providers Baker TW1 King W Soto W Asher C Stolfi A Rowin ME
bull Sutton RM Case E et al ROC investigators A quantitative analysis of out-of-hospital pediatric and adolescent resuscitation quality A report from the ROC Epistry- Cardiac Arrest Resusciation 201593150-157
bull Resuscitation 2014 Aug85(8)1059-64 doi 101016jresuscitation201403307 Epub 2014 Apr 4 Neurocognitive long term follow-up study on drowned children Suominen PK1 Sutinen N2 Valle S3 Olkkola KT4 Loumlnnqvist T3
bull J Pediatr Surg 2010 Jul45(7)1413-9 doi 101016jjpedsurg200912020 Prehospital cardiopulmonary resuscitation in the pediatric trauma patient Murphy JT1 Jaiswal K Sabella J Vinson L Megison S Maxson RT
References 3 bull Pre atv accident
httpwwwctvnewscapolopoly_fs119871591409741949httpImageimagejpg_genderivativeslandscape_960imagejpg bull atv pic httpswwwutahadvocatescomwp-contentuploads201402atvAccidentLawyerjpg bull Blunt abdominal solid organ injury adult vs pediatric trauma center J Pediatr Surg 2015 Aug 28 pii S0022-3468(15)00526-6 doi
101016jjpedsurg201508012 [Epub ahead of print] Trauma center variation in the management of pediatric patients with blunt abdominal solid organ injury a national trauma data bank analysis Safavi A1 Skarsgard ED2 Rhee P1 Zangbar B1 Kulvatunyou N1 Tang A1 OKeeffe T1 Friese RS1 Joseph B3
bull Pediatric blunt abdominal injury Curr Opin Crit Care 2015 Sep 28 [Epub ahead of print] Pediatric blunt abdominal trauma current management Notrica DM1
bull Pediatric splenic injury management Am J Surg 2015 Jul 31 pii S0002-9610(15)00417-1 doi 101016jamjsurg201506009 [Epub ahead of print] Comparative effectiveness of treatment strategies for severe splenic trauma in the pediatric population Rialon KL1 Englum BR1 Gulack BC1 Guevara CJ2 Bhattacharya SD3 Shapiro ML4 Rice HE5 Scarborough JE4 Adibe OO6
bull Liver pic httpss-media-cache-ak0pinimgcom736x7da50e7da50eb2bb603c99ef6649ff897e26b5jpg bull Solid organ injury non op in peds J Trauma Acute Care Surg 2015 Oct79(4)683-93 doi 101097TA0000000000000808
Nonoperative management of blunt liver and spleen injury in children Evaluation of the ATOMAC guideline using GRADE Notrica DM1 Eubanks JW 3rd Tuggle DW Maxson RT Letton RW Garcia NM Alder AC Lawson KA St Peter SD Megison S Garcia Filion P
bull Pediaric vs nonped trauma ct use J Pediatr 2015 Oct167(4)897-904e3 doi 101016jjpeds201506052 Epub 2015 Jul 29 Variation in Computed Tomography Imaging for Pediatric Injury-Related Emergency Visits Marin JR1 Wang L2 Winger DG2 Mannix RC3
bull Solid organ management in ped population J Trauma Acute Care Surg 2015 Aug79(2)206-14quiz 332 doi 101097TA0000000000000731 Management of children with solid organ injuries after blunt torso trauma Wisner DH1 Kuppermann N Cooper A Menaker J Ehrlich P Kooistra J Mahajan P Lee L Cook LJ Yen K Lillis K Holmes JF
bull Triad of death image httpimageslidesharecdncomdamage-control-resuscitation-1304253390-phpapp0195damage-control-resuscitation-14-728jpgcb=1304235553
bull Tranexamic acid study Eckert MJ Wertin TM Tyner SD et al 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 77852
bull Image care accident httpsuploadwikimediaorgwikipediacommonsthumbee1Car_crash_1jpg1280px-Car_crash_1jpg
References 4 bull httpwwwsurgeryvcuedudivisionsacutesurghtml bull Trauma management Approach to the unstable child
httpwwwuptodatecomcontentstrauma-management-approach-to-the-unstable-childsource=search_resultampsearch=pediatric+trauma+childrenampselectedTitle=17E150
bull Trauma management Unique pediatric considerations httpwwwuptodatecomcontentstrauma-management-unique-pediatric-considerationssource=search_resultampsearch=pediatric+trauma+childrenampselectedTitle=37E150
References 5 bull httpwwwetiquettehellcomsmfindexphptopic=8666360 bull httpwwwstlouischildrensorghealth-care-professionalsems-providers bull httpwwwuchicagokidshospitalorgspecialtiesemergency-medicinespecialhtml bull httpwwwsimsacademyinfoFXpatienthtm bull httptheemtspotcomwp-contentuploads200902another-burn-patient-by-annette-larsonjpg bull httplastangryfancomwp-contentuploads200910Clint-Malarchukjpg bull httpwwwtraumaorgarchiveresusmassivehtml bull httpwwwuptodatecomcontentsimageimageKey=PEDS68694amptopicKey=EM2F6389ampsourc
e=previewampsearch=pediatric+hemorrhagic+shockampselectedTitle=17E150amprank=undefined bull httptheemtspotcomwp-contentuploads200902gcsgif bull httpwwwuptodatecomcontentsimageimageKey=EM2F60409amptopicKey=EM2F6571amprank
=17E150ampsource=see_linkampsearch=traumaamputdPopup=true bull httpwwwuptodatecomcontentsimageimageKey=EM2F80874amptopicKey=EM2F6571amprank
=17E150ampsource=see_linkampsearch=traumaamputdPopup=true bull httpempracticenewswordpresscomcategorynexus-criteria bull httpswwwgooglecomsearchq=pediatric+glasgow+coma+scaleamptbm=ischamptbo=uampsource=uni
vampsa=Xampei=8TiOU7TNC5WuyATp5YG4BQampsqi=2ampved=0CDYQsAQampbiw=1426ampbih=883q=canadian+c-spine+rulesamptbm=ischampfacrc=_ampimgdii=_ampimgrc=WI94QMHgMLTQmM253A3BP5nbsFhNCXK0FM3Bhttp253A252F252Fwwwbmjcom252Fhighwire252Ffilestream252F436003252Ffield_highwire_fragment_image_l252F0jpg3Bhttp253A252F252Fwwwbmjcom252Fcontent252F339252Fbmjb41463B12803B1253
References 5 bull httpwwwuptodatecomcontentsimageimageKey=EM2F76777amptopicKey=EM2F6571amprank
=17E150ampsource=see_linkampsearch=traumaamputdPopup=true bull httpwwwdocumentingrealitycomforumattachmentsf14964898d1246625322-firework-injury-
m80injury1jpg bull httpwwwpediatriceducationorg20050620 bull httpwwwarmstrongmedicalcomindexcfmgoproductdetailsec3ssec19cat61fam515 bull httpwwwuptodatecomcontentsimageimageKey=PEDS61087amptopicKey=ID2F7661ampsource
=outline_linkampsearch=tetanus+prophylaxisamputdPopup=true bull httpwwwafsecafmilsharedmediaphotodbweb110609-F-MJ378-009jpg bull httpwwwuptodatecomcontentsimageimageKey=EM75765amptopicKey= bull EM2F6389ampsource=outline_linkampsearch=massive+transfusion+protocolamputdPopup=true bull httpwwwmotifakecomimagedemotivational-postersmall0910whats-the-question-ignorance-
calvin-and-hobbes-demotivational-poster-1255020127jpg
XXXXBoston study ems peds trauma procedures- limited pediatric procedural exposure (but more adult experience) bull Catchment area 590000
over 1 year bull 555 pediatric ALS
transport ndash 19 blunt trauma ndash 10 penetrating trauma
bull IV 33 bull BMV 5 bull Intubation 3 bull 50 ALS providers average
year ndash IV- 37 ndash Intubation- 03 ndash IO- 006
bull 7 ped ems ndash 13 trauma
bull Critical procedures ndash 101000 peds cases ndash Intubation 671000 ndash IO 51000 ndash 81 successful
Pediatr Emerg Care 2001 Feb17(1)5-9 Pediatric pre-hospital advanced life support care in an urban setting
Babl FE1 Vinci RJ Bauchner H Mottley L
Pediatr Crit Care Med 2015 Oct16(8)e260-7 doi 101097PCC0000000000000505 Pediatric Out-of-Hospital Critical Procedures in the United States
Carlson JN1 Gannon E Mann NC Jacobson KE Dai M Colleran C Wang HE
C-spine bull C-spine injuries rare bull Take pt to closest hospital if over injuries
call for it (ie resuscitation altered mental status) primary guide
bull Mechanism ndash Altered mental status focal neuro change
torticollis substantial torso injury diving high speed auto neck pain underlying predisposing condition Acad Emerg Med 2014 Jan21(1)55-64 doi 101111acem12288
Comparison of outcomes for children with cervical spine injury based on destination hospital from scene of injury Anders JF1 Adelgais K Hoyle JD Jr Olsen C Jaffe DM Leonard JC Pediatric Emergency Care Applied Research Network
(PECARN)
Ann Emerg Med 2011 Aug58(2)145-55 doi 101016jannemergmed201008038 Epub 2010 Oct 29 Factors associated with cervical spine injury in children after blunt trauma
Leonard JC Kuppermann N Olsen C Babcock-Cimpello L Brown K Mahajan P Adelgais KM Anders J Borgialli D Donoghue A Hoyle JD Jr Kim E Leonard JR Lillis KA Nigrovic LE Powell EC Rebella
G Reeves SD Rogers AJ Stankovic C Teshome G Jaffe DM Pediatric Emergency Care Applied Research Network
- Itrsquos Hard to Put a Band-Aid on a Broken Spleen Pediatric Trauma
- Disclosures
- Objectives
- Pediatric Prehospital Care
- Mechanism
- Traumatic Pain Management
- Pediatric Trauma
- Deaths by Mechanism of Injury
- Pediatric Trauma
- Pediatric Trauma
- Airway Differences
- Pediatric-Adult Differences
- Pediatric Challenges
- Prehospital Pediatric Challenges
- Pediatric and Adult Trauma
- Scene Response
- Prehospital Intervention
- Where do you take the patient
- Patient arrives at the EDhellip
- Primary Survey
- Order is critical
- Slide Number 22
- Slide Number 23
- Airway
- Indications for Intubation
- Breathing
- ETT Intubation Basics
- Circulation
- Slide Number 29
- CirculationHemodynamic Changes
- Circulation
- Fluid Resuscitation Algorithm
- Reconsidering Crystalloid Resuscitation
- When to start MTP
- Disability
- Finishing Up the Evaluation
- Bad Scene Responses
- OHCA from Trauma
- Blunt Trauma- No Signs of Life
- OHCA with CPR on Arrival
- Pediatric Trauma
- Questions
- References 1
- References 2
- References 3
- References 4
- References 5
- References 5
- XXXXBoston study ems peds trauma procedures- limited pediatric procedural exposure (but more adult experience)
- C-spine
Where do you take the patient
bull Pediatric trauma centers ndash Less surgery on solid organ injuries ndash Less radiation- of scans and dosage ndash Less comorbidities
bull Lower costs bull Shorter length of stay bull Lower infections bull Less multi-organ failure
Patient arrives at the EDhellip
bull Where do you start ndash Primary Survey
Primary Survey bull Your ABCrsquoshellip
bull Airway bull Breathing bull Circulation bull Disability (Neuro- GCS) bull Exposure
Order is critical
bull A before B or C bull Morbiditymortality will
occur much faster from airway compromise than from breathing or circulatory problems
bull Systematic approach is the cornerstone of ATLS success
httpwwwuptodatecomcontentsimageimageKey=EM2F64241amptopicKey=EM2F6571amprank=17E150ampsource=see_linkampsearch=traumaamputdPopup=true
httpwwwuptodatecomcontentsimageimageKey=EM2F64241amptopicKey=EM2F6571amprank=17E150ampsource=see_linkampsearch=traumaamputdPopup=true
Airway bull What are you assessing
ndash Airway patency bull What makes the airway not patent
ndash Foreign bodies ndash Vomitbloodsecretions ndash Edemahematoma ndash Impending obstruction
bull Interventions ndash Clearing foreign bodies ndash Suction secretionsvomit with yankauer ndash Repositioning- jaw thrust ndash Nasal trumpetoral airway ndash Intubation ndash Cricothyrotomy jet ventilation
Indications for Intubation
bull Respiratory arrest bull Impending respiratory failure bull Impending airway obstruction bull Inability to protect the airway bull GCS lt8 bull Declining GCS
Breathing bull What are you assessing
ndash ldquoGoodrdquo symmetric chest rise ndash Lung sounds ndash Aeration ndash Basic RR assessment (fast or minimalnone)
bull Interventions ndash Oxygen ndash Albuterolatrovent racemic epi ndash Positive pressure (CPAP BIPAP BMV) ndash Needle decompression ndash Chest tube thoracostomy ndash Intubation ndash Jet ventilation
ETT Intubation Basics bull Size
ndash Age4 + 4 or (Age +16)4 bull Depth
ndash ~ 3 x ETT size when over 1 year of age bull Blade size mac vs miller
ndash 0~ newborn ndash 1~ up to 2 years of life ndash 2~ 2-10 years ndash 3~ 10+ years
bull RSI medications ndash +-Sedation (Always before paralytic) ndash +-Paralytic (May not need it and never wo sedation)
Circulation
bull What do you assess ndash Central and peripheral pulses ndash Heart rate ndash Blood pressure systolic (age x2) +70 ndash Capillary refill ndash Cardiac activity on FAST ndash End organ perfusion
bull Mental status bull Urine output
Circulation Hemodynamic Changes
Percent Blood Volume Loss 0 15 25 35 45
Heart Rate
Blood Pressure
Cardiac Output
Circulation
ndash Access 2 large bore IVrsquos ndash IVFrsquos ndash pRBCrsquos
bull Hgb lt7gdl or ongoing blood losses
ndash Massive Transfusion Protocol
bull (111 ratio of PRBCS FFP Platelets)
ndash Vasopressors (epi norepi dopamine)
ndash Control of Hemorrhage bull Pelvic binders bull Direct pressure bull Indirectproximal pressure bull Tourniquet (only when
absolutely necessary)
ndash Chest Compressions ndash Pericardiocentesis ndash Delayed resuscitation
controlled hypotension (MAP 50 vs 65)
ndash Tranexamic acid in the near future
bull Interventions
Fluid Resuscitation Algorithm 20 mLkg isotonic crystalloid
Reassess
20 mLkg isotonic crystalloid
Reassess
20 mLkg isotonic crystalloid (31 rule)
or consider 10 to 20 mLkg packed red cells
Reconsidering Crystalloid Resuscitation
bull Less fluid ndash Permissive hypotension to
prevent clot rupture (select cases)
bull Too much fluid ndash Excessive Third Spacing ndash Secondary Compartment
Syndrome ndash Greater risk of ARDS ndash Dilutional Coagulopathy
When to start MTP
bull As soon as you believe you will need it ndash Institution specific guidelines
bull gt4 units or 40mlkg of PRBCrsquos expected bull Earlier use of Massive Transfusion Protocol
(pRBC FFP PLT) in ldquoDamage Controlrdquo resuscitations may improve outcome
bull 111 unit ratio bull Risk of TRALI ARDS etc
Disability bull GCS
ndash Range 3-15 ndash We should be 15 ndash Dead are still 3 ndash Less than 8 intubate ndash Eyes- 4 eyes ndash Verbal- most difficult ndash Motor- V6 engine ndash Intubated T
bull AVPU
Finishing Up the Evaluation
bull Airway bull Breathing bull Circulation bull Disability bull Exposure
ndash Expose and examine all parts ndash Cover quickly and keep warm
bull Secondary Survey
Bad Scene Responses
bull What are the outcomes of out-of-hospital cardiac arrest from blunt trauma
bull What are the outcomes of pediatric drowning patients
OHCA from Trauma
bull 2000-2003 bull 123 pts bull Mean age 73 yrs bull Most common
rhythms ndash Asystole 59 ndash PEA 29 ndash V-fib 35
bull 195 rosc in field ndash 98 survived for 24
hrs ndash 57 survived to
discharge ndash Drowning- 19
survival to discharge ndash Bystander CPR tripled
the survivor rate
Blunt Trauma- No Signs of Life
bull Review from 2002-2010 bull No signs of life- 025 of blunt trauma
ndash 25 resuscitated prior to hospital arrival bull 138 of these patients survived to discharge
bull 44 overall survived to hospital discharge
OHCA with CPR on Arrival
bull 169 children bull 141 deaths bull 69 required cpr on arrival- none survived bull 87 of patients requiring CPR on arrival
expired in the ED bull Of the 28 survivors
ndash 55 of survivors had full neurologic recovery
Pediatric Trauma
bull Fortunately these cases represent only a small fraction of EMS transports
bull Despite a few key differences pediatric trauma care overall is very similar to adult trauma care
Questions
References 1 bull NTDB 2013 pediatric Report bull Monkey bars httpsplaygroundchroniclesfileswordpresscom201307soccerjpg bull Screaming child httpblogsbabycentercomwp-contentuploads201409screaming-child-tantrum-fitjpg bull Pediatric airway image httpwwwcelebritydiagnosiscomwp-contentuploads201003pediatric-airwayjpg bull Child on backboard httpsencrypted-tbn2gstaticcomimagesq=tbnANd9GcQscrDVc8IH4MwkNGF6F1A9p7mSVzik5zrWyNvI-
qSwQT5S3GNyVg bull Elbow fracture httpwwwimageinterpretationcoukimageselbowSUPRACONDYLAR20LAT3jpg bull Bike riding httpsmile-per-daycomwp-contentuploads201412klr03jpg bull Dad and child pic httplaughingsquidcomwp-contentuploads471160jpg bull Weigth estimation inner city Am J Emerg Med 2015 Oct33(10)1364-7 doi 101016jajem201507040 Epub 2015 Jul 29 Weight
estimation in an inner-city pediatric ED the effect of obesity Chavez H1 Peterson RE2 Lo K3 Arel M4
bull Guess weight sign httpmedialiveauctiongroupneti963110572971_1jpgv=8CDDAAF8A5B9E20 bull Broselow tape httpsuploadwikimediaorgwikipediacommons994BTape1jpg bull Parent screaming httpmommyofamonstercomwp-contentuploads201301yellingjpg bull Prehospital pain management Am J Emerg Med 2015 Mar33(3)451-4 doi 101016jajem201412012 Epub 2014 Dec 18
Prehospital pain management of injured children a systematic review of current evidence Samuel N1 Steiner IP2 Shavit I3 bull Prehospital pain ped pain assessment Prehosp Emerg Care 2008 Apr-Jun12(2)182-6 doi 10108010903120801907471 Prehospital
pain assessment in pediatric trauma Izsak E1 Moore JL Stringfellow K Oswanski MF Lindstrom DA Stombaugh HA bull Ped pain management Prehosp Emerg Care 2005 Jan-Mar9(1)40-3 Prehospital pain management in children suffering traumatic
injury Swor R1 McEachin CM Seguin D Grall KH bull Prehospital intervention Allen CJ Teisch LF et al Prehospital care and transportation of pediatric trauma patients J Surg Res 2015
Aug197(2)240-6 JAMA 2000 Feb 9283(6)783-90 bull Effect of out-of-hospital pediatric endotracheal intubation on survival and neurological outcome a controlled clinical trial
Gausche M1 Lewis RJ Stratton SJ Haynes BE Gunter CS Goodrich SM Poore PD McCollough MD Henderson DP Pratt FD Seidel JS
bull Pediatric pain management survey Pediatr Emerg Care 2015 Sep 23 [Epub ahead of print] An Assessment of Newly Identified Barriers to and Enablers for Prehospital Pediatric Pain Management Whitley DE1 Li T Jones CM Cushman JT Williams DM Shah MN
References 2 bull httpwwwuptodatecomcontentsprehospital-pediatrics-and-emergency-medical-services-emsabstract6 bull httpwwwuptodatecomcontentsprehospital-pediatrics-and-emergency-medical-services-emsabstract7 bull Pediatr Crit Care Med 2011 Jul12(4)e166-70 doi 101097PCC0b013e3181f36f6e First responder
performance in pediatric trauma a comparison with an adult cohortBankole S1 Asuncion A Ross S Aghai Z Nollah L Echols H Da-Silva S
bull Drayna pc Browne LR et al Prehospital pediatric care Oppportunities for training treatment and research Prehosp Emerg Care 2015 Jul-Sep 19(3) Epub 2015 Feb 6
bull Pediatr Emerg Care 2001 Feb17(1) 5-9Pediatric pre-hospital advanced life support care in an urban setting Babl FE1 Vinci RJ Bauchner H Mottley L
bull Pediatr Crit Care Med 2015 Oct16(8)e260-7 doi 101097PCC0000000000000505Pediatric Out-of-Hospital Critical Procedures in the United States Carlson JN1 Gannon E Mann NC Jacobson KE Dai M Colleran C Wang HE
bull Pediatr Emerg Care 2009 Aug25(8)508-12 doi 101097PEC0b013e3181b0a0da The efficacy of pediatric advanced life support training in emergency medical service providers Baker TW1 King W Soto W Asher C Stolfi A Rowin ME
bull Sutton RM Case E et al ROC investigators A quantitative analysis of out-of-hospital pediatric and adolescent resuscitation quality A report from the ROC Epistry- Cardiac Arrest Resusciation 201593150-157
bull Resuscitation 2014 Aug85(8)1059-64 doi 101016jresuscitation201403307 Epub 2014 Apr 4 Neurocognitive long term follow-up study on drowned children Suominen PK1 Sutinen N2 Valle S3 Olkkola KT4 Loumlnnqvist T3
bull J Pediatr Surg 2010 Jul45(7)1413-9 doi 101016jjpedsurg200912020 Prehospital cardiopulmonary resuscitation in the pediatric trauma patient Murphy JT1 Jaiswal K Sabella J Vinson L Megison S Maxson RT
References 3 bull Pre atv accident
httpwwwctvnewscapolopoly_fs119871591409741949httpImageimagejpg_genderivativeslandscape_960imagejpg bull atv pic httpswwwutahadvocatescomwp-contentuploads201402atvAccidentLawyerjpg bull Blunt abdominal solid organ injury adult vs pediatric trauma center J Pediatr Surg 2015 Aug 28 pii S0022-3468(15)00526-6 doi
101016jjpedsurg201508012 [Epub ahead of print] Trauma center variation in the management of pediatric patients with blunt abdominal solid organ injury a national trauma data bank analysis Safavi A1 Skarsgard ED2 Rhee P1 Zangbar B1 Kulvatunyou N1 Tang A1 OKeeffe T1 Friese RS1 Joseph B3
bull Pediatric blunt abdominal injury Curr Opin Crit Care 2015 Sep 28 [Epub ahead of print] Pediatric blunt abdominal trauma current management Notrica DM1
bull Pediatric splenic injury management Am J Surg 2015 Jul 31 pii S0002-9610(15)00417-1 doi 101016jamjsurg201506009 [Epub ahead of print] Comparative effectiveness of treatment strategies for severe splenic trauma in the pediatric population Rialon KL1 Englum BR1 Gulack BC1 Guevara CJ2 Bhattacharya SD3 Shapiro ML4 Rice HE5 Scarborough JE4 Adibe OO6
bull Liver pic httpss-media-cache-ak0pinimgcom736x7da50e7da50eb2bb603c99ef6649ff897e26b5jpg bull Solid organ injury non op in peds J Trauma Acute Care Surg 2015 Oct79(4)683-93 doi 101097TA0000000000000808
Nonoperative management of blunt liver and spleen injury in children Evaluation of the ATOMAC guideline using GRADE Notrica DM1 Eubanks JW 3rd Tuggle DW Maxson RT Letton RW Garcia NM Alder AC Lawson KA St Peter SD Megison S Garcia Filion P
bull Pediaric vs nonped trauma ct use J Pediatr 2015 Oct167(4)897-904e3 doi 101016jjpeds201506052 Epub 2015 Jul 29 Variation in Computed Tomography Imaging for Pediatric Injury-Related Emergency Visits Marin JR1 Wang L2 Winger DG2 Mannix RC3
bull Solid organ management in ped population J Trauma Acute Care Surg 2015 Aug79(2)206-14quiz 332 doi 101097TA0000000000000731 Management of children with solid organ injuries after blunt torso trauma Wisner DH1 Kuppermann N Cooper A Menaker J Ehrlich P Kooistra J Mahajan P Lee L Cook LJ Yen K Lillis K Holmes JF
bull Triad of death image httpimageslidesharecdncomdamage-control-resuscitation-1304253390-phpapp0195damage-control-resuscitation-14-728jpgcb=1304235553
bull Tranexamic acid study Eckert MJ Wertin TM Tyner SD et al 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 77852
bull Image care accident httpsuploadwikimediaorgwikipediacommonsthumbee1Car_crash_1jpg1280px-Car_crash_1jpg
References 4 bull httpwwwsurgeryvcuedudivisionsacutesurghtml bull Trauma management Approach to the unstable child
httpwwwuptodatecomcontentstrauma-management-approach-to-the-unstable-childsource=search_resultampsearch=pediatric+trauma+childrenampselectedTitle=17E150
bull Trauma management Unique pediatric considerations httpwwwuptodatecomcontentstrauma-management-unique-pediatric-considerationssource=search_resultampsearch=pediatric+trauma+childrenampselectedTitle=37E150
References 5 bull httpwwwetiquettehellcomsmfindexphptopic=8666360 bull httpwwwstlouischildrensorghealth-care-professionalsems-providers bull httpwwwuchicagokidshospitalorgspecialtiesemergency-medicinespecialhtml bull httpwwwsimsacademyinfoFXpatienthtm bull httptheemtspotcomwp-contentuploads200902another-burn-patient-by-annette-larsonjpg bull httplastangryfancomwp-contentuploads200910Clint-Malarchukjpg bull httpwwwtraumaorgarchiveresusmassivehtml bull httpwwwuptodatecomcontentsimageimageKey=PEDS68694amptopicKey=EM2F6389ampsourc
e=previewampsearch=pediatric+hemorrhagic+shockampselectedTitle=17E150amprank=undefined bull httptheemtspotcomwp-contentuploads200902gcsgif bull httpwwwuptodatecomcontentsimageimageKey=EM2F60409amptopicKey=EM2F6571amprank
=17E150ampsource=see_linkampsearch=traumaamputdPopup=true bull httpwwwuptodatecomcontentsimageimageKey=EM2F80874amptopicKey=EM2F6571amprank
=17E150ampsource=see_linkampsearch=traumaamputdPopup=true bull httpempracticenewswordpresscomcategorynexus-criteria bull httpswwwgooglecomsearchq=pediatric+glasgow+coma+scaleamptbm=ischamptbo=uampsource=uni
vampsa=Xampei=8TiOU7TNC5WuyATp5YG4BQampsqi=2ampved=0CDYQsAQampbiw=1426ampbih=883q=canadian+c-spine+rulesamptbm=ischampfacrc=_ampimgdii=_ampimgrc=WI94QMHgMLTQmM253A3BP5nbsFhNCXK0FM3Bhttp253A252F252Fwwwbmjcom252Fhighwire252Ffilestream252F436003252Ffield_highwire_fragment_image_l252F0jpg3Bhttp253A252F252Fwwwbmjcom252Fcontent252F339252Fbmjb41463B12803B1253
References 5 bull httpwwwuptodatecomcontentsimageimageKey=EM2F76777amptopicKey=EM2F6571amprank
=17E150ampsource=see_linkampsearch=traumaamputdPopup=true bull httpwwwdocumentingrealitycomforumattachmentsf14964898d1246625322-firework-injury-
m80injury1jpg bull httpwwwpediatriceducationorg20050620 bull httpwwwarmstrongmedicalcomindexcfmgoproductdetailsec3ssec19cat61fam515 bull httpwwwuptodatecomcontentsimageimageKey=PEDS61087amptopicKey=ID2F7661ampsource
=outline_linkampsearch=tetanus+prophylaxisamputdPopup=true bull httpwwwafsecafmilsharedmediaphotodbweb110609-F-MJ378-009jpg bull httpwwwuptodatecomcontentsimageimageKey=EM75765amptopicKey= bull EM2F6389ampsource=outline_linkampsearch=massive+transfusion+protocolamputdPopup=true bull httpwwwmotifakecomimagedemotivational-postersmall0910whats-the-question-ignorance-
calvin-and-hobbes-demotivational-poster-1255020127jpg
XXXXBoston study ems peds trauma procedures- limited pediatric procedural exposure (but more adult experience) bull Catchment area 590000
over 1 year bull 555 pediatric ALS
transport ndash 19 blunt trauma ndash 10 penetrating trauma
bull IV 33 bull BMV 5 bull Intubation 3 bull 50 ALS providers average
year ndash IV- 37 ndash Intubation- 03 ndash IO- 006
bull 7 ped ems ndash 13 trauma
bull Critical procedures ndash 101000 peds cases ndash Intubation 671000 ndash IO 51000 ndash 81 successful
Pediatr Emerg Care 2001 Feb17(1)5-9 Pediatric pre-hospital advanced life support care in an urban setting
Babl FE1 Vinci RJ Bauchner H Mottley L
Pediatr Crit Care Med 2015 Oct16(8)e260-7 doi 101097PCC0000000000000505 Pediatric Out-of-Hospital Critical Procedures in the United States
Carlson JN1 Gannon E Mann NC Jacobson KE Dai M Colleran C Wang HE
C-spine bull C-spine injuries rare bull Take pt to closest hospital if over injuries
call for it (ie resuscitation altered mental status) primary guide
bull Mechanism ndash Altered mental status focal neuro change
torticollis substantial torso injury diving high speed auto neck pain underlying predisposing condition Acad Emerg Med 2014 Jan21(1)55-64 doi 101111acem12288
Comparison of outcomes for children with cervical spine injury based on destination hospital from scene of injury Anders JF1 Adelgais K Hoyle JD Jr Olsen C Jaffe DM Leonard JC Pediatric Emergency Care Applied Research Network
(PECARN)
Ann Emerg Med 2011 Aug58(2)145-55 doi 101016jannemergmed201008038 Epub 2010 Oct 29 Factors associated with cervical spine injury in children after blunt trauma
Leonard JC Kuppermann N Olsen C Babcock-Cimpello L Brown K Mahajan P Adelgais KM Anders J Borgialli D Donoghue A Hoyle JD Jr Kim E Leonard JR Lillis KA Nigrovic LE Powell EC Rebella
G Reeves SD Rogers AJ Stankovic C Teshome G Jaffe DM Pediatric Emergency Care Applied Research Network
- Itrsquos Hard to Put a Band-Aid on a Broken Spleen Pediatric Trauma
- Disclosures
- Objectives
- Pediatric Prehospital Care
- Mechanism
- Traumatic Pain Management
- Pediatric Trauma
- Deaths by Mechanism of Injury
- Pediatric Trauma
- Pediatric Trauma
- Airway Differences
- Pediatric-Adult Differences
- Pediatric Challenges
- Prehospital Pediatric Challenges
- Pediatric and Adult Trauma
- Scene Response
- Prehospital Intervention
- Where do you take the patient
- Patient arrives at the EDhellip
- Primary Survey
- Order is critical
- Slide Number 22
- Slide Number 23
- Airway
- Indications for Intubation
- Breathing
- ETT Intubation Basics
- Circulation
- Slide Number 29
- CirculationHemodynamic Changes
- Circulation
- Fluid Resuscitation Algorithm
- Reconsidering Crystalloid Resuscitation
- When to start MTP
- Disability
- Finishing Up the Evaluation
- Bad Scene Responses
- OHCA from Trauma
- Blunt Trauma- No Signs of Life
- OHCA with CPR on Arrival
- Pediatric Trauma
- Questions
- References 1
- References 2
- References 3
- References 4
- References 5
- References 5
- XXXXBoston study ems peds trauma procedures- limited pediatric procedural exposure (but more adult experience)
- C-spine
Patient arrives at the EDhellip
bull Where do you start ndash Primary Survey
Primary Survey bull Your ABCrsquoshellip
bull Airway bull Breathing bull Circulation bull Disability (Neuro- GCS) bull Exposure
Order is critical
bull A before B or C bull Morbiditymortality will
occur much faster from airway compromise than from breathing or circulatory problems
bull Systematic approach is the cornerstone of ATLS success
httpwwwuptodatecomcontentsimageimageKey=EM2F64241amptopicKey=EM2F6571amprank=17E150ampsource=see_linkampsearch=traumaamputdPopup=true
httpwwwuptodatecomcontentsimageimageKey=EM2F64241amptopicKey=EM2F6571amprank=17E150ampsource=see_linkampsearch=traumaamputdPopup=true
Airway bull What are you assessing
ndash Airway patency bull What makes the airway not patent
ndash Foreign bodies ndash Vomitbloodsecretions ndash Edemahematoma ndash Impending obstruction
bull Interventions ndash Clearing foreign bodies ndash Suction secretionsvomit with yankauer ndash Repositioning- jaw thrust ndash Nasal trumpetoral airway ndash Intubation ndash Cricothyrotomy jet ventilation
Indications for Intubation
bull Respiratory arrest bull Impending respiratory failure bull Impending airway obstruction bull Inability to protect the airway bull GCS lt8 bull Declining GCS
Breathing bull What are you assessing
ndash ldquoGoodrdquo symmetric chest rise ndash Lung sounds ndash Aeration ndash Basic RR assessment (fast or minimalnone)
bull Interventions ndash Oxygen ndash Albuterolatrovent racemic epi ndash Positive pressure (CPAP BIPAP BMV) ndash Needle decompression ndash Chest tube thoracostomy ndash Intubation ndash Jet ventilation
ETT Intubation Basics bull Size
ndash Age4 + 4 or (Age +16)4 bull Depth
ndash ~ 3 x ETT size when over 1 year of age bull Blade size mac vs miller
ndash 0~ newborn ndash 1~ up to 2 years of life ndash 2~ 2-10 years ndash 3~ 10+ years
bull RSI medications ndash +-Sedation (Always before paralytic) ndash +-Paralytic (May not need it and never wo sedation)
Circulation
bull What do you assess ndash Central and peripheral pulses ndash Heart rate ndash Blood pressure systolic (age x2) +70 ndash Capillary refill ndash Cardiac activity on FAST ndash End organ perfusion
bull Mental status bull Urine output
Circulation Hemodynamic Changes
Percent Blood Volume Loss 0 15 25 35 45
Heart Rate
Blood Pressure
Cardiac Output
Circulation
ndash Access 2 large bore IVrsquos ndash IVFrsquos ndash pRBCrsquos
bull Hgb lt7gdl or ongoing blood losses
ndash Massive Transfusion Protocol
bull (111 ratio of PRBCS FFP Platelets)
ndash Vasopressors (epi norepi dopamine)
ndash Control of Hemorrhage bull Pelvic binders bull Direct pressure bull Indirectproximal pressure bull Tourniquet (only when
absolutely necessary)
ndash Chest Compressions ndash Pericardiocentesis ndash Delayed resuscitation
controlled hypotension (MAP 50 vs 65)
ndash Tranexamic acid in the near future
bull Interventions
Fluid Resuscitation Algorithm 20 mLkg isotonic crystalloid
Reassess
20 mLkg isotonic crystalloid
Reassess
20 mLkg isotonic crystalloid (31 rule)
or consider 10 to 20 mLkg packed red cells
Reconsidering Crystalloid Resuscitation
bull Less fluid ndash Permissive hypotension to
prevent clot rupture (select cases)
bull Too much fluid ndash Excessive Third Spacing ndash Secondary Compartment
Syndrome ndash Greater risk of ARDS ndash Dilutional Coagulopathy
When to start MTP
bull As soon as you believe you will need it ndash Institution specific guidelines
bull gt4 units or 40mlkg of PRBCrsquos expected bull Earlier use of Massive Transfusion Protocol
(pRBC FFP PLT) in ldquoDamage Controlrdquo resuscitations may improve outcome
bull 111 unit ratio bull Risk of TRALI ARDS etc
Disability bull GCS
ndash Range 3-15 ndash We should be 15 ndash Dead are still 3 ndash Less than 8 intubate ndash Eyes- 4 eyes ndash Verbal- most difficult ndash Motor- V6 engine ndash Intubated T
bull AVPU
Finishing Up the Evaluation
bull Airway bull Breathing bull Circulation bull Disability bull Exposure
ndash Expose and examine all parts ndash Cover quickly and keep warm
bull Secondary Survey
Bad Scene Responses
bull What are the outcomes of out-of-hospital cardiac arrest from blunt trauma
bull What are the outcomes of pediatric drowning patients
OHCA from Trauma
bull 2000-2003 bull 123 pts bull Mean age 73 yrs bull Most common
rhythms ndash Asystole 59 ndash PEA 29 ndash V-fib 35
bull 195 rosc in field ndash 98 survived for 24
hrs ndash 57 survived to
discharge ndash Drowning- 19
survival to discharge ndash Bystander CPR tripled
the survivor rate
Blunt Trauma- No Signs of Life
bull Review from 2002-2010 bull No signs of life- 025 of blunt trauma
ndash 25 resuscitated prior to hospital arrival bull 138 of these patients survived to discharge
bull 44 overall survived to hospital discharge
OHCA with CPR on Arrival
bull 169 children bull 141 deaths bull 69 required cpr on arrival- none survived bull 87 of patients requiring CPR on arrival
expired in the ED bull Of the 28 survivors
ndash 55 of survivors had full neurologic recovery
Pediatric Trauma
bull Fortunately these cases represent only a small fraction of EMS transports
bull Despite a few key differences pediatric trauma care overall is very similar to adult trauma care
Questions
References 1 bull NTDB 2013 pediatric Report bull Monkey bars httpsplaygroundchroniclesfileswordpresscom201307soccerjpg bull Screaming child httpblogsbabycentercomwp-contentuploads201409screaming-child-tantrum-fitjpg bull Pediatric airway image httpwwwcelebritydiagnosiscomwp-contentuploads201003pediatric-airwayjpg bull Child on backboard httpsencrypted-tbn2gstaticcomimagesq=tbnANd9GcQscrDVc8IH4MwkNGF6F1A9p7mSVzik5zrWyNvI-
qSwQT5S3GNyVg bull Elbow fracture httpwwwimageinterpretationcoukimageselbowSUPRACONDYLAR20LAT3jpg bull Bike riding httpsmile-per-daycomwp-contentuploads201412klr03jpg bull Dad and child pic httplaughingsquidcomwp-contentuploads471160jpg bull Weigth estimation inner city Am J Emerg Med 2015 Oct33(10)1364-7 doi 101016jajem201507040 Epub 2015 Jul 29 Weight
estimation in an inner-city pediatric ED the effect of obesity Chavez H1 Peterson RE2 Lo K3 Arel M4
bull Guess weight sign httpmedialiveauctiongroupneti963110572971_1jpgv=8CDDAAF8A5B9E20 bull Broselow tape httpsuploadwikimediaorgwikipediacommons994BTape1jpg bull Parent screaming httpmommyofamonstercomwp-contentuploads201301yellingjpg bull Prehospital pain management Am J Emerg Med 2015 Mar33(3)451-4 doi 101016jajem201412012 Epub 2014 Dec 18
Prehospital pain management of injured children a systematic review of current evidence Samuel N1 Steiner IP2 Shavit I3 bull Prehospital pain ped pain assessment Prehosp Emerg Care 2008 Apr-Jun12(2)182-6 doi 10108010903120801907471 Prehospital
pain assessment in pediatric trauma Izsak E1 Moore JL Stringfellow K Oswanski MF Lindstrom DA Stombaugh HA bull Ped pain management Prehosp Emerg Care 2005 Jan-Mar9(1)40-3 Prehospital pain management in children suffering traumatic
injury Swor R1 McEachin CM Seguin D Grall KH bull Prehospital intervention Allen CJ Teisch LF et al Prehospital care and transportation of pediatric trauma patients J Surg Res 2015
Aug197(2)240-6 JAMA 2000 Feb 9283(6)783-90 bull Effect of out-of-hospital pediatric endotracheal intubation on survival and neurological outcome a controlled clinical trial
Gausche M1 Lewis RJ Stratton SJ Haynes BE Gunter CS Goodrich SM Poore PD McCollough MD Henderson DP Pratt FD Seidel JS
bull Pediatric pain management survey Pediatr Emerg Care 2015 Sep 23 [Epub ahead of print] An Assessment of Newly Identified Barriers to and Enablers for Prehospital Pediatric Pain Management Whitley DE1 Li T Jones CM Cushman JT Williams DM Shah MN
References 2 bull httpwwwuptodatecomcontentsprehospital-pediatrics-and-emergency-medical-services-emsabstract6 bull httpwwwuptodatecomcontentsprehospital-pediatrics-and-emergency-medical-services-emsabstract7 bull Pediatr Crit Care Med 2011 Jul12(4)e166-70 doi 101097PCC0b013e3181f36f6e First responder
performance in pediatric trauma a comparison with an adult cohortBankole S1 Asuncion A Ross S Aghai Z Nollah L Echols H Da-Silva S
bull Drayna pc Browne LR et al Prehospital pediatric care Oppportunities for training treatment and research Prehosp Emerg Care 2015 Jul-Sep 19(3) Epub 2015 Feb 6
bull Pediatr Emerg Care 2001 Feb17(1) 5-9Pediatric pre-hospital advanced life support care in an urban setting Babl FE1 Vinci RJ Bauchner H Mottley L
bull Pediatr Crit Care Med 2015 Oct16(8)e260-7 doi 101097PCC0000000000000505Pediatric Out-of-Hospital Critical Procedures in the United States Carlson JN1 Gannon E Mann NC Jacobson KE Dai M Colleran C Wang HE
bull Pediatr Emerg Care 2009 Aug25(8)508-12 doi 101097PEC0b013e3181b0a0da The efficacy of pediatric advanced life support training in emergency medical service providers Baker TW1 King W Soto W Asher C Stolfi A Rowin ME
bull Sutton RM Case E et al ROC investigators A quantitative analysis of out-of-hospital pediatric and adolescent resuscitation quality A report from the ROC Epistry- Cardiac Arrest Resusciation 201593150-157
bull Resuscitation 2014 Aug85(8)1059-64 doi 101016jresuscitation201403307 Epub 2014 Apr 4 Neurocognitive long term follow-up study on drowned children Suominen PK1 Sutinen N2 Valle S3 Olkkola KT4 Loumlnnqvist T3
bull J Pediatr Surg 2010 Jul45(7)1413-9 doi 101016jjpedsurg200912020 Prehospital cardiopulmonary resuscitation in the pediatric trauma patient Murphy JT1 Jaiswal K Sabella J Vinson L Megison S Maxson RT
References 3 bull Pre atv accident
httpwwwctvnewscapolopoly_fs119871591409741949httpImageimagejpg_genderivativeslandscape_960imagejpg bull atv pic httpswwwutahadvocatescomwp-contentuploads201402atvAccidentLawyerjpg bull Blunt abdominal solid organ injury adult vs pediatric trauma center J Pediatr Surg 2015 Aug 28 pii S0022-3468(15)00526-6 doi
101016jjpedsurg201508012 [Epub ahead of print] Trauma center variation in the management of pediatric patients with blunt abdominal solid organ injury a national trauma data bank analysis Safavi A1 Skarsgard ED2 Rhee P1 Zangbar B1 Kulvatunyou N1 Tang A1 OKeeffe T1 Friese RS1 Joseph B3
bull Pediatric blunt abdominal injury Curr Opin Crit Care 2015 Sep 28 [Epub ahead of print] Pediatric blunt abdominal trauma current management Notrica DM1
bull Pediatric splenic injury management Am J Surg 2015 Jul 31 pii S0002-9610(15)00417-1 doi 101016jamjsurg201506009 [Epub ahead of print] Comparative effectiveness of treatment strategies for severe splenic trauma in the pediatric population Rialon KL1 Englum BR1 Gulack BC1 Guevara CJ2 Bhattacharya SD3 Shapiro ML4 Rice HE5 Scarborough JE4 Adibe OO6
bull Liver pic httpss-media-cache-ak0pinimgcom736x7da50e7da50eb2bb603c99ef6649ff897e26b5jpg bull Solid organ injury non op in peds J Trauma Acute Care Surg 2015 Oct79(4)683-93 doi 101097TA0000000000000808
Nonoperative management of blunt liver and spleen injury in children Evaluation of the ATOMAC guideline using GRADE Notrica DM1 Eubanks JW 3rd Tuggle DW Maxson RT Letton RW Garcia NM Alder AC Lawson KA St Peter SD Megison S Garcia Filion P
bull Pediaric vs nonped trauma ct use J Pediatr 2015 Oct167(4)897-904e3 doi 101016jjpeds201506052 Epub 2015 Jul 29 Variation in Computed Tomography Imaging for Pediatric Injury-Related Emergency Visits Marin JR1 Wang L2 Winger DG2 Mannix RC3
bull Solid organ management in ped population J Trauma Acute Care Surg 2015 Aug79(2)206-14quiz 332 doi 101097TA0000000000000731 Management of children with solid organ injuries after blunt torso trauma Wisner DH1 Kuppermann N Cooper A Menaker J Ehrlich P Kooistra J Mahajan P Lee L Cook LJ Yen K Lillis K Holmes JF
bull Triad of death image httpimageslidesharecdncomdamage-control-resuscitation-1304253390-phpapp0195damage-control-resuscitation-14-728jpgcb=1304235553
bull Tranexamic acid study Eckert MJ Wertin TM Tyner SD et al 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 77852
bull Image care accident httpsuploadwikimediaorgwikipediacommonsthumbee1Car_crash_1jpg1280px-Car_crash_1jpg
References 4 bull httpwwwsurgeryvcuedudivisionsacutesurghtml bull Trauma management Approach to the unstable child
httpwwwuptodatecomcontentstrauma-management-approach-to-the-unstable-childsource=search_resultampsearch=pediatric+trauma+childrenampselectedTitle=17E150
bull Trauma management Unique pediatric considerations httpwwwuptodatecomcontentstrauma-management-unique-pediatric-considerationssource=search_resultampsearch=pediatric+trauma+childrenampselectedTitle=37E150
References 5 bull httpwwwetiquettehellcomsmfindexphptopic=8666360 bull httpwwwstlouischildrensorghealth-care-professionalsems-providers bull httpwwwuchicagokidshospitalorgspecialtiesemergency-medicinespecialhtml bull httpwwwsimsacademyinfoFXpatienthtm bull httptheemtspotcomwp-contentuploads200902another-burn-patient-by-annette-larsonjpg bull httplastangryfancomwp-contentuploads200910Clint-Malarchukjpg bull httpwwwtraumaorgarchiveresusmassivehtml bull httpwwwuptodatecomcontentsimageimageKey=PEDS68694amptopicKey=EM2F6389ampsourc
e=previewampsearch=pediatric+hemorrhagic+shockampselectedTitle=17E150amprank=undefined bull httptheemtspotcomwp-contentuploads200902gcsgif bull httpwwwuptodatecomcontentsimageimageKey=EM2F60409amptopicKey=EM2F6571amprank
=17E150ampsource=see_linkampsearch=traumaamputdPopup=true bull httpwwwuptodatecomcontentsimageimageKey=EM2F80874amptopicKey=EM2F6571amprank
=17E150ampsource=see_linkampsearch=traumaamputdPopup=true bull httpempracticenewswordpresscomcategorynexus-criteria bull httpswwwgooglecomsearchq=pediatric+glasgow+coma+scaleamptbm=ischamptbo=uampsource=uni
vampsa=Xampei=8TiOU7TNC5WuyATp5YG4BQampsqi=2ampved=0CDYQsAQampbiw=1426ampbih=883q=canadian+c-spine+rulesamptbm=ischampfacrc=_ampimgdii=_ampimgrc=WI94QMHgMLTQmM253A3BP5nbsFhNCXK0FM3Bhttp253A252F252Fwwwbmjcom252Fhighwire252Ffilestream252F436003252Ffield_highwire_fragment_image_l252F0jpg3Bhttp253A252F252Fwwwbmjcom252Fcontent252F339252Fbmjb41463B12803B1253
References 5 bull httpwwwuptodatecomcontentsimageimageKey=EM2F76777amptopicKey=EM2F6571amprank
=17E150ampsource=see_linkampsearch=traumaamputdPopup=true bull httpwwwdocumentingrealitycomforumattachmentsf14964898d1246625322-firework-injury-
m80injury1jpg bull httpwwwpediatriceducationorg20050620 bull httpwwwarmstrongmedicalcomindexcfmgoproductdetailsec3ssec19cat61fam515 bull httpwwwuptodatecomcontentsimageimageKey=PEDS61087amptopicKey=ID2F7661ampsource
=outline_linkampsearch=tetanus+prophylaxisamputdPopup=true bull httpwwwafsecafmilsharedmediaphotodbweb110609-F-MJ378-009jpg bull httpwwwuptodatecomcontentsimageimageKey=EM75765amptopicKey= bull EM2F6389ampsource=outline_linkampsearch=massive+transfusion+protocolamputdPopup=true bull httpwwwmotifakecomimagedemotivational-postersmall0910whats-the-question-ignorance-
calvin-and-hobbes-demotivational-poster-1255020127jpg
XXXXBoston study ems peds trauma procedures- limited pediatric procedural exposure (but more adult experience) bull Catchment area 590000
over 1 year bull 555 pediatric ALS
transport ndash 19 blunt trauma ndash 10 penetrating trauma
bull IV 33 bull BMV 5 bull Intubation 3 bull 50 ALS providers average
year ndash IV- 37 ndash Intubation- 03 ndash IO- 006
bull 7 ped ems ndash 13 trauma
bull Critical procedures ndash 101000 peds cases ndash Intubation 671000 ndash IO 51000 ndash 81 successful
Pediatr Emerg Care 2001 Feb17(1)5-9 Pediatric pre-hospital advanced life support care in an urban setting
Babl FE1 Vinci RJ Bauchner H Mottley L
Pediatr Crit Care Med 2015 Oct16(8)e260-7 doi 101097PCC0000000000000505 Pediatric Out-of-Hospital Critical Procedures in the United States
Carlson JN1 Gannon E Mann NC Jacobson KE Dai M Colleran C Wang HE
C-spine bull C-spine injuries rare bull Take pt to closest hospital if over injuries
call for it (ie resuscitation altered mental status) primary guide
bull Mechanism ndash Altered mental status focal neuro change
torticollis substantial torso injury diving high speed auto neck pain underlying predisposing condition Acad Emerg Med 2014 Jan21(1)55-64 doi 101111acem12288
Comparison of outcomes for children with cervical spine injury based on destination hospital from scene of injury Anders JF1 Adelgais K Hoyle JD Jr Olsen C Jaffe DM Leonard JC Pediatric Emergency Care Applied Research Network
(PECARN)
Ann Emerg Med 2011 Aug58(2)145-55 doi 101016jannemergmed201008038 Epub 2010 Oct 29 Factors associated with cervical spine injury in children after blunt trauma
Leonard JC Kuppermann N Olsen C Babcock-Cimpello L Brown K Mahajan P Adelgais KM Anders J Borgialli D Donoghue A Hoyle JD Jr Kim E Leonard JR Lillis KA Nigrovic LE Powell EC Rebella
G Reeves SD Rogers AJ Stankovic C Teshome G Jaffe DM Pediatric Emergency Care Applied Research Network
- Itrsquos Hard to Put a Band-Aid on a Broken Spleen Pediatric Trauma
- Disclosures
- Objectives
- Pediatric Prehospital Care
- Mechanism
- Traumatic Pain Management
- Pediatric Trauma
- Deaths by Mechanism of Injury
- Pediatric Trauma
- Pediatric Trauma
- Airway Differences
- Pediatric-Adult Differences
- Pediatric Challenges
- Prehospital Pediatric Challenges
- Pediatric and Adult Trauma
- Scene Response
- Prehospital Intervention
- Where do you take the patient
- Patient arrives at the EDhellip
- Primary Survey
- Order is critical
- Slide Number 22
- Slide Number 23
- Airway
- Indications for Intubation
- Breathing
- ETT Intubation Basics
- Circulation
- Slide Number 29
- CirculationHemodynamic Changes
- Circulation
- Fluid Resuscitation Algorithm
- Reconsidering Crystalloid Resuscitation
- When to start MTP
- Disability
- Finishing Up the Evaluation
- Bad Scene Responses
- OHCA from Trauma
- Blunt Trauma- No Signs of Life
- OHCA with CPR on Arrival
- Pediatric Trauma
- Questions
- References 1
- References 2
- References 3
- References 4
- References 5
- References 5
- XXXXBoston study ems peds trauma procedures- limited pediatric procedural exposure (but more adult experience)
- C-spine
Primary Survey bull Your ABCrsquoshellip
bull Airway bull Breathing bull Circulation bull Disability (Neuro- GCS) bull Exposure
Order is critical
bull A before B or C bull Morbiditymortality will
occur much faster from airway compromise than from breathing or circulatory problems
bull Systematic approach is the cornerstone of ATLS success
httpwwwuptodatecomcontentsimageimageKey=EM2F64241amptopicKey=EM2F6571amprank=17E150ampsource=see_linkampsearch=traumaamputdPopup=true
httpwwwuptodatecomcontentsimageimageKey=EM2F64241amptopicKey=EM2F6571amprank=17E150ampsource=see_linkampsearch=traumaamputdPopup=true
Airway bull What are you assessing
ndash Airway patency bull What makes the airway not patent
ndash Foreign bodies ndash Vomitbloodsecretions ndash Edemahematoma ndash Impending obstruction
bull Interventions ndash Clearing foreign bodies ndash Suction secretionsvomit with yankauer ndash Repositioning- jaw thrust ndash Nasal trumpetoral airway ndash Intubation ndash Cricothyrotomy jet ventilation
Indications for Intubation
bull Respiratory arrest bull Impending respiratory failure bull Impending airway obstruction bull Inability to protect the airway bull GCS lt8 bull Declining GCS
Breathing bull What are you assessing
ndash ldquoGoodrdquo symmetric chest rise ndash Lung sounds ndash Aeration ndash Basic RR assessment (fast or minimalnone)
bull Interventions ndash Oxygen ndash Albuterolatrovent racemic epi ndash Positive pressure (CPAP BIPAP BMV) ndash Needle decompression ndash Chest tube thoracostomy ndash Intubation ndash Jet ventilation
ETT Intubation Basics bull Size
ndash Age4 + 4 or (Age +16)4 bull Depth
ndash ~ 3 x ETT size when over 1 year of age bull Blade size mac vs miller
ndash 0~ newborn ndash 1~ up to 2 years of life ndash 2~ 2-10 years ndash 3~ 10+ years
bull RSI medications ndash +-Sedation (Always before paralytic) ndash +-Paralytic (May not need it and never wo sedation)
Circulation
bull What do you assess ndash Central and peripheral pulses ndash Heart rate ndash Blood pressure systolic (age x2) +70 ndash Capillary refill ndash Cardiac activity on FAST ndash End organ perfusion
bull Mental status bull Urine output
Circulation Hemodynamic Changes
Percent Blood Volume Loss 0 15 25 35 45
Heart Rate
Blood Pressure
Cardiac Output
Circulation
ndash Access 2 large bore IVrsquos ndash IVFrsquos ndash pRBCrsquos
bull Hgb lt7gdl or ongoing blood losses
ndash Massive Transfusion Protocol
bull (111 ratio of PRBCS FFP Platelets)
ndash Vasopressors (epi norepi dopamine)
ndash Control of Hemorrhage bull Pelvic binders bull Direct pressure bull Indirectproximal pressure bull Tourniquet (only when
absolutely necessary)
ndash Chest Compressions ndash Pericardiocentesis ndash Delayed resuscitation
controlled hypotension (MAP 50 vs 65)
ndash Tranexamic acid in the near future
bull Interventions
Fluid Resuscitation Algorithm 20 mLkg isotonic crystalloid
Reassess
20 mLkg isotonic crystalloid
Reassess
20 mLkg isotonic crystalloid (31 rule)
or consider 10 to 20 mLkg packed red cells
Reconsidering Crystalloid Resuscitation
bull Less fluid ndash Permissive hypotension to
prevent clot rupture (select cases)
bull Too much fluid ndash Excessive Third Spacing ndash Secondary Compartment
Syndrome ndash Greater risk of ARDS ndash Dilutional Coagulopathy
When to start MTP
bull As soon as you believe you will need it ndash Institution specific guidelines
bull gt4 units or 40mlkg of PRBCrsquos expected bull Earlier use of Massive Transfusion Protocol
(pRBC FFP PLT) in ldquoDamage Controlrdquo resuscitations may improve outcome
bull 111 unit ratio bull Risk of TRALI ARDS etc
Disability bull GCS
ndash Range 3-15 ndash We should be 15 ndash Dead are still 3 ndash Less than 8 intubate ndash Eyes- 4 eyes ndash Verbal- most difficult ndash Motor- V6 engine ndash Intubated T
bull AVPU
Finishing Up the Evaluation
bull Airway bull Breathing bull Circulation bull Disability bull Exposure
ndash Expose and examine all parts ndash Cover quickly and keep warm
bull Secondary Survey
Bad Scene Responses
bull What are the outcomes of out-of-hospital cardiac arrest from blunt trauma
bull What are the outcomes of pediatric drowning patients
OHCA from Trauma
bull 2000-2003 bull 123 pts bull Mean age 73 yrs bull Most common
rhythms ndash Asystole 59 ndash PEA 29 ndash V-fib 35
bull 195 rosc in field ndash 98 survived for 24
hrs ndash 57 survived to
discharge ndash Drowning- 19
survival to discharge ndash Bystander CPR tripled
the survivor rate
Blunt Trauma- No Signs of Life
bull Review from 2002-2010 bull No signs of life- 025 of blunt trauma
ndash 25 resuscitated prior to hospital arrival bull 138 of these patients survived to discharge
bull 44 overall survived to hospital discharge
OHCA with CPR on Arrival
bull 169 children bull 141 deaths bull 69 required cpr on arrival- none survived bull 87 of patients requiring CPR on arrival
expired in the ED bull Of the 28 survivors
ndash 55 of survivors had full neurologic recovery
Pediatric Trauma
bull Fortunately these cases represent only a small fraction of EMS transports
bull Despite a few key differences pediatric trauma care overall is very similar to adult trauma care
Questions
References 1 bull NTDB 2013 pediatric Report bull Monkey bars httpsplaygroundchroniclesfileswordpresscom201307soccerjpg bull Screaming child httpblogsbabycentercomwp-contentuploads201409screaming-child-tantrum-fitjpg bull Pediatric airway image httpwwwcelebritydiagnosiscomwp-contentuploads201003pediatric-airwayjpg bull Child on backboard httpsencrypted-tbn2gstaticcomimagesq=tbnANd9GcQscrDVc8IH4MwkNGF6F1A9p7mSVzik5zrWyNvI-
qSwQT5S3GNyVg bull Elbow fracture httpwwwimageinterpretationcoukimageselbowSUPRACONDYLAR20LAT3jpg bull Bike riding httpsmile-per-daycomwp-contentuploads201412klr03jpg bull Dad and child pic httplaughingsquidcomwp-contentuploads471160jpg bull Weigth estimation inner city Am J Emerg Med 2015 Oct33(10)1364-7 doi 101016jajem201507040 Epub 2015 Jul 29 Weight
estimation in an inner-city pediatric ED the effect of obesity Chavez H1 Peterson RE2 Lo K3 Arel M4
bull Guess weight sign httpmedialiveauctiongroupneti963110572971_1jpgv=8CDDAAF8A5B9E20 bull Broselow tape httpsuploadwikimediaorgwikipediacommons994BTape1jpg bull Parent screaming httpmommyofamonstercomwp-contentuploads201301yellingjpg bull Prehospital pain management Am J Emerg Med 2015 Mar33(3)451-4 doi 101016jajem201412012 Epub 2014 Dec 18
Prehospital pain management of injured children a systematic review of current evidence Samuel N1 Steiner IP2 Shavit I3 bull Prehospital pain ped pain assessment Prehosp Emerg Care 2008 Apr-Jun12(2)182-6 doi 10108010903120801907471 Prehospital
pain assessment in pediatric trauma Izsak E1 Moore JL Stringfellow K Oswanski MF Lindstrom DA Stombaugh HA bull Ped pain management Prehosp Emerg Care 2005 Jan-Mar9(1)40-3 Prehospital pain management in children suffering traumatic
injury Swor R1 McEachin CM Seguin D Grall KH bull Prehospital intervention Allen CJ Teisch LF et al Prehospital care and transportation of pediatric trauma patients J Surg Res 2015
Aug197(2)240-6 JAMA 2000 Feb 9283(6)783-90 bull Effect of out-of-hospital pediatric endotracheal intubation on survival and neurological outcome a controlled clinical trial
Gausche M1 Lewis RJ Stratton SJ Haynes BE Gunter CS Goodrich SM Poore PD McCollough MD Henderson DP Pratt FD Seidel JS
bull Pediatric pain management survey Pediatr Emerg Care 2015 Sep 23 [Epub ahead of print] An Assessment of Newly Identified Barriers to and Enablers for Prehospital Pediatric Pain Management Whitley DE1 Li T Jones CM Cushman JT Williams DM Shah MN
References 2 bull httpwwwuptodatecomcontentsprehospital-pediatrics-and-emergency-medical-services-emsabstract6 bull httpwwwuptodatecomcontentsprehospital-pediatrics-and-emergency-medical-services-emsabstract7 bull Pediatr Crit Care Med 2011 Jul12(4)e166-70 doi 101097PCC0b013e3181f36f6e First responder
performance in pediatric trauma a comparison with an adult cohortBankole S1 Asuncion A Ross S Aghai Z Nollah L Echols H Da-Silva S
bull Drayna pc Browne LR et al Prehospital pediatric care Oppportunities for training treatment and research Prehosp Emerg Care 2015 Jul-Sep 19(3) Epub 2015 Feb 6
bull Pediatr Emerg Care 2001 Feb17(1) 5-9Pediatric pre-hospital advanced life support care in an urban setting Babl FE1 Vinci RJ Bauchner H Mottley L
bull Pediatr Crit Care Med 2015 Oct16(8)e260-7 doi 101097PCC0000000000000505Pediatric Out-of-Hospital Critical Procedures in the United States Carlson JN1 Gannon E Mann NC Jacobson KE Dai M Colleran C Wang HE
bull Pediatr Emerg Care 2009 Aug25(8)508-12 doi 101097PEC0b013e3181b0a0da The efficacy of pediatric advanced life support training in emergency medical service providers Baker TW1 King W Soto W Asher C Stolfi A Rowin ME
bull Sutton RM Case E et al ROC investigators A quantitative analysis of out-of-hospital pediatric and adolescent resuscitation quality A report from the ROC Epistry- Cardiac Arrest Resusciation 201593150-157
bull Resuscitation 2014 Aug85(8)1059-64 doi 101016jresuscitation201403307 Epub 2014 Apr 4 Neurocognitive long term follow-up study on drowned children Suominen PK1 Sutinen N2 Valle S3 Olkkola KT4 Loumlnnqvist T3
bull J Pediatr Surg 2010 Jul45(7)1413-9 doi 101016jjpedsurg200912020 Prehospital cardiopulmonary resuscitation in the pediatric trauma patient Murphy JT1 Jaiswal K Sabella J Vinson L Megison S Maxson RT
References 3 bull Pre atv accident
httpwwwctvnewscapolopoly_fs119871591409741949httpImageimagejpg_genderivativeslandscape_960imagejpg bull atv pic httpswwwutahadvocatescomwp-contentuploads201402atvAccidentLawyerjpg bull Blunt abdominal solid organ injury adult vs pediatric trauma center J Pediatr Surg 2015 Aug 28 pii S0022-3468(15)00526-6 doi
101016jjpedsurg201508012 [Epub ahead of print] Trauma center variation in the management of pediatric patients with blunt abdominal solid organ injury a national trauma data bank analysis Safavi A1 Skarsgard ED2 Rhee P1 Zangbar B1 Kulvatunyou N1 Tang A1 OKeeffe T1 Friese RS1 Joseph B3
bull Pediatric blunt abdominal injury Curr Opin Crit Care 2015 Sep 28 [Epub ahead of print] Pediatric blunt abdominal trauma current management Notrica DM1
bull Pediatric splenic injury management Am J Surg 2015 Jul 31 pii S0002-9610(15)00417-1 doi 101016jamjsurg201506009 [Epub ahead of print] Comparative effectiveness of treatment strategies for severe splenic trauma in the pediatric population Rialon KL1 Englum BR1 Gulack BC1 Guevara CJ2 Bhattacharya SD3 Shapiro ML4 Rice HE5 Scarborough JE4 Adibe OO6
bull Liver pic httpss-media-cache-ak0pinimgcom736x7da50e7da50eb2bb603c99ef6649ff897e26b5jpg bull Solid organ injury non op in peds J Trauma Acute Care Surg 2015 Oct79(4)683-93 doi 101097TA0000000000000808
Nonoperative management of blunt liver and spleen injury in children Evaluation of the ATOMAC guideline using GRADE Notrica DM1 Eubanks JW 3rd Tuggle DW Maxson RT Letton RW Garcia NM Alder AC Lawson KA St Peter SD Megison S Garcia Filion P
bull Pediaric vs nonped trauma ct use J Pediatr 2015 Oct167(4)897-904e3 doi 101016jjpeds201506052 Epub 2015 Jul 29 Variation in Computed Tomography Imaging for Pediatric Injury-Related Emergency Visits Marin JR1 Wang L2 Winger DG2 Mannix RC3
bull Solid organ management in ped population J Trauma Acute Care Surg 2015 Aug79(2)206-14quiz 332 doi 101097TA0000000000000731 Management of children with solid organ injuries after blunt torso trauma Wisner DH1 Kuppermann N Cooper A Menaker J Ehrlich P Kooistra J Mahajan P Lee L Cook LJ Yen K Lillis K Holmes JF
bull Triad of death image httpimageslidesharecdncomdamage-control-resuscitation-1304253390-phpapp0195damage-control-resuscitation-14-728jpgcb=1304235553
bull Tranexamic acid study Eckert MJ Wertin TM Tyner SD et al 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 77852
bull Image care accident httpsuploadwikimediaorgwikipediacommonsthumbee1Car_crash_1jpg1280px-Car_crash_1jpg
References 4 bull httpwwwsurgeryvcuedudivisionsacutesurghtml bull Trauma management Approach to the unstable child
httpwwwuptodatecomcontentstrauma-management-approach-to-the-unstable-childsource=search_resultampsearch=pediatric+trauma+childrenampselectedTitle=17E150
bull Trauma management Unique pediatric considerations httpwwwuptodatecomcontentstrauma-management-unique-pediatric-considerationssource=search_resultampsearch=pediatric+trauma+childrenampselectedTitle=37E150
References 5 bull httpwwwetiquettehellcomsmfindexphptopic=8666360 bull httpwwwstlouischildrensorghealth-care-professionalsems-providers bull httpwwwuchicagokidshospitalorgspecialtiesemergency-medicinespecialhtml bull httpwwwsimsacademyinfoFXpatienthtm bull httptheemtspotcomwp-contentuploads200902another-burn-patient-by-annette-larsonjpg bull httplastangryfancomwp-contentuploads200910Clint-Malarchukjpg bull httpwwwtraumaorgarchiveresusmassivehtml bull httpwwwuptodatecomcontentsimageimageKey=PEDS68694amptopicKey=EM2F6389ampsourc
e=previewampsearch=pediatric+hemorrhagic+shockampselectedTitle=17E150amprank=undefined bull httptheemtspotcomwp-contentuploads200902gcsgif bull httpwwwuptodatecomcontentsimageimageKey=EM2F60409amptopicKey=EM2F6571amprank
=17E150ampsource=see_linkampsearch=traumaamputdPopup=true bull httpwwwuptodatecomcontentsimageimageKey=EM2F80874amptopicKey=EM2F6571amprank
=17E150ampsource=see_linkampsearch=traumaamputdPopup=true bull httpempracticenewswordpresscomcategorynexus-criteria bull httpswwwgooglecomsearchq=pediatric+glasgow+coma+scaleamptbm=ischamptbo=uampsource=uni
vampsa=Xampei=8TiOU7TNC5WuyATp5YG4BQampsqi=2ampved=0CDYQsAQampbiw=1426ampbih=883q=canadian+c-spine+rulesamptbm=ischampfacrc=_ampimgdii=_ampimgrc=WI94QMHgMLTQmM253A3BP5nbsFhNCXK0FM3Bhttp253A252F252Fwwwbmjcom252Fhighwire252Ffilestream252F436003252Ffield_highwire_fragment_image_l252F0jpg3Bhttp253A252F252Fwwwbmjcom252Fcontent252F339252Fbmjb41463B12803B1253
References 5 bull httpwwwuptodatecomcontentsimageimageKey=EM2F76777amptopicKey=EM2F6571amprank
=17E150ampsource=see_linkampsearch=traumaamputdPopup=true bull httpwwwdocumentingrealitycomforumattachmentsf14964898d1246625322-firework-injury-
m80injury1jpg bull httpwwwpediatriceducationorg20050620 bull httpwwwarmstrongmedicalcomindexcfmgoproductdetailsec3ssec19cat61fam515 bull httpwwwuptodatecomcontentsimageimageKey=PEDS61087amptopicKey=ID2F7661ampsource
=outline_linkampsearch=tetanus+prophylaxisamputdPopup=true bull httpwwwafsecafmilsharedmediaphotodbweb110609-F-MJ378-009jpg bull httpwwwuptodatecomcontentsimageimageKey=EM75765amptopicKey= bull EM2F6389ampsource=outline_linkampsearch=massive+transfusion+protocolamputdPopup=true bull httpwwwmotifakecomimagedemotivational-postersmall0910whats-the-question-ignorance-
calvin-and-hobbes-demotivational-poster-1255020127jpg
XXXXBoston study ems peds trauma procedures- limited pediatric procedural exposure (but more adult experience) bull Catchment area 590000
over 1 year bull 555 pediatric ALS
transport ndash 19 blunt trauma ndash 10 penetrating trauma
bull IV 33 bull BMV 5 bull Intubation 3 bull 50 ALS providers average
year ndash IV- 37 ndash Intubation- 03 ndash IO- 006
bull 7 ped ems ndash 13 trauma
bull Critical procedures ndash 101000 peds cases ndash Intubation 671000 ndash IO 51000 ndash 81 successful
Pediatr Emerg Care 2001 Feb17(1)5-9 Pediatric pre-hospital advanced life support care in an urban setting
Babl FE1 Vinci RJ Bauchner H Mottley L
Pediatr Crit Care Med 2015 Oct16(8)e260-7 doi 101097PCC0000000000000505 Pediatric Out-of-Hospital Critical Procedures in the United States
Carlson JN1 Gannon E Mann NC Jacobson KE Dai M Colleran C Wang HE
C-spine bull C-spine injuries rare bull Take pt to closest hospital if over injuries
call for it (ie resuscitation altered mental status) primary guide
bull Mechanism ndash Altered mental status focal neuro change
torticollis substantial torso injury diving high speed auto neck pain underlying predisposing condition Acad Emerg Med 2014 Jan21(1)55-64 doi 101111acem12288
Comparison of outcomes for children with cervical spine injury based on destination hospital from scene of injury Anders JF1 Adelgais K Hoyle JD Jr Olsen C Jaffe DM Leonard JC Pediatric Emergency Care Applied Research Network
(PECARN)
Ann Emerg Med 2011 Aug58(2)145-55 doi 101016jannemergmed201008038 Epub 2010 Oct 29 Factors associated with cervical spine injury in children after blunt trauma
Leonard JC Kuppermann N Olsen C Babcock-Cimpello L Brown K Mahajan P Adelgais KM Anders J Borgialli D Donoghue A Hoyle JD Jr Kim E Leonard JR Lillis KA Nigrovic LE Powell EC Rebella
G Reeves SD Rogers AJ Stankovic C Teshome G Jaffe DM Pediatric Emergency Care Applied Research Network
- Itrsquos Hard to Put a Band-Aid on a Broken Spleen Pediatric Trauma
- Disclosures
- Objectives
- Pediatric Prehospital Care
- Mechanism
- Traumatic Pain Management
- Pediatric Trauma
- Deaths by Mechanism of Injury
- Pediatric Trauma
- Pediatric Trauma
- Airway Differences
- Pediatric-Adult Differences
- Pediatric Challenges
- Prehospital Pediatric Challenges
- Pediatric and Adult Trauma
- Scene Response
- Prehospital Intervention
- Where do you take the patient
- Patient arrives at the EDhellip
- Primary Survey
- Order is critical
- Slide Number 22
- Slide Number 23
- Airway
- Indications for Intubation
- Breathing
- ETT Intubation Basics
- Circulation
- Slide Number 29
- CirculationHemodynamic Changes
- Circulation
- Fluid Resuscitation Algorithm
- Reconsidering Crystalloid Resuscitation
- When to start MTP
- Disability
- Finishing Up the Evaluation
- Bad Scene Responses
- OHCA from Trauma
- Blunt Trauma- No Signs of Life
- OHCA with CPR on Arrival
- Pediatric Trauma
- Questions
- References 1
- References 2
- References 3
- References 4
- References 5
- References 5
- XXXXBoston study ems peds trauma procedures- limited pediatric procedural exposure (but more adult experience)
- C-spine
Order is critical
bull A before B or C bull Morbiditymortality will
occur much faster from airway compromise than from breathing or circulatory problems
bull Systematic approach is the cornerstone of ATLS success
httpwwwuptodatecomcontentsimageimageKey=EM2F64241amptopicKey=EM2F6571amprank=17E150ampsource=see_linkampsearch=traumaamputdPopup=true
httpwwwuptodatecomcontentsimageimageKey=EM2F64241amptopicKey=EM2F6571amprank=17E150ampsource=see_linkampsearch=traumaamputdPopup=true
Airway bull What are you assessing
ndash Airway patency bull What makes the airway not patent
ndash Foreign bodies ndash Vomitbloodsecretions ndash Edemahematoma ndash Impending obstruction
bull Interventions ndash Clearing foreign bodies ndash Suction secretionsvomit with yankauer ndash Repositioning- jaw thrust ndash Nasal trumpetoral airway ndash Intubation ndash Cricothyrotomy jet ventilation
Indications for Intubation
bull Respiratory arrest bull Impending respiratory failure bull Impending airway obstruction bull Inability to protect the airway bull GCS lt8 bull Declining GCS
Breathing bull What are you assessing
ndash ldquoGoodrdquo symmetric chest rise ndash Lung sounds ndash Aeration ndash Basic RR assessment (fast or minimalnone)
bull Interventions ndash Oxygen ndash Albuterolatrovent racemic epi ndash Positive pressure (CPAP BIPAP BMV) ndash Needle decompression ndash Chest tube thoracostomy ndash Intubation ndash Jet ventilation
ETT Intubation Basics bull Size
ndash Age4 + 4 or (Age +16)4 bull Depth
ndash ~ 3 x ETT size when over 1 year of age bull Blade size mac vs miller
ndash 0~ newborn ndash 1~ up to 2 years of life ndash 2~ 2-10 years ndash 3~ 10+ years
bull RSI medications ndash +-Sedation (Always before paralytic) ndash +-Paralytic (May not need it and never wo sedation)
Circulation
bull What do you assess ndash Central and peripheral pulses ndash Heart rate ndash Blood pressure systolic (age x2) +70 ndash Capillary refill ndash Cardiac activity on FAST ndash End organ perfusion
bull Mental status bull Urine output
Circulation Hemodynamic Changes
Percent Blood Volume Loss 0 15 25 35 45
Heart Rate
Blood Pressure
Cardiac Output
Circulation
ndash Access 2 large bore IVrsquos ndash IVFrsquos ndash pRBCrsquos
bull Hgb lt7gdl or ongoing blood losses
ndash Massive Transfusion Protocol
bull (111 ratio of PRBCS FFP Platelets)
ndash Vasopressors (epi norepi dopamine)
ndash Control of Hemorrhage bull Pelvic binders bull Direct pressure bull Indirectproximal pressure bull Tourniquet (only when
absolutely necessary)
ndash Chest Compressions ndash Pericardiocentesis ndash Delayed resuscitation
controlled hypotension (MAP 50 vs 65)
ndash Tranexamic acid in the near future
bull Interventions
Fluid Resuscitation Algorithm 20 mLkg isotonic crystalloid
Reassess
20 mLkg isotonic crystalloid
Reassess
20 mLkg isotonic crystalloid (31 rule)
or consider 10 to 20 mLkg packed red cells
Reconsidering Crystalloid Resuscitation
bull Less fluid ndash Permissive hypotension to
prevent clot rupture (select cases)
bull Too much fluid ndash Excessive Third Spacing ndash Secondary Compartment
Syndrome ndash Greater risk of ARDS ndash Dilutional Coagulopathy
When to start MTP
bull As soon as you believe you will need it ndash Institution specific guidelines
bull gt4 units or 40mlkg of PRBCrsquos expected bull Earlier use of Massive Transfusion Protocol
(pRBC FFP PLT) in ldquoDamage Controlrdquo resuscitations may improve outcome
bull 111 unit ratio bull Risk of TRALI ARDS etc
Disability bull GCS
ndash Range 3-15 ndash We should be 15 ndash Dead are still 3 ndash Less than 8 intubate ndash Eyes- 4 eyes ndash Verbal- most difficult ndash Motor- V6 engine ndash Intubated T
bull AVPU
Finishing Up the Evaluation
bull Airway bull Breathing bull Circulation bull Disability bull Exposure
ndash Expose and examine all parts ndash Cover quickly and keep warm
bull Secondary Survey
Bad Scene Responses
bull What are the outcomes of out-of-hospital cardiac arrest from blunt trauma
bull What are the outcomes of pediatric drowning patients
OHCA from Trauma
bull 2000-2003 bull 123 pts bull Mean age 73 yrs bull Most common
rhythms ndash Asystole 59 ndash PEA 29 ndash V-fib 35
bull 195 rosc in field ndash 98 survived for 24
hrs ndash 57 survived to
discharge ndash Drowning- 19
survival to discharge ndash Bystander CPR tripled
the survivor rate
Blunt Trauma- No Signs of Life
bull Review from 2002-2010 bull No signs of life- 025 of blunt trauma
ndash 25 resuscitated prior to hospital arrival bull 138 of these patients survived to discharge
bull 44 overall survived to hospital discharge
OHCA with CPR on Arrival
bull 169 children bull 141 deaths bull 69 required cpr on arrival- none survived bull 87 of patients requiring CPR on arrival
expired in the ED bull Of the 28 survivors
ndash 55 of survivors had full neurologic recovery
Pediatric Trauma
bull Fortunately these cases represent only a small fraction of EMS transports
bull Despite a few key differences pediatric trauma care overall is very similar to adult trauma care
Questions
References 1 bull NTDB 2013 pediatric Report bull Monkey bars httpsplaygroundchroniclesfileswordpresscom201307soccerjpg bull Screaming child httpblogsbabycentercomwp-contentuploads201409screaming-child-tantrum-fitjpg bull Pediatric airway image httpwwwcelebritydiagnosiscomwp-contentuploads201003pediatric-airwayjpg bull Child on backboard httpsencrypted-tbn2gstaticcomimagesq=tbnANd9GcQscrDVc8IH4MwkNGF6F1A9p7mSVzik5zrWyNvI-
qSwQT5S3GNyVg bull Elbow fracture httpwwwimageinterpretationcoukimageselbowSUPRACONDYLAR20LAT3jpg bull Bike riding httpsmile-per-daycomwp-contentuploads201412klr03jpg bull Dad and child pic httplaughingsquidcomwp-contentuploads471160jpg bull Weigth estimation inner city Am J Emerg Med 2015 Oct33(10)1364-7 doi 101016jajem201507040 Epub 2015 Jul 29 Weight
estimation in an inner-city pediatric ED the effect of obesity Chavez H1 Peterson RE2 Lo K3 Arel M4
bull Guess weight sign httpmedialiveauctiongroupneti963110572971_1jpgv=8CDDAAF8A5B9E20 bull Broselow tape httpsuploadwikimediaorgwikipediacommons994BTape1jpg bull Parent screaming httpmommyofamonstercomwp-contentuploads201301yellingjpg bull Prehospital pain management Am J Emerg Med 2015 Mar33(3)451-4 doi 101016jajem201412012 Epub 2014 Dec 18
Prehospital pain management of injured children a systematic review of current evidence Samuel N1 Steiner IP2 Shavit I3 bull Prehospital pain ped pain assessment Prehosp Emerg Care 2008 Apr-Jun12(2)182-6 doi 10108010903120801907471 Prehospital
pain assessment in pediatric trauma Izsak E1 Moore JL Stringfellow K Oswanski MF Lindstrom DA Stombaugh HA bull Ped pain management Prehosp Emerg Care 2005 Jan-Mar9(1)40-3 Prehospital pain management in children suffering traumatic
injury Swor R1 McEachin CM Seguin D Grall KH bull Prehospital intervention Allen CJ Teisch LF et al Prehospital care and transportation of pediatric trauma patients J Surg Res 2015
Aug197(2)240-6 JAMA 2000 Feb 9283(6)783-90 bull Effect of out-of-hospital pediatric endotracheal intubation on survival and neurological outcome a controlled clinical trial
Gausche M1 Lewis RJ Stratton SJ Haynes BE Gunter CS Goodrich SM Poore PD McCollough MD Henderson DP Pratt FD Seidel JS
bull Pediatric pain management survey Pediatr Emerg Care 2015 Sep 23 [Epub ahead of print] An Assessment of Newly Identified Barriers to and Enablers for Prehospital Pediatric Pain Management Whitley DE1 Li T Jones CM Cushman JT Williams DM Shah MN
References 2 bull httpwwwuptodatecomcontentsprehospital-pediatrics-and-emergency-medical-services-emsabstract6 bull httpwwwuptodatecomcontentsprehospital-pediatrics-and-emergency-medical-services-emsabstract7 bull Pediatr Crit Care Med 2011 Jul12(4)e166-70 doi 101097PCC0b013e3181f36f6e First responder
performance in pediatric trauma a comparison with an adult cohortBankole S1 Asuncion A Ross S Aghai Z Nollah L Echols H Da-Silva S
bull Drayna pc Browne LR et al Prehospital pediatric care Oppportunities for training treatment and research Prehosp Emerg Care 2015 Jul-Sep 19(3) Epub 2015 Feb 6
bull Pediatr Emerg Care 2001 Feb17(1) 5-9Pediatric pre-hospital advanced life support care in an urban setting Babl FE1 Vinci RJ Bauchner H Mottley L
bull Pediatr Crit Care Med 2015 Oct16(8)e260-7 doi 101097PCC0000000000000505Pediatric Out-of-Hospital Critical Procedures in the United States Carlson JN1 Gannon E Mann NC Jacobson KE Dai M Colleran C Wang HE
bull Pediatr Emerg Care 2009 Aug25(8)508-12 doi 101097PEC0b013e3181b0a0da The efficacy of pediatric advanced life support training in emergency medical service providers Baker TW1 King W Soto W Asher C Stolfi A Rowin ME
bull Sutton RM Case E et al ROC investigators A quantitative analysis of out-of-hospital pediatric and adolescent resuscitation quality A report from the ROC Epistry- Cardiac Arrest Resusciation 201593150-157
bull Resuscitation 2014 Aug85(8)1059-64 doi 101016jresuscitation201403307 Epub 2014 Apr 4 Neurocognitive long term follow-up study on drowned children Suominen PK1 Sutinen N2 Valle S3 Olkkola KT4 Loumlnnqvist T3
bull J Pediatr Surg 2010 Jul45(7)1413-9 doi 101016jjpedsurg200912020 Prehospital cardiopulmonary resuscitation in the pediatric trauma patient Murphy JT1 Jaiswal K Sabella J Vinson L Megison S Maxson RT
References 3 bull Pre atv accident
httpwwwctvnewscapolopoly_fs119871591409741949httpImageimagejpg_genderivativeslandscape_960imagejpg bull atv pic httpswwwutahadvocatescomwp-contentuploads201402atvAccidentLawyerjpg bull Blunt abdominal solid organ injury adult vs pediatric trauma center J Pediatr Surg 2015 Aug 28 pii S0022-3468(15)00526-6 doi
101016jjpedsurg201508012 [Epub ahead of print] Trauma center variation in the management of pediatric patients with blunt abdominal solid organ injury a national trauma data bank analysis Safavi A1 Skarsgard ED2 Rhee P1 Zangbar B1 Kulvatunyou N1 Tang A1 OKeeffe T1 Friese RS1 Joseph B3
bull Pediatric blunt abdominal injury Curr Opin Crit Care 2015 Sep 28 [Epub ahead of print] Pediatric blunt abdominal trauma current management Notrica DM1
bull Pediatric splenic injury management Am J Surg 2015 Jul 31 pii S0002-9610(15)00417-1 doi 101016jamjsurg201506009 [Epub ahead of print] Comparative effectiveness of treatment strategies for severe splenic trauma in the pediatric population Rialon KL1 Englum BR1 Gulack BC1 Guevara CJ2 Bhattacharya SD3 Shapiro ML4 Rice HE5 Scarborough JE4 Adibe OO6
bull Liver pic httpss-media-cache-ak0pinimgcom736x7da50e7da50eb2bb603c99ef6649ff897e26b5jpg bull Solid organ injury non op in peds J Trauma Acute Care Surg 2015 Oct79(4)683-93 doi 101097TA0000000000000808
Nonoperative management of blunt liver and spleen injury in children Evaluation of the ATOMAC guideline using GRADE Notrica DM1 Eubanks JW 3rd Tuggle DW Maxson RT Letton RW Garcia NM Alder AC Lawson KA St Peter SD Megison S Garcia Filion P
bull Pediaric vs nonped trauma ct use J Pediatr 2015 Oct167(4)897-904e3 doi 101016jjpeds201506052 Epub 2015 Jul 29 Variation in Computed Tomography Imaging for Pediatric Injury-Related Emergency Visits Marin JR1 Wang L2 Winger DG2 Mannix RC3
bull Solid organ management in ped population J Trauma Acute Care Surg 2015 Aug79(2)206-14quiz 332 doi 101097TA0000000000000731 Management of children with solid organ injuries after blunt torso trauma Wisner DH1 Kuppermann N Cooper A Menaker J Ehrlich P Kooistra J Mahajan P Lee L Cook LJ Yen K Lillis K Holmes JF
bull Triad of death image httpimageslidesharecdncomdamage-control-resuscitation-1304253390-phpapp0195damage-control-resuscitation-14-728jpgcb=1304235553
bull Tranexamic acid study Eckert MJ Wertin TM Tyner SD et al 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 77852
bull Image care accident httpsuploadwikimediaorgwikipediacommonsthumbee1Car_crash_1jpg1280px-Car_crash_1jpg
References 4 bull httpwwwsurgeryvcuedudivisionsacutesurghtml bull Trauma management Approach to the unstable child
httpwwwuptodatecomcontentstrauma-management-approach-to-the-unstable-childsource=search_resultampsearch=pediatric+trauma+childrenampselectedTitle=17E150
bull Trauma management Unique pediatric considerations httpwwwuptodatecomcontentstrauma-management-unique-pediatric-considerationssource=search_resultampsearch=pediatric+trauma+childrenampselectedTitle=37E150
References 5 bull httpwwwetiquettehellcomsmfindexphptopic=8666360 bull httpwwwstlouischildrensorghealth-care-professionalsems-providers bull httpwwwuchicagokidshospitalorgspecialtiesemergency-medicinespecialhtml bull httpwwwsimsacademyinfoFXpatienthtm bull httptheemtspotcomwp-contentuploads200902another-burn-patient-by-annette-larsonjpg bull httplastangryfancomwp-contentuploads200910Clint-Malarchukjpg bull httpwwwtraumaorgarchiveresusmassivehtml bull httpwwwuptodatecomcontentsimageimageKey=PEDS68694amptopicKey=EM2F6389ampsourc
e=previewampsearch=pediatric+hemorrhagic+shockampselectedTitle=17E150amprank=undefined bull httptheemtspotcomwp-contentuploads200902gcsgif bull httpwwwuptodatecomcontentsimageimageKey=EM2F60409amptopicKey=EM2F6571amprank
=17E150ampsource=see_linkampsearch=traumaamputdPopup=true bull httpwwwuptodatecomcontentsimageimageKey=EM2F80874amptopicKey=EM2F6571amprank
=17E150ampsource=see_linkampsearch=traumaamputdPopup=true bull httpempracticenewswordpresscomcategorynexus-criteria bull httpswwwgooglecomsearchq=pediatric+glasgow+coma+scaleamptbm=ischamptbo=uampsource=uni
vampsa=Xampei=8TiOU7TNC5WuyATp5YG4BQampsqi=2ampved=0CDYQsAQampbiw=1426ampbih=883q=canadian+c-spine+rulesamptbm=ischampfacrc=_ampimgdii=_ampimgrc=WI94QMHgMLTQmM253A3BP5nbsFhNCXK0FM3Bhttp253A252F252Fwwwbmjcom252Fhighwire252Ffilestream252F436003252Ffield_highwire_fragment_image_l252F0jpg3Bhttp253A252F252Fwwwbmjcom252Fcontent252F339252Fbmjb41463B12803B1253
References 5 bull httpwwwuptodatecomcontentsimageimageKey=EM2F76777amptopicKey=EM2F6571amprank
=17E150ampsource=see_linkampsearch=traumaamputdPopup=true bull httpwwwdocumentingrealitycomforumattachmentsf14964898d1246625322-firework-injury-
m80injury1jpg bull httpwwwpediatriceducationorg20050620 bull httpwwwarmstrongmedicalcomindexcfmgoproductdetailsec3ssec19cat61fam515 bull httpwwwuptodatecomcontentsimageimageKey=PEDS61087amptopicKey=ID2F7661ampsource
=outline_linkampsearch=tetanus+prophylaxisamputdPopup=true bull httpwwwafsecafmilsharedmediaphotodbweb110609-F-MJ378-009jpg bull httpwwwuptodatecomcontentsimageimageKey=EM75765amptopicKey= bull EM2F6389ampsource=outline_linkampsearch=massive+transfusion+protocolamputdPopup=true bull httpwwwmotifakecomimagedemotivational-postersmall0910whats-the-question-ignorance-
calvin-and-hobbes-demotivational-poster-1255020127jpg
XXXXBoston study ems peds trauma procedures- limited pediatric procedural exposure (but more adult experience) bull Catchment area 590000
over 1 year bull 555 pediatric ALS
transport ndash 19 blunt trauma ndash 10 penetrating trauma
bull IV 33 bull BMV 5 bull Intubation 3 bull 50 ALS providers average
year ndash IV- 37 ndash Intubation- 03 ndash IO- 006
bull 7 ped ems ndash 13 trauma
bull Critical procedures ndash 101000 peds cases ndash Intubation 671000 ndash IO 51000 ndash 81 successful
Pediatr Emerg Care 2001 Feb17(1)5-9 Pediatric pre-hospital advanced life support care in an urban setting
Babl FE1 Vinci RJ Bauchner H Mottley L
Pediatr Crit Care Med 2015 Oct16(8)e260-7 doi 101097PCC0000000000000505 Pediatric Out-of-Hospital Critical Procedures in the United States
Carlson JN1 Gannon E Mann NC Jacobson KE Dai M Colleran C Wang HE
C-spine bull C-spine injuries rare bull Take pt to closest hospital if over injuries
call for it (ie resuscitation altered mental status) primary guide
bull Mechanism ndash Altered mental status focal neuro change
torticollis substantial torso injury diving high speed auto neck pain underlying predisposing condition Acad Emerg Med 2014 Jan21(1)55-64 doi 101111acem12288
Comparison of outcomes for children with cervical spine injury based on destination hospital from scene of injury Anders JF1 Adelgais K Hoyle JD Jr Olsen C Jaffe DM Leonard JC Pediatric Emergency Care Applied Research Network
(PECARN)
Ann Emerg Med 2011 Aug58(2)145-55 doi 101016jannemergmed201008038 Epub 2010 Oct 29 Factors associated with cervical spine injury in children after blunt trauma
Leonard JC Kuppermann N Olsen C Babcock-Cimpello L Brown K Mahajan P Adelgais KM Anders J Borgialli D Donoghue A Hoyle JD Jr Kim E Leonard JR Lillis KA Nigrovic LE Powell EC Rebella
G Reeves SD Rogers AJ Stankovic C Teshome G Jaffe DM Pediatric Emergency Care Applied Research Network
- Itrsquos Hard to Put a Band-Aid on a Broken Spleen Pediatric Trauma
- Disclosures
- Objectives
- Pediatric Prehospital Care
- Mechanism
- Traumatic Pain Management
- Pediatric Trauma
- Deaths by Mechanism of Injury
- Pediatric Trauma
- Pediatric Trauma
- Airway Differences
- Pediatric-Adult Differences
- Pediatric Challenges
- Prehospital Pediatric Challenges
- Pediatric and Adult Trauma
- Scene Response
- Prehospital Intervention
- Where do you take the patient
- Patient arrives at the EDhellip
- Primary Survey
- Order is critical
- Slide Number 22
- Slide Number 23
- Airway
- Indications for Intubation
- Breathing
- ETT Intubation Basics
- Circulation
- Slide Number 29
- CirculationHemodynamic Changes
- Circulation
- Fluid Resuscitation Algorithm
- Reconsidering Crystalloid Resuscitation
- When to start MTP
- Disability
- Finishing Up the Evaluation
- Bad Scene Responses
- OHCA from Trauma
- Blunt Trauma- No Signs of Life
- OHCA with CPR on Arrival
- Pediatric Trauma
- Questions
- References 1
- References 2
- References 3
- References 4
- References 5
- References 5
- XXXXBoston study ems peds trauma procedures- limited pediatric procedural exposure (but more adult experience)
- C-spine
httpwwwuptodatecomcontentsimageimageKey=EM2F64241amptopicKey=EM2F6571amprank=17E150ampsource=see_linkampsearch=traumaamputdPopup=true
httpwwwuptodatecomcontentsimageimageKey=EM2F64241amptopicKey=EM2F6571amprank=17E150ampsource=see_linkampsearch=traumaamputdPopup=true
Airway bull What are you assessing
ndash Airway patency bull What makes the airway not patent
ndash Foreign bodies ndash Vomitbloodsecretions ndash Edemahematoma ndash Impending obstruction
bull Interventions ndash Clearing foreign bodies ndash Suction secretionsvomit with yankauer ndash Repositioning- jaw thrust ndash Nasal trumpetoral airway ndash Intubation ndash Cricothyrotomy jet ventilation
Indications for Intubation
bull Respiratory arrest bull Impending respiratory failure bull Impending airway obstruction bull Inability to protect the airway bull GCS lt8 bull Declining GCS
Breathing bull What are you assessing
ndash ldquoGoodrdquo symmetric chest rise ndash Lung sounds ndash Aeration ndash Basic RR assessment (fast or minimalnone)
bull Interventions ndash Oxygen ndash Albuterolatrovent racemic epi ndash Positive pressure (CPAP BIPAP BMV) ndash Needle decompression ndash Chest tube thoracostomy ndash Intubation ndash Jet ventilation
ETT Intubation Basics bull Size
ndash Age4 + 4 or (Age +16)4 bull Depth
ndash ~ 3 x ETT size when over 1 year of age bull Blade size mac vs miller
ndash 0~ newborn ndash 1~ up to 2 years of life ndash 2~ 2-10 years ndash 3~ 10+ years
bull RSI medications ndash +-Sedation (Always before paralytic) ndash +-Paralytic (May not need it and never wo sedation)
Circulation
bull What do you assess ndash Central and peripheral pulses ndash Heart rate ndash Blood pressure systolic (age x2) +70 ndash Capillary refill ndash Cardiac activity on FAST ndash End organ perfusion
bull Mental status bull Urine output
Circulation Hemodynamic Changes
Percent Blood Volume Loss 0 15 25 35 45
Heart Rate
Blood Pressure
Cardiac Output
Circulation
ndash Access 2 large bore IVrsquos ndash IVFrsquos ndash pRBCrsquos
bull Hgb lt7gdl or ongoing blood losses
ndash Massive Transfusion Protocol
bull (111 ratio of PRBCS FFP Platelets)
ndash Vasopressors (epi norepi dopamine)
ndash Control of Hemorrhage bull Pelvic binders bull Direct pressure bull Indirectproximal pressure bull Tourniquet (only when
absolutely necessary)
ndash Chest Compressions ndash Pericardiocentesis ndash Delayed resuscitation
controlled hypotension (MAP 50 vs 65)
ndash Tranexamic acid in the near future
bull Interventions
Fluid Resuscitation Algorithm 20 mLkg isotonic crystalloid
Reassess
20 mLkg isotonic crystalloid
Reassess
20 mLkg isotonic crystalloid (31 rule)
or consider 10 to 20 mLkg packed red cells
Reconsidering Crystalloid Resuscitation
bull Less fluid ndash Permissive hypotension to
prevent clot rupture (select cases)
bull Too much fluid ndash Excessive Third Spacing ndash Secondary Compartment
Syndrome ndash Greater risk of ARDS ndash Dilutional Coagulopathy
When to start MTP
bull As soon as you believe you will need it ndash Institution specific guidelines
bull gt4 units or 40mlkg of PRBCrsquos expected bull Earlier use of Massive Transfusion Protocol
(pRBC FFP PLT) in ldquoDamage Controlrdquo resuscitations may improve outcome
bull 111 unit ratio bull Risk of TRALI ARDS etc
Disability bull GCS
ndash Range 3-15 ndash We should be 15 ndash Dead are still 3 ndash Less than 8 intubate ndash Eyes- 4 eyes ndash Verbal- most difficult ndash Motor- V6 engine ndash Intubated T
bull AVPU
Finishing Up the Evaluation
bull Airway bull Breathing bull Circulation bull Disability bull Exposure
ndash Expose and examine all parts ndash Cover quickly and keep warm
bull Secondary Survey
Bad Scene Responses
bull What are the outcomes of out-of-hospital cardiac arrest from blunt trauma
bull What are the outcomes of pediatric drowning patients
OHCA from Trauma
bull 2000-2003 bull 123 pts bull Mean age 73 yrs bull Most common
rhythms ndash Asystole 59 ndash PEA 29 ndash V-fib 35
bull 195 rosc in field ndash 98 survived for 24
hrs ndash 57 survived to
discharge ndash Drowning- 19
survival to discharge ndash Bystander CPR tripled
the survivor rate
Blunt Trauma- No Signs of Life
bull Review from 2002-2010 bull No signs of life- 025 of blunt trauma
ndash 25 resuscitated prior to hospital arrival bull 138 of these patients survived to discharge
bull 44 overall survived to hospital discharge
OHCA with CPR on Arrival
bull 169 children bull 141 deaths bull 69 required cpr on arrival- none survived bull 87 of patients requiring CPR on arrival
expired in the ED bull Of the 28 survivors
ndash 55 of survivors had full neurologic recovery
Pediatric Trauma
bull Fortunately these cases represent only a small fraction of EMS transports
bull Despite a few key differences pediatric trauma care overall is very similar to adult trauma care
Questions
References 1 bull NTDB 2013 pediatric Report bull Monkey bars httpsplaygroundchroniclesfileswordpresscom201307soccerjpg bull Screaming child httpblogsbabycentercomwp-contentuploads201409screaming-child-tantrum-fitjpg bull Pediatric airway image httpwwwcelebritydiagnosiscomwp-contentuploads201003pediatric-airwayjpg bull Child on backboard httpsencrypted-tbn2gstaticcomimagesq=tbnANd9GcQscrDVc8IH4MwkNGF6F1A9p7mSVzik5zrWyNvI-
qSwQT5S3GNyVg bull Elbow fracture httpwwwimageinterpretationcoukimageselbowSUPRACONDYLAR20LAT3jpg bull Bike riding httpsmile-per-daycomwp-contentuploads201412klr03jpg bull Dad and child pic httplaughingsquidcomwp-contentuploads471160jpg bull Weigth estimation inner city Am J Emerg Med 2015 Oct33(10)1364-7 doi 101016jajem201507040 Epub 2015 Jul 29 Weight
estimation in an inner-city pediatric ED the effect of obesity Chavez H1 Peterson RE2 Lo K3 Arel M4
bull Guess weight sign httpmedialiveauctiongroupneti963110572971_1jpgv=8CDDAAF8A5B9E20 bull Broselow tape httpsuploadwikimediaorgwikipediacommons994BTape1jpg bull Parent screaming httpmommyofamonstercomwp-contentuploads201301yellingjpg bull Prehospital pain management Am J Emerg Med 2015 Mar33(3)451-4 doi 101016jajem201412012 Epub 2014 Dec 18
Prehospital pain management of injured children a systematic review of current evidence Samuel N1 Steiner IP2 Shavit I3 bull Prehospital pain ped pain assessment Prehosp Emerg Care 2008 Apr-Jun12(2)182-6 doi 10108010903120801907471 Prehospital
pain assessment in pediatric trauma Izsak E1 Moore JL Stringfellow K Oswanski MF Lindstrom DA Stombaugh HA bull Ped pain management Prehosp Emerg Care 2005 Jan-Mar9(1)40-3 Prehospital pain management in children suffering traumatic
injury Swor R1 McEachin CM Seguin D Grall KH bull Prehospital intervention Allen CJ Teisch LF et al Prehospital care and transportation of pediatric trauma patients J Surg Res 2015
Aug197(2)240-6 JAMA 2000 Feb 9283(6)783-90 bull Effect of out-of-hospital pediatric endotracheal intubation on survival and neurological outcome a controlled clinical trial
Gausche M1 Lewis RJ Stratton SJ Haynes BE Gunter CS Goodrich SM Poore PD McCollough MD Henderson DP Pratt FD Seidel JS
bull Pediatric pain management survey Pediatr Emerg Care 2015 Sep 23 [Epub ahead of print] An Assessment of Newly Identified Barriers to and Enablers for Prehospital Pediatric Pain Management Whitley DE1 Li T Jones CM Cushman JT Williams DM Shah MN
References 2 bull httpwwwuptodatecomcontentsprehospital-pediatrics-and-emergency-medical-services-emsabstract6 bull httpwwwuptodatecomcontentsprehospital-pediatrics-and-emergency-medical-services-emsabstract7 bull Pediatr Crit Care Med 2011 Jul12(4)e166-70 doi 101097PCC0b013e3181f36f6e First responder
performance in pediatric trauma a comparison with an adult cohortBankole S1 Asuncion A Ross S Aghai Z Nollah L Echols H Da-Silva S
bull Drayna pc Browne LR et al Prehospital pediatric care Oppportunities for training treatment and research Prehosp Emerg Care 2015 Jul-Sep 19(3) Epub 2015 Feb 6
bull Pediatr Emerg Care 2001 Feb17(1) 5-9Pediatric pre-hospital advanced life support care in an urban setting Babl FE1 Vinci RJ Bauchner H Mottley L
bull Pediatr Crit Care Med 2015 Oct16(8)e260-7 doi 101097PCC0000000000000505Pediatric Out-of-Hospital Critical Procedures in the United States Carlson JN1 Gannon E Mann NC Jacobson KE Dai M Colleran C Wang HE
bull Pediatr Emerg Care 2009 Aug25(8)508-12 doi 101097PEC0b013e3181b0a0da The efficacy of pediatric advanced life support training in emergency medical service providers Baker TW1 King W Soto W Asher C Stolfi A Rowin ME
bull Sutton RM Case E et al ROC investigators A quantitative analysis of out-of-hospital pediatric and adolescent resuscitation quality A report from the ROC Epistry- Cardiac Arrest Resusciation 201593150-157
bull Resuscitation 2014 Aug85(8)1059-64 doi 101016jresuscitation201403307 Epub 2014 Apr 4 Neurocognitive long term follow-up study on drowned children Suominen PK1 Sutinen N2 Valle S3 Olkkola KT4 Loumlnnqvist T3
bull J Pediatr Surg 2010 Jul45(7)1413-9 doi 101016jjpedsurg200912020 Prehospital cardiopulmonary resuscitation in the pediatric trauma patient Murphy JT1 Jaiswal K Sabella J Vinson L Megison S Maxson RT
References 3 bull Pre atv accident
httpwwwctvnewscapolopoly_fs119871591409741949httpImageimagejpg_genderivativeslandscape_960imagejpg bull atv pic httpswwwutahadvocatescomwp-contentuploads201402atvAccidentLawyerjpg bull Blunt abdominal solid organ injury adult vs pediatric trauma center J Pediatr Surg 2015 Aug 28 pii S0022-3468(15)00526-6 doi
101016jjpedsurg201508012 [Epub ahead of print] Trauma center variation in the management of pediatric patients with blunt abdominal solid organ injury a national trauma data bank analysis Safavi A1 Skarsgard ED2 Rhee P1 Zangbar B1 Kulvatunyou N1 Tang A1 OKeeffe T1 Friese RS1 Joseph B3
bull Pediatric blunt abdominal injury Curr Opin Crit Care 2015 Sep 28 [Epub ahead of print] Pediatric blunt abdominal trauma current management Notrica DM1
bull Pediatric splenic injury management Am J Surg 2015 Jul 31 pii S0002-9610(15)00417-1 doi 101016jamjsurg201506009 [Epub ahead of print] Comparative effectiveness of treatment strategies for severe splenic trauma in the pediatric population Rialon KL1 Englum BR1 Gulack BC1 Guevara CJ2 Bhattacharya SD3 Shapiro ML4 Rice HE5 Scarborough JE4 Adibe OO6
bull Liver pic httpss-media-cache-ak0pinimgcom736x7da50e7da50eb2bb603c99ef6649ff897e26b5jpg bull Solid organ injury non op in peds J Trauma Acute Care Surg 2015 Oct79(4)683-93 doi 101097TA0000000000000808
Nonoperative management of blunt liver and spleen injury in children Evaluation of the ATOMAC guideline using GRADE Notrica DM1 Eubanks JW 3rd Tuggle DW Maxson RT Letton RW Garcia NM Alder AC Lawson KA St Peter SD Megison S Garcia Filion P
bull Pediaric vs nonped trauma ct use J Pediatr 2015 Oct167(4)897-904e3 doi 101016jjpeds201506052 Epub 2015 Jul 29 Variation in Computed Tomography Imaging for Pediatric Injury-Related Emergency Visits Marin JR1 Wang L2 Winger DG2 Mannix RC3
bull Solid organ management in ped population J Trauma Acute Care Surg 2015 Aug79(2)206-14quiz 332 doi 101097TA0000000000000731 Management of children with solid organ injuries after blunt torso trauma Wisner DH1 Kuppermann N Cooper A Menaker J Ehrlich P Kooistra J Mahajan P Lee L Cook LJ Yen K Lillis K Holmes JF
bull Triad of death image httpimageslidesharecdncomdamage-control-resuscitation-1304253390-phpapp0195damage-control-resuscitation-14-728jpgcb=1304235553
bull Tranexamic acid study Eckert MJ Wertin TM Tyner SD et al 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 77852
bull Image care accident httpsuploadwikimediaorgwikipediacommonsthumbee1Car_crash_1jpg1280px-Car_crash_1jpg
References 4 bull httpwwwsurgeryvcuedudivisionsacutesurghtml bull Trauma management Approach to the unstable child
httpwwwuptodatecomcontentstrauma-management-approach-to-the-unstable-childsource=search_resultampsearch=pediatric+trauma+childrenampselectedTitle=17E150
bull Trauma management Unique pediatric considerations httpwwwuptodatecomcontentstrauma-management-unique-pediatric-considerationssource=search_resultampsearch=pediatric+trauma+childrenampselectedTitle=37E150
References 5 bull httpwwwetiquettehellcomsmfindexphptopic=8666360 bull httpwwwstlouischildrensorghealth-care-professionalsems-providers bull httpwwwuchicagokidshospitalorgspecialtiesemergency-medicinespecialhtml bull httpwwwsimsacademyinfoFXpatienthtm bull httptheemtspotcomwp-contentuploads200902another-burn-patient-by-annette-larsonjpg bull httplastangryfancomwp-contentuploads200910Clint-Malarchukjpg bull httpwwwtraumaorgarchiveresusmassivehtml bull httpwwwuptodatecomcontentsimageimageKey=PEDS68694amptopicKey=EM2F6389ampsourc
e=previewampsearch=pediatric+hemorrhagic+shockampselectedTitle=17E150amprank=undefined bull httptheemtspotcomwp-contentuploads200902gcsgif bull httpwwwuptodatecomcontentsimageimageKey=EM2F60409amptopicKey=EM2F6571amprank
=17E150ampsource=see_linkampsearch=traumaamputdPopup=true bull httpwwwuptodatecomcontentsimageimageKey=EM2F80874amptopicKey=EM2F6571amprank
=17E150ampsource=see_linkampsearch=traumaamputdPopup=true bull httpempracticenewswordpresscomcategorynexus-criteria bull httpswwwgooglecomsearchq=pediatric+glasgow+coma+scaleamptbm=ischamptbo=uampsource=uni
vampsa=Xampei=8TiOU7TNC5WuyATp5YG4BQampsqi=2ampved=0CDYQsAQampbiw=1426ampbih=883q=canadian+c-spine+rulesamptbm=ischampfacrc=_ampimgdii=_ampimgrc=WI94QMHgMLTQmM253A3BP5nbsFhNCXK0FM3Bhttp253A252F252Fwwwbmjcom252Fhighwire252Ffilestream252F436003252Ffield_highwire_fragment_image_l252F0jpg3Bhttp253A252F252Fwwwbmjcom252Fcontent252F339252Fbmjb41463B12803B1253
References 5 bull httpwwwuptodatecomcontentsimageimageKey=EM2F76777amptopicKey=EM2F6571amprank
=17E150ampsource=see_linkampsearch=traumaamputdPopup=true bull httpwwwdocumentingrealitycomforumattachmentsf14964898d1246625322-firework-injury-
m80injury1jpg bull httpwwwpediatriceducationorg20050620 bull httpwwwarmstrongmedicalcomindexcfmgoproductdetailsec3ssec19cat61fam515 bull httpwwwuptodatecomcontentsimageimageKey=PEDS61087amptopicKey=ID2F7661ampsource
=outline_linkampsearch=tetanus+prophylaxisamputdPopup=true bull httpwwwafsecafmilsharedmediaphotodbweb110609-F-MJ378-009jpg bull httpwwwuptodatecomcontentsimageimageKey=EM75765amptopicKey= bull EM2F6389ampsource=outline_linkampsearch=massive+transfusion+protocolamputdPopup=true bull httpwwwmotifakecomimagedemotivational-postersmall0910whats-the-question-ignorance-
calvin-and-hobbes-demotivational-poster-1255020127jpg
XXXXBoston study ems peds trauma procedures- limited pediatric procedural exposure (but more adult experience) bull Catchment area 590000
over 1 year bull 555 pediatric ALS
transport ndash 19 blunt trauma ndash 10 penetrating trauma
bull IV 33 bull BMV 5 bull Intubation 3 bull 50 ALS providers average
year ndash IV- 37 ndash Intubation- 03 ndash IO- 006
bull 7 ped ems ndash 13 trauma
bull Critical procedures ndash 101000 peds cases ndash Intubation 671000 ndash IO 51000 ndash 81 successful
Pediatr Emerg Care 2001 Feb17(1)5-9 Pediatric pre-hospital advanced life support care in an urban setting
Babl FE1 Vinci RJ Bauchner H Mottley L
Pediatr Crit Care Med 2015 Oct16(8)e260-7 doi 101097PCC0000000000000505 Pediatric Out-of-Hospital Critical Procedures in the United States
Carlson JN1 Gannon E Mann NC Jacobson KE Dai M Colleran C Wang HE
C-spine bull C-spine injuries rare bull Take pt to closest hospital if over injuries
call for it (ie resuscitation altered mental status) primary guide
bull Mechanism ndash Altered mental status focal neuro change
torticollis substantial torso injury diving high speed auto neck pain underlying predisposing condition Acad Emerg Med 2014 Jan21(1)55-64 doi 101111acem12288
Comparison of outcomes for children with cervical spine injury based on destination hospital from scene of injury Anders JF1 Adelgais K Hoyle JD Jr Olsen C Jaffe DM Leonard JC Pediatric Emergency Care Applied Research Network
(PECARN)
Ann Emerg Med 2011 Aug58(2)145-55 doi 101016jannemergmed201008038 Epub 2010 Oct 29 Factors associated with cervical spine injury in children after blunt trauma
Leonard JC Kuppermann N Olsen C Babcock-Cimpello L Brown K Mahajan P Adelgais KM Anders J Borgialli D Donoghue A Hoyle JD Jr Kim E Leonard JR Lillis KA Nigrovic LE Powell EC Rebella
G Reeves SD Rogers AJ Stankovic C Teshome G Jaffe DM Pediatric Emergency Care Applied Research Network
- Itrsquos Hard to Put a Band-Aid on a Broken Spleen Pediatric Trauma
- Disclosures
- Objectives
- Pediatric Prehospital Care
- Mechanism
- Traumatic Pain Management
- Pediatric Trauma
- Deaths by Mechanism of Injury
- Pediatric Trauma
- Pediatric Trauma
- Airway Differences
- Pediatric-Adult Differences
- Pediatric Challenges
- Prehospital Pediatric Challenges
- Pediatric and Adult Trauma
- Scene Response
- Prehospital Intervention
- Where do you take the patient
- Patient arrives at the EDhellip
- Primary Survey
- Order is critical
- Slide Number 22
- Slide Number 23
- Airway
- Indications for Intubation
- Breathing
- ETT Intubation Basics
- Circulation
- Slide Number 29
- CirculationHemodynamic Changes
- Circulation
- Fluid Resuscitation Algorithm
- Reconsidering Crystalloid Resuscitation
- When to start MTP
- Disability
- Finishing Up the Evaluation
- Bad Scene Responses
- OHCA from Trauma
- Blunt Trauma- No Signs of Life
- OHCA with CPR on Arrival
- Pediatric Trauma
- Questions
- References 1
- References 2
- References 3
- References 4
- References 5
- References 5
- XXXXBoston study ems peds trauma procedures- limited pediatric procedural exposure (but more adult experience)
- C-spine
httpwwwuptodatecomcontentsimageimageKey=EM2F64241amptopicKey=EM2F6571amprank=17E150ampsource=see_linkampsearch=traumaamputdPopup=true
Airway bull What are you assessing
ndash Airway patency bull What makes the airway not patent
ndash Foreign bodies ndash Vomitbloodsecretions ndash Edemahematoma ndash Impending obstruction
bull Interventions ndash Clearing foreign bodies ndash Suction secretionsvomit with yankauer ndash Repositioning- jaw thrust ndash Nasal trumpetoral airway ndash Intubation ndash Cricothyrotomy jet ventilation
Indications for Intubation
bull Respiratory arrest bull Impending respiratory failure bull Impending airway obstruction bull Inability to protect the airway bull GCS lt8 bull Declining GCS
Breathing bull What are you assessing
ndash ldquoGoodrdquo symmetric chest rise ndash Lung sounds ndash Aeration ndash Basic RR assessment (fast or minimalnone)
bull Interventions ndash Oxygen ndash Albuterolatrovent racemic epi ndash Positive pressure (CPAP BIPAP BMV) ndash Needle decompression ndash Chest tube thoracostomy ndash Intubation ndash Jet ventilation
ETT Intubation Basics bull Size
ndash Age4 + 4 or (Age +16)4 bull Depth
ndash ~ 3 x ETT size when over 1 year of age bull Blade size mac vs miller
ndash 0~ newborn ndash 1~ up to 2 years of life ndash 2~ 2-10 years ndash 3~ 10+ years
bull RSI medications ndash +-Sedation (Always before paralytic) ndash +-Paralytic (May not need it and never wo sedation)
Circulation
bull What do you assess ndash Central and peripheral pulses ndash Heart rate ndash Blood pressure systolic (age x2) +70 ndash Capillary refill ndash Cardiac activity on FAST ndash End organ perfusion
bull Mental status bull Urine output
Circulation Hemodynamic Changes
Percent Blood Volume Loss 0 15 25 35 45
Heart Rate
Blood Pressure
Cardiac Output
Circulation
ndash Access 2 large bore IVrsquos ndash IVFrsquos ndash pRBCrsquos
bull Hgb lt7gdl or ongoing blood losses
ndash Massive Transfusion Protocol
bull (111 ratio of PRBCS FFP Platelets)
ndash Vasopressors (epi norepi dopamine)
ndash Control of Hemorrhage bull Pelvic binders bull Direct pressure bull Indirectproximal pressure bull Tourniquet (only when
absolutely necessary)
ndash Chest Compressions ndash Pericardiocentesis ndash Delayed resuscitation
controlled hypotension (MAP 50 vs 65)
ndash Tranexamic acid in the near future
bull Interventions
Fluid Resuscitation Algorithm 20 mLkg isotonic crystalloid
Reassess
20 mLkg isotonic crystalloid
Reassess
20 mLkg isotonic crystalloid (31 rule)
or consider 10 to 20 mLkg packed red cells
Reconsidering Crystalloid Resuscitation
bull Less fluid ndash Permissive hypotension to
prevent clot rupture (select cases)
bull Too much fluid ndash Excessive Third Spacing ndash Secondary Compartment
Syndrome ndash Greater risk of ARDS ndash Dilutional Coagulopathy
When to start MTP
bull As soon as you believe you will need it ndash Institution specific guidelines
bull gt4 units or 40mlkg of PRBCrsquos expected bull Earlier use of Massive Transfusion Protocol
(pRBC FFP PLT) in ldquoDamage Controlrdquo resuscitations may improve outcome
bull 111 unit ratio bull Risk of TRALI ARDS etc
Disability bull GCS
ndash Range 3-15 ndash We should be 15 ndash Dead are still 3 ndash Less than 8 intubate ndash Eyes- 4 eyes ndash Verbal- most difficult ndash Motor- V6 engine ndash Intubated T
bull AVPU
Finishing Up the Evaluation
bull Airway bull Breathing bull Circulation bull Disability bull Exposure
ndash Expose and examine all parts ndash Cover quickly and keep warm
bull Secondary Survey
Bad Scene Responses
bull What are the outcomes of out-of-hospital cardiac arrest from blunt trauma
bull What are the outcomes of pediatric drowning patients
OHCA from Trauma
bull 2000-2003 bull 123 pts bull Mean age 73 yrs bull Most common
rhythms ndash Asystole 59 ndash PEA 29 ndash V-fib 35
bull 195 rosc in field ndash 98 survived for 24
hrs ndash 57 survived to
discharge ndash Drowning- 19
survival to discharge ndash Bystander CPR tripled
the survivor rate
Blunt Trauma- No Signs of Life
bull Review from 2002-2010 bull No signs of life- 025 of blunt trauma
ndash 25 resuscitated prior to hospital arrival bull 138 of these patients survived to discharge
bull 44 overall survived to hospital discharge
OHCA with CPR on Arrival
bull 169 children bull 141 deaths bull 69 required cpr on arrival- none survived bull 87 of patients requiring CPR on arrival
expired in the ED bull Of the 28 survivors
ndash 55 of survivors had full neurologic recovery
Pediatric Trauma
bull Fortunately these cases represent only a small fraction of EMS transports
bull Despite a few key differences pediatric trauma care overall is very similar to adult trauma care
Questions
References 1 bull NTDB 2013 pediatric Report bull Monkey bars httpsplaygroundchroniclesfileswordpresscom201307soccerjpg bull Screaming child httpblogsbabycentercomwp-contentuploads201409screaming-child-tantrum-fitjpg bull Pediatric airway image httpwwwcelebritydiagnosiscomwp-contentuploads201003pediatric-airwayjpg bull Child on backboard httpsencrypted-tbn2gstaticcomimagesq=tbnANd9GcQscrDVc8IH4MwkNGF6F1A9p7mSVzik5zrWyNvI-
qSwQT5S3GNyVg bull Elbow fracture httpwwwimageinterpretationcoukimageselbowSUPRACONDYLAR20LAT3jpg bull Bike riding httpsmile-per-daycomwp-contentuploads201412klr03jpg bull Dad and child pic httplaughingsquidcomwp-contentuploads471160jpg bull Weigth estimation inner city Am J Emerg Med 2015 Oct33(10)1364-7 doi 101016jajem201507040 Epub 2015 Jul 29 Weight
estimation in an inner-city pediatric ED the effect of obesity Chavez H1 Peterson RE2 Lo K3 Arel M4
bull Guess weight sign httpmedialiveauctiongroupneti963110572971_1jpgv=8CDDAAF8A5B9E20 bull Broselow tape httpsuploadwikimediaorgwikipediacommons994BTape1jpg bull Parent screaming httpmommyofamonstercomwp-contentuploads201301yellingjpg bull Prehospital pain management Am J Emerg Med 2015 Mar33(3)451-4 doi 101016jajem201412012 Epub 2014 Dec 18
Prehospital pain management of injured children a systematic review of current evidence Samuel N1 Steiner IP2 Shavit I3 bull Prehospital pain ped pain assessment Prehosp Emerg Care 2008 Apr-Jun12(2)182-6 doi 10108010903120801907471 Prehospital
pain assessment in pediatric trauma Izsak E1 Moore JL Stringfellow K Oswanski MF Lindstrom DA Stombaugh HA bull Ped pain management Prehosp Emerg Care 2005 Jan-Mar9(1)40-3 Prehospital pain management in children suffering traumatic
injury Swor R1 McEachin CM Seguin D Grall KH bull Prehospital intervention Allen CJ Teisch LF et al Prehospital care and transportation of pediatric trauma patients J Surg Res 2015
Aug197(2)240-6 JAMA 2000 Feb 9283(6)783-90 bull Effect of out-of-hospital pediatric endotracheal intubation on survival and neurological outcome a controlled clinical trial
Gausche M1 Lewis RJ Stratton SJ Haynes BE Gunter CS Goodrich SM Poore PD McCollough MD Henderson DP Pratt FD Seidel JS
bull Pediatric pain management survey Pediatr Emerg Care 2015 Sep 23 [Epub ahead of print] An Assessment of Newly Identified Barriers to and Enablers for Prehospital Pediatric Pain Management Whitley DE1 Li T Jones CM Cushman JT Williams DM Shah MN
References 2 bull httpwwwuptodatecomcontentsprehospital-pediatrics-and-emergency-medical-services-emsabstract6 bull httpwwwuptodatecomcontentsprehospital-pediatrics-and-emergency-medical-services-emsabstract7 bull Pediatr Crit Care Med 2011 Jul12(4)e166-70 doi 101097PCC0b013e3181f36f6e First responder
performance in pediatric trauma a comparison with an adult cohortBankole S1 Asuncion A Ross S Aghai Z Nollah L Echols H Da-Silva S
bull Drayna pc Browne LR et al Prehospital pediatric care Oppportunities for training treatment and research Prehosp Emerg Care 2015 Jul-Sep 19(3) Epub 2015 Feb 6
bull Pediatr Emerg Care 2001 Feb17(1) 5-9Pediatric pre-hospital advanced life support care in an urban setting Babl FE1 Vinci RJ Bauchner H Mottley L
bull Pediatr Crit Care Med 2015 Oct16(8)e260-7 doi 101097PCC0000000000000505Pediatric Out-of-Hospital Critical Procedures in the United States Carlson JN1 Gannon E Mann NC Jacobson KE Dai M Colleran C Wang HE
bull Pediatr Emerg Care 2009 Aug25(8)508-12 doi 101097PEC0b013e3181b0a0da The efficacy of pediatric advanced life support training in emergency medical service providers Baker TW1 King W Soto W Asher C Stolfi A Rowin ME
bull Sutton RM Case E et al ROC investigators A quantitative analysis of out-of-hospital pediatric and adolescent resuscitation quality A report from the ROC Epistry- Cardiac Arrest Resusciation 201593150-157
bull Resuscitation 2014 Aug85(8)1059-64 doi 101016jresuscitation201403307 Epub 2014 Apr 4 Neurocognitive long term follow-up study on drowned children Suominen PK1 Sutinen N2 Valle S3 Olkkola KT4 Loumlnnqvist T3
bull J Pediatr Surg 2010 Jul45(7)1413-9 doi 101016jjpedsurg200912020 Prehospital cardiopulmonary resuscitation in the pediatric trauma patient Murphy JT1 Jaiswal K Sabella J Vinson L Megison S Maxson RT
References 3 bull Pre atv accident
httpwwwctvnewscapolopoly_fs119871591409741949httpImageimagejpg_genderivativeslandscape_960imagejpg bull atv pic httpswwwutahadvocatescomwp-contentuploads201402atvAccidentLawyerjpg bull Blunt abdominal solid organ injury adult vs pediatric trauma center J Pediatr Surg 2015 Aug 28 pii S0022-3468(15)00526-6 doi
101016jjpedsurg201508012 [Epub ahead of print] Trauma center variation in the management of pediatric patients with blunt abdominal solid organ injury a national trauma data bank analysis Safavi A1 Skarsgard ED2 Rhee P1 Zangbar B1 Kulvatunyou N1 Tang A1 OKeeffe T1 Friese RS1 Joseph B3
bull Pediatric blunt abdominal injury Curr Opin Crit Care 2015 Sep 28 [Epub ahead of print] Pediatric blunt abdominal trauma current management Notrica DM1
bull Pediatric splenic injury management Am J Surg 2015 Jul 31 pii S0002-9610(15)00417-1 doi 101016jamjsurg201506009 [Epub ahead of print] Comparative effectiveness of treatment strategies for severe splenic trauma in the pediatric population Rialon KL1 Englum BR1 Gulack BC1 Guevara CJ2 Bhattacharya SD3 Shapiro ML4 Rice HE5 Scarborough JE4 Adibe OO6
bull Liver pic httpss-media-cache-ak0pinimgcom736x7da50e7da50eb2bb603c99ef6649ff897e26b5jpg bull Solid organ injury non op in peds J Trauma Acute Care Surg 2015 Oct79(4)683-93 doi 101097TA0000000000000808
Nonoperative management of blunt liver and spleen injury in children Evaluation of the ATOMAC guideline using GRADE Notrica DM1 Eubanks JW 3rd Tuggle DW Maxson RT Letton RW Garcia NM Alder AC Lawson KA St Peter SD Megison S Garcia Filion P
bull Pediaric vs nonped trauma ct use J Pediatr 2015 Oct167(4)897-904e3 doi 101016jjpeds201506052 Epub 2015 Jul 29 Variation in Computed Tomography Imaging for Pediatric Injury-Related Emergency Visits Marin JR1 Wang L2 Winger DG2 Mannix RC3
bull Solid organ management in ped population J Trauma Acute Care Surg 2015 Aug79(2)206-14quiz 332 doi 101097TA0000000000000731 Management of children with solid organ injuries after blunt torso trauma Wisner DH1 Kuppermann N Cooper A Menaker J Ehrlich P Kooistra J Mahajan P Lee L Cook LJ Yen K Lillis K Holmes JF
bull Triad of death image httpimageslidesharecdncomdamage-control-resuscitation-1304253390-phpapp0195damage-control-resuscitation-14-728jpgcb=1304235553
bull Tranexamic acid study Eckert MJ Wertin TM Tyner SD et al 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 77852
bull Image care accident httpsuploadwikimediaorgwikipediacommonsthumbee1Car_crash_1jpg1280px-Car_crash_1jpg
References 4 bull httpwwwsurgeryvcuedudivisionsacutesurghtml bull Trauma management Approach to the unstable child
httpwwwuptodatecomcontentstrauma-management-approach-to-the-unstable-childsource=search_resultampsearch=pediatric+trauma+childrenampselectedTitle=17E150
bull Trauma management Unique pediatric considerations httpwwwuptodatecomcontentstrauma-management-unique-pediatric-considerationssource=search_resultampsearch=pediatric+trauma+childrenampselectedTitle=37E150
References 5 bull httpwwwetiquettehellcomsmfindexphptopic=8666360 bull httpwwwstlouischildrensorghealth-care-professionalsems-providers bull httpwwwuchicagokidshospitalorgspecialtiesemergency-medicinespecialhtml bull httpwwwsimsacademyinfoFXpatienthtm bull httptheemtspotcomwp-contentuploads200902another-burn-patient-by-annette-larsonjpg bull httplastangryfancomwp-contentuploads200910Clint-Malarchukjpg bull httpwwwtraumaorgarchiveresusmassivehtml bull httpwwwuptodatecomcontentsimageimageKey=PEDS68694amptopicKey=EM2F6389ampsourc
e=previewampsearch=pediatric+hemorrhagic+shockampselectedTitle=17E150amprank=undefined bull httptheemtspotcomwp-contentuploads200902gcsgif bull httpwwwuptodatecomcontentsimageimageKey=EM2F60409amptopicKey=EM2F6571amprank
=17E150ampsource=see_linkampsearch=traumaamputdPopup=true bull httpwwwuptodatecomcontentsimageimageKey=EM2F80874amptopicKey=EM2F6571amprank
=17E150ampsource=see_linkampsearch=traumaamputdPopup=true bull httpempracticenewswordpresscomcategorynexus-criteria bull httpswwwgooglecomsearchq=pediatric+glasgow+coma+scaleamptbm=ischamptbo=uampsource=uni
vampsa=Xampei=8TiOU7TNC5WuyATp5YG4BQampsqi=2ampved=0CDYQsAQampbiw=1426ampbih=883q=canadian+c-spine+rulesamptbm=ischampfacrc=_ampimgdii=_ampimgrc=WI94QMHgMLTQmM253A3BP5nbsFhNCXK0FM3Bhttp253A252F252Fwwwbmjcom252Fhighwire252Ffilestream252F436003252Ffield_highwire_fragment_image_l252F0jpg3Bhttp253A252F252Fwwwbmjcom252Fcontent252F339252Fbmjb41463B12803B1253
References 5 bull httpwwwuptodatecomcontentsimageimageKey=EM2F76777amptopicKey=EM2F6571amprank
=17E150ampsource=see_linkampsearch=traumaamputdPopup=true bull httpwwwdocumentingrealitycomforumattachmentsf14964898d1246625322-firework-injury-
m80injury1jpg bull httpwwwpediatriceducationorg20050620 bull httpwwwarmstrongmedicalcomindexcfmgoproductdetailsec3ssec19cat61fam515 bull httpwwwuptodatecomcontentsimageimageKey=PEDS61087amptopicKey=ID2F7661ampsource
=outline_linkampsearch=tetanus+prophylaxisamputdPopup=true bull httpwwwafsecafmilsharedmediaphotodbweb110609-F-MJ378-009jpg bull httpwwwuptodatecomcontentsimageimageKey=EM75765amptopicKey= bull EM2F6389ampsource=outline_linkampsearch=massive+transfusion+protocolamputdPopup=true bull httpwwwmotifakecomimagedemotivational-postersmall0910whats-the-question-ignorance-
calvin-and-hobbes-demotivational-poster-1255020127jpg
XXXXBoston study ems peds trauma procedures- limited pediatric procedural exposure (but more adult experience) bull Catchment area 590000
over 1 year bull 555 pediatric ALS
transport ndash 19 blunt trauma ndash 10 penetrating trauma
bull IV 33 bull BMV 5 bull Intubation 3 bull 50 ALS providers average
year ndash IV- 37 ndash Intubation- 03 ndash IO- 006
bull 7 ped ems ndash 13 trauma
bull Critical procedures ndash 101000 peds cases ndash Intubation 671000 ndash IO 51000 ndash 81 successful
Pediatr Emerg Care 2001 Feb17(1)5-9 Pediatric pre-hospital advanced life support care in an urban setting
Babl FE1 Vinci RJ Bauchner H Mottley L
Pediatr Crit Care Med 2015 Oct16(8)e260-7 doi 101097PCC0000000000000505 Pediatric Out-of-Hospital Critical Procedures in the United States
Carlson JN1 Gannon E Mann NC Jacobson KE Dai M Colleran C Wang HE
C-spine bull C-spine injuries rare bull Take pt to closest hospital if over injuries
call for it (ie resuscitation altered mental status) primary guide
bull Mechanism ndash Altered mental status focal neuro change
torticollis substantial torso injury diving high speed auto neck pain underlying predisposing condition Acad Emerg Med 2014 Jan21(1)55-64 doi 101111acem12288
Comparison of outcomes for children with cervical spine injury based on destination hospital from scene of injury Anders JF1 Adelgais K Hoyle JD Jr Olsen C Jaffe DM Leonard JC Pediatric Emergency Care Applied Research Network
(PECARN)
Ann Emerg Med 2011 Aug58(2)145-55 doi 101016jannemergmed201008038 Epub 2010 Oct 29 Factors associated with cervical spine injury in children after blunt trauma
Leonard JC Kuppermann N Olsen C Babcock-Cimpello L Brown K Mahajan P Adelgais KM Anders J Borgialli D Donoghue A Hoyle JD Jr Kim E Leonard JR Lillis KA Nigrovic LE Powell EC Rebella
G Reeves SD Rogers AJ Stankovic C Teshome G Jaffe DM Pediatric Emergency Care Applied Research Network
- Itrsquos Hard to Put a Band-Aid on a Broken Spleen Pediatric Trauma
- Disclosures
- Objectives
- Pediatric Prehospital Care
- Mechanism
- Traumatic Pain Management
- Pediatric Trauma
- Deaths by Mechanism of Injury
- Pediatric Trauma
- Pediatric Trauma
- Airway Differences
- Pediatric-Adult Differences
- Pediatric Challenges
- Prehospital Pediatric Challenges
- Pediatric and Adult Trauma
- Scene Response
- Prehospital Intervention
- Where do you take the patient
- Patient arrives at the EDhellip
- Primary Survey
- Order is critical
- Slide Number 22
- Slide Number 23
- Airway
- Indications for Intubation
- Breathing
- ETT Intubation Basics
- Circulation
- Slide Number 29
- CirculationHemodynamic Changes
- Circulation
- Fluid Resuscitation Algorithm
- Reconsidering Crystalloid Resuscitation
- When to start MTP
- Disability
- Finishing Up the Evaluation
- Bad Scene Responses
- OHCA from Trauma
- Blunt Trauma- No Signs of Life
- OHCA with CPR on Arrival
- Pediatric Trauma
- Questions
- References 1
- References 2
- References 3
- References 4
- References 5
- References 5
- XXXXBoston study ems peds trauma procedures- limited pediatric procedural exposure (but more adult experience)
- C-spine
Airway bull What are you assessing
ndash Airway patency bull What makes the airway not patent
ndash Foreign bodies ndash Vomitbloodsecretions ndash Edemahematoma ndash Impending obstruction
bull Interventions ndash Clearing foreign bodies ndash Suction secretionsvomit with yankauer ndash Repositioning- jaw thrust ndash Nasal trumpetoral airway ndash Intubation ndash Cricothyrotomy jet ventilation
Indications for Intubation
bull Respiratory arrest bull Impending respiratory failure bull Impending airway obstruction bull Inability to protect the airway bull GCS lt8 bull Declining GCS
Breathing bull What are you assessing
ndash ldquoGoodrdquo symmetric chest rise ndash Lung sounds ndash Aeration ndash Basic RR assessment (fast or minimalnone)
bull Interventions ndash Oxygen ndash Albuterolatrovent racemic epi ndash Positive pressure (CPAP BIPAP BMV) ndash Needle decompression ndash Chest tube thoracostomy ndash Intubation ndash Jet ventilation
ETT Intubation Basics bull Size
ndash Age4 + 4 or (Age +16)4 bull Depth
ndash ~ 3 x ETT size when over 1 year of age bull Blade size mac vs miller
ndash 0~ newborn ndash 1~ up to 2 years of life ndash 2~ 2-10 years ndash 3~ 10+ years
bull RSI medications ndash +-Sedation (Always before paralytic) ndash +-Paralytic (May not need it and never wo sedation)
Circulation
bull What do you assess ndash Central and peripheral pulses ndash Heart rate ndash Blood pressure systolic (age x2) +70 ndash Capillary refill ndash Cardiac activity on FAST ndash End organ perfusion
bull Mental status bull Urine output
Circulation Hemodynamic Changes
Percent Blood Volume Loss 0 15 25 35 45
Heart Rate
Blood Pressure
Cardiac Output
Circulation
ndash Access 2 large bore IVrsquos ndash IVFrsquos ndash pRBCrsquos
bull Hgb lt7gdl or ongoing blood losses
ndash Massive Transfusion Protocol
bull (111 ratio of PRBCS FFP Platelets)
ndash Vasopressors (epi norepi dopamine)
ndash Control of Hemorrhage bull Pelvic binders bull Direct pressure bull Indirectproximal pressure bull Tourniquet (only when
absolutely necessary)
ndash Chest Compressions ndash Pericardiocentesis ndash Delayed resuscitation
controlled hypotension (MAP 50 vs 65)
ndash Tranexamic acid in the near future
bull Interventions
Fluid Resuscitation Algorithm 20 mLkg isotonic crystalloid
Reassess
20 mLkg isotonic crystalloid
Reassess
20 mLkg isotonic crystalloid (31 rule)
or consider 10 to 20 mLkg packed red cells
Reconsidering Crystalloid Resuscitation
bull Less fluid ndash Permissive hypotension to
prevent clot rupture (select cases)
bull Too much fluid ndash Excessive Third Spacing ndash Secondary Compartment
Syndrome ndash Greater risk of ARDS ndash Dilutional Coagulopathy
When to start MTP
bull As soon as you believe you will need it ndash Institution specific guidelines
bull gt4 units or 40mlkg of PRBCrsquos expected bull Earlier use of Massive Transfusion Protocol
(pRBC FFP PLT) in ldquoDamage Controlrdquo resuscitations may improve outcome
bull 111 unit ratio bull Risk of TRALI ARDS etc
Disability bull GCS
ndash Range 3-15 ndash We should be 15 ndash Dead are still 3 ndash Less than 8 intubate ndash Eyes- 4 eyes ndash Verbal- most difficult ndash Motor- V6 engine ndash Intubated T
bull AVPU
Finishing Up the Evaluation
bull Airway bull Breathing bull Circulation bull Disability bull Exposure
ndash Expose and examine all parts ndash Cover quickly and keep warm
bull Secondary Survey
Bad Scene Responses
bull What are the outcomes of out-of-hospital cardiac arrest from blunt trauma
bull What are the outcomes of pediatric drowning patients
OHCA from Trauma
bull 2000-2003 bull 123 pts bull Mean age 73 yrs bull Most common
rhythms ndash Asystole 59 ndash PEA 29 ndash V-fib 35
bull 195 rosc in field ndash 98 survived for 24
hrs ndash 57 survived to
discharge ndash Drowning- 19
survival to discharge ndash Bystander CPR tripled
the survivor rate
Blunt Trauma- No Signs of Life
bull Review from 2002-2010 bull No signs of life- 025 of blunt trauma
ndash 25 resuscitated prior to hospital arrival bull 138 of these patients survived to discharge
bull 44 overall survived to hospital discharge
OHCA with CPR on Arrival
bull 169 children bull 141 deaths bull 69 required cpr on arrival- none survived bull 87 of patients requiring CPR on arrival
expired in the ED bull Of the 28 survivors
ndash 55 of survivors had full neurologic recovery
Pediatric Trauma
bull Fortunately these cases represent only a small fraction of EMS transports
bull Despite a few key differences pediatric trauma care overall is very similar to adult trauma care
Questions
References 1 bull NTDB 2013 pediatric Report bull Monkey bars httpsplaygroundchroniclesfileswordpresscom201307soccerjpg bull Screaming child httpblogsbabycentercomwp-contentuploads201409screaming-child-tantrum-fitjpg bull Pediatric airway image httpwwwcelebritydiagnosiscomwp-contentuploads201003pediatric-airwayjpg bull Child on backboard httpsencrypted-tbn2gstaticcomimagesq=tbnANd9GcQscrDVc8IH4MwkNGF6F1A9p7mSVzik5zrWyNvI-
qSwQT5S3GNyVg bull Elbow fracture httpwwwimageinterpretationcoukimageselbowSUPRACONDYLAR20LAT3jpg bull Bike riding httpsmile-per-daycomwp-contentuploads201412klr03jpg bull Dad and child pic httplaughingsquidcomwp-contentuploads471160jpg bull Weigth estimation inner city Am J Emerg Med 2015 Oct33(10)1364-7 doi 101016jajem201507040 Epub 2015 Jul 29 Weight
estimation in an inner-city pediatric ED the effect of obesity Chavez H1 Peterson RE2 Lo K3 Arel M4
bull Guess weight sign httpmedialiveauctiongroupneti963110572971_1jpgv=8CDDAAF8A5B9E20 bull Broselow tape httpsuploadwikimediaorgwikipediacommons994BTape1jpg bull Parent screaming httpmommyofamonstercomwp-contentuploads201301yellingjpg bull Prehospital pain management Am J Emerg Med 2015 Mar33(3)451-4 doi 101016jajem201412012 Epub 2014 Dec 18
Prehospital pain management of injured children a systematic review of current evidence Samuel N1 Steiner IP2 Shavit I3 bull Prehospital pain ped pain assessment Prehosp Emerg Care 2008 Apr-Jun12(2)182-6 doi 10108010903120801907471 Prehospital
pain assessment in pediatric trauma Izsak E1 Moore JL Stringfellow K Oswanski MF Lindstrom DA Stombaugh HA bull Ped pain management Prehosp Emerg Care 2005 Jan-Mar9(1)40-3 Prehospital pain management in children suffering traumatic
injury Swor R1 McEachin CM Seguin D Grall KH bull Prehospital intervention Allen CJ Teisch LF et al Prehospital care and transportation of pediatric trauma patients J Surg Res 2015
Aug197(2)240-6 JAMA 2000 Feb 9283(6)783-90 bull Effect of out-of-hospital pediatric endotracheal intubation on survival and neurological outcome a controlled clinical trial
Gausche M1 Lewis RJ Stratton SJ Haynes BE Gunter CS Goodrich SM Poore PD McCollough MD Henderson DP Pratt FD Seidel JS
bull Pediatric pain management survey Pediatr Emerg Care 2015 Sep 23 [Epub ahead of print] An Assessment of Newly Identified Barriers to and Enablers for Prehospital Pediatric Pain Management Whitley DE1 Li T Jones CM Cushman JT Williams DM Shah MN
References 2 bull httpwwwuptodatecomcontentsprehospital-pediatrics-and-emergency-medical-services-emsabstract6 bull httpwwwuptodatecomcontentsprehospital-pediatrics-and-emergency-medical-services-emsabstract7 bull Pediatr Crit Care Med 2011 Jul12(4)e166-70 doi 101097PCC0b013e3181f36f6e First responder
performance in pediatric trauma a comparison with an adult cohortBankole S1 Asuncion A Ross S Aghai Z Nollah L Echols H Da-Silva S
bull Drayna pc Browne LR et al Prehospital pediatric care Oppportunities for training treatment and research Prehosp Emerg Care 2015 Jul-Sep 19(3) Epub 2015 Feb 6
bull Pediatr Emerg Care 2001 Feb17(1) 5-9Pediatric pre-hospital advanced life support care in an urban setting Babl FE1 Vinci RJ Bauchner H Mottley L
bull Pediatr Crit Care Med 2015 Oct16(8)e260-7 doi 101097PCC0000000000000505Pediatric Out-of-Hospital Critical Procedures in the United States Carlson JN1 Gannon E Mann NC Jacobson KE Dai M Colleran C Wang HE
bull Pediatr Emerg Care 2009 Aug25(8)508-12 doi 101097PEC0b013e3181b0a0da The efficacy of pediatric advanced life support training in emergency medical service providers Baker TW1 King W Soto W Asher C Stolfi A Rowin ME
bull Sutton RM Case E et al ROC investigators A quantitative analysis of out-of-hospital pediatric and adolescent resuscitation quality A report from the ROC Epistry- Cardiac Arrest Resusciation 201593150-157
bull Resuscitation 2014 Aug85(8)1059-64 doi 101016jresuscitation201403307 Epub 2014 Apr 4 Neurocognitive long term follow-up study on drowned children Suominen PK1 Sutinen N2 Valle S3 Olkkola KT4 Loumlnnqvist T3
bull J Pediatr Surg 2010 Jul45(7)1413-9 doi 101016jjpedsurg200912020 Prehospital cardiopulmonary resuscitation in the pediatric trauma patient Murphy JT1 Jaiswal K Sabella J Vinson L Megison S Maxson RT
References 3 bull Pre atv accident
httpwwwctvnewscapolopoly_fs119871591409741949httpImageimagejpg_genderivativeslandscape_960imagejpg bull atv pic httpswwwutahadvocatescomwp-contentuploads201402atvAccidentLawyerjpg bull Blunt abdominal solid organ injury adult vs pediatric trauma center J Pediatr Surg 2015 Aug 28 pii S0022-3468(15)00526-6 doi
101016jjpedsurg201508012 [Epub ahead of print] Trauma center variation in the management of pediatric patients with blunt abdominal solid organ injury a national trauma data bank analysis Safavi A1 Skarsgard ED2 Rhee P1 Zangbar B1 Kulvatunyou N1 Tang A1 OKeeffe T1 Friese RS1 Joseph B3
bull Pediatric blunt abdominal injury Curr Opin Crit Care 2015 Sep 28 [Epub ahead of print] Pediatric blunt abdominal trauma current management Notrica DM1
bull Pediatric splenic injury management Am J Surg 2015 Jul 31 pii S0002-9610(15)00417-1 doi 101016jamjsurg201506009 [Epub ahead of print] Comparative effectiveness of treatment strategies for severe splenic trauma in the pediatric population Rialon KL1 Englum BR1 Gulack BC1 Guevara CJ2 Bhattacharya SD3 Shapiro ML4 Rice HE5 Scarborough JE4 Adibe OO6
bull Liver pic httpss-media-cache-ak0pinimgcom736x7da50e7da50eb2bb603c99ef6649ff897e26b5jpg bull Solid organ injury non op in peds J Trauma Acute Care Surg 2015 Oct79(4)683-93 doi 101097TA0000000000000808
Nonoperative management of blunt liver and spleen injury in children Evaluation of the ATOMAC guideline using GRADE Notrica DM1 Eubanks JW 3rd Tuggle DW Maxson RT Letton RW Garcia NM Alder AC Lawson KA St Peter SD Megison S Garcia Filion P
bull Pediaric vs nonped trauma ct use J Pediatr 2015 Oct167(4)897-904e3 doi 101016jjpeds201506052 Epub 2015 Jul 29 Variation in Computed Tomography Imaging for Pediatric Injury-Related Emergency Visits Marin JR1 Wang L2 Winger DG2 Mannix RC3
bull Solid organ management in ped population J Trauma Acute Care Surg 2015 Aug79(2)206-14quiz 332 doi 101097TA0000000000000731 Management of children with solid organ injuries after blunt torso trauma Wisner DH1 Kuppermann N Cooper A Menaker J Ehrlich P Kooistra J Mahajan P Lee L Cook LJ Yen K Lillis K Holmes JF
bull Triad of death image httpimageslidesharecdncomdamage-control-resuscitation-1304253390-phpapp0195damage-control-resuscitation-14-728jpgcb=1304235553
bull Tranexamic acid study Eckert MJ Wertin TM Tyner SD et al 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 77852
bull Image care accident httpsuploadwikimediaorgwikipediacommonsthumbee1Car_crash_1jpg1280px-Car_crash_1jpg
References 4 bull httpwwwsurgeryvcuedudivisionsacutesurghtml bull Trauma management Approach to the unstable child
httpwwwuptodatecomcontentstrauma-management-approach-to-the-unstable-childsource=search_resultampsearch=pediatric+trauma+childrenampselectedTitle=17E150
bull Trauma management Unique pediatric considerations httpwwwuptodatecomcontentstrauma-management-unique-pediatric-considerationssource=search_resultampsearch=pediatric+trauma+childrenampselectedTitle=37E150
References 5 bull httpwwwetiquettehellcomsmfindexphptopic=8666360 bull httpwwwstlouischildrensorghealth-care-professionalsems-providers bull httpwwwuchicagokidshospitalorgspecialtiesemergency-medicinespecialhtml bull httpwwwsimsacademyinfoFXpatienthtm bull httptheemtspotcomwp-contentuploads200902another-burn-patient-by-annette-larsonjpg bull httplastangryfancomwp-contentuploads200910Clint-Malarchukjpg bull httpwwwtraumaorgarchiveresusmassivehtml bull httpwwwuptodatecomcontentsimageimageKey=PEDS68694amptopicKey=EM2F6389ampsourc
e=previewampsearch=pediatric+hemorrhagic+shockampselectedTitle=17E150amprank=undefined bull httptheemtspotcomwp-contentuploads200902gcsgif bull httpwwwuptodatecomcontentsimageimageKey=EM2F60409amptopicKey=EM2F6571amprank
=17E150ampsource=see_linkampsearch=traumaamputdPopup=true bull httpwwwuptodatecomcontentsimageimageKey=EM2F80874amptopicKey=EM2F6571amprank
=17E150ampsource=see_linkampsearch=traumaamputdPopup=true bull httpempracticenewswordpresscomcategorynexus-criteria bull httpswwwgooglecomsearchq=pediatric+glasgow+coma+scaleamptbm=ischamptbo=uampsource=uni
vampsa=Xampei=8TiOU7TNC5WuyATp5YG4BQampsqi=2ampved=0CDYQsAQampbiw=1426ampbih=883q=canadian+c-spine+rulesamptbm=ischampfacrc=_ampimgdii=_ampimgrc=WI94QMHgMLTQmM253A3BP5nbsFhNCXK0FM3Bhttp253A252F252Fwwwbmjcom252Fhighwire252Ffilestream252F436003252Ffield_highwire_fragment_image_l252F0jpg3Bhttp253A252F252Fwwwbmjcom252Fcontent252F339252Fbmjb41463B12803B1253
References 5 bull httpwwwuptodatecomcontentsimageimageKey=EM2F76777amptopicKey=EM2F6571amprank
=17E150ampsource=see_linkampsearch=traumaamputdPopup=true bull httpwwwdocumentingrealitycomforumattachmentsf14964898d1246625322-firework-injury-
m80injury1jpg bull httpwwwpediatriceducationorg20050620 bull httpwwwarmstrongmedicalcomindexcfmgoproductdetailsec3ssec19cat61fam515 bull httpwwwuptodatecomcontentsimageimageKey=PEDS61087amptopicKey=ID2F7661ampsource
=outline_linkampsearch=tetanus+prophylaxisamputdPopup=true bull httpwwwafsecafmilsharedmediaphotodbweb110609-F-MJ378-009jpg bull httpwwwuptodatecomcontentsimageimageKey=EM75765amptopicKey= bull EM2F6389ampsource=outline_linkampsearch=massive+transfusion+protocolamputdPopup=true bull httpwwwmotifakecomimagedemotivational-postersmall0910whats-the-question-ignorance-
calvin-and-hobbes-demotivational-poster-1255020127jpg
XXXXBoston study ems peds trauma procedures- limited pediatric procedural exposure (but more adult experience) bull Catchment area 590000
over 1 year bull 555 pediatric ALS
transport ndash 19 blunt trauma ndash 10 penetrating trauma
bull IV 33 bull BMV 5 bull Intubation 3 bull 50 ALS providers average
year ndash IV- 37 ndash Intubation- 03 ndash IO- 006
bull 7 ped ems ndash 13 trauma
bull Critical procedures ndash 101000 peds cases ndash Intubation 671000 ndash IO 51000 ndash 81 successful
Pediatr Emerg Care 2001 Feb17(1)5-9 Pediatric pre-hospital advanced life support care in an urban setting
Babl FE1 Vinci RJ Bauchner H Mottley L
Pediatr Crit Care Med 2015 Oct16(8)e260-7 doi 101097PCC0000000000000505 Pediatric Out-of-Hospital Critical Procedures in the United States
Carlson JN1 Gannon E Mann NC Jacobson KE Dai M Colleran C Wang HE
C-spine bull C-spine injuries rare bull Take pt to closest hospital if over injuries
call for it (ie resuscitation altered mental status) primary guide
bull Mechanism ndash Altered mental status focal neuro change
torticollis substantial torso injury diving high speed auto neck pain underlying predisposing condition Acad Emerg Med 2014 Jan21(1)55-64 doi 101111acem12288
Comparison of outcomes for children with cervical spine injury based on destination hospital from scene of injury Anders JF1 Adelgais K Hoyle JD Jr Olsen C Jaffe DM Leonard JC Pediatric Emergency Care Applied Research Network
(PECARN)
Ann Emerg Med 2011 Aug58(2)145-55 doi 101016jannemergmed201008038 Epub 2010 Oct 29 Factors associated with cervical spine injury in children after blunt trauma
Leonard JC Kuppermann N Olsen C Babcock-Cimpello L Brown K Mahajan P Adelgais KM Anders J Borgialli D Donoghue A Hoyle JD Jr Kim E Leonard JR Lillis KA Nigrovic LE Powell EC Rebella
G Reeves SD Rogers AJ Stankovic C Teshome G Jaffe DM Pediatric Emergency Care Applied Research Network
- Itrsquos Hard to Put a Band-Aid on a Broken Spleen Pediatric Trauma
- Disclosures
- Objectives
- Pediatric Prehospital Care
- Mechanism
- Traumatic Pain Management
- Pediatric Trauma
- Deaths by Mechanism of Injury
- Pediatric Trauma
- Pediatric Trauma
- Airway Differences
- Pediatric-Adult Differences
- Pediatric Challenges
- Prehospital Pediatric Challenges
- Pediatric and Adult Trauma
- Scene Response
- Prehospital Intervention
- Where do you take the patient
- Patient arrives at the EDhellip
- Primary Survey
- Order is critical
- Slide Number 22
- Slide Number 23
- Airway
- Indications for Intubation
- Breathing
- ETT Intubation Basics
- Circulation
- Slide Number 29
- CirculationHemodynamic Changes
- Circulation
- Fluid Resuscitation Algorithm
- Reconsidering Crystalloid Resuscitation
- When to start MTP
- Disability
- Finishing Up the Evaluation
- Bad Scene Responses
- OHCA from Trauma
- Blunt Trauma- No Signs of Life
- OHCA with CPR on Arrival
- Pediatric Trauma
- Questions
- References 1
- References 2
- References 3
- References 4
- References 5
- References 5
- XXXXBoston study ems peds trauma procedures- limited pediatric procedural exposure (but more adult experience)
- C-spine
Indications for Intubation
bull Respiratory arrest bull Impending respiratory failure bull Impending airway obstruction bull Inability to protect the airway bull GCS lt8 bull Declining GCS
Breathing bull What are you assessing
ndash ldquoGoodrdquo symmetric chest rise ndash Lung sounds ndash Aeration ndash Basic RR assessment (fast or minimalnone)
bull Interventions ndash Oxygen ndash Albuterolatrovent racemic epi ndash Positive pressure (CPAP BIPAP BMV) ndash Needle decompression ndash Chest tube thoracostomy ndash Intubation ndash Jet ventilation
ETT Intubation Basics bull Size
ndash Age4 + 4 or (Age +16)4 bull Depth
ndash ~ 3 x ETT size when over 1 year of age bull Blade size mac vs miller
ndash 0~ newborn ndash 1~ up to 2 years of life ndash 2~ 2-10 years ndash 3~ 10+ years
bull RSI medications ndash +-Sedation (Always before paralytic) ndash +-Paralytic (May not need it and never wo sedation)
Circulation
bull What do you assess ndash Central and peripheral pulses ndash Heart rate ndash Blood pressure systolic (age x2) +70 ndash Capillary refill ndash Cardiac activity on FAST ndash End organ perfusion
bull Mental status bull Urine output
Circulation Hemodynamic Changes
Percent Blood Volume Loss 0 15 25 35 45
Heart Rate
Blood Pressure
Cardiac Output
Circulation
ndash Access 2 large bore IVrsquos ndash IVFrsquos ndash pRBCrsquos
bull Hgb lt7gdl or ongoing blood losses
ndash Massive Transfusion Protocol
bull (111 ratio of PRBCS FFP Platelets)
ndash Vasopressors (epi norepi dopamine)
ndash Control of Hemorrhage bull Pelvic binders bull Direct pressure bull Indirectproximal pressure bull Tourniquet (only when
absolutely necessary)
ndash Chest Compressions ndash Pericardiocentesis ndash Delayed resuscitation
controlled hypotension (MAP 50 vs 65)
ndash Tranexamic acid in the near future
bull Interventions
Fluid Resuscitation Algorithm 20 mLkg isotonic crystalloid
Reassess
20 mLkg isotonic crystalloid
Reassess
20 mLkg isotonic crystalloid (31 rule)
or consider 10 to 20 mLkg packed red cells
Reconsidering Crystalloid Resuscitation
bull Less fluid ndash Permissive hypotension to
prevent clot rupture (select cases)
bull Too much fluid ndash Excessive Third Spacing ndash Secondary Compartment
Syndrome ndash Greater risk of ARDS ndash Dilutional Coagulopathy
When to start MTP
bull As soon as you believe you will need it ndash Institution specific guidelines
bull gt4 units or 40mlkg of PRBCrsquos expected bull Earlier use of Massive Transfusion Protocol
(pRBC FFP PLT) in ldquoDamage Controlrdquo resuscitations may improve outcome
bull 111 unit ratio bull Risk of TRALI ARDS etc
Disability bull GCS
ndash Range 3-15 ndash We should be 15 ndash Dead are still 3 ndash Less than 8 intubate ndash Eyes- 4 eyes ndash Verbal- most difficult ndash Motor- V6 engine ndash Intubated T
bull AVPU
Finishing Up the Evaluation
bull Airway bull Breathing bull Circulation bull Disability bull Exposure
ndash Expose and examine all parts ndash Cover quickly and keep warm
bull Secondary Survey
Bad Scene Responses
bull What are the outcomes of out-of-hospital cardiac arrest from blunt trauma
bull What are the outcomes of pediatric drowning patients
OHCA from Trauma
bull 2000-2003 bull 123 pts bull Mean age 73 yrs bull Most common
rhythms ndash Asystole 59 ndash PEA 29 ndash V-fib 35
bull 195 rosc in field ndash 98 survived for 24
hrs ndash 57 survived to
discharge ndash Drowning- 19
survival to discharge ndash Bystander CPR tripled
the survivor rate
Blunt Trauma- No Signs of Life
bull Review from 2002-2010 bull No signs of life- 025 of blunt trauma
ndash 25 resuscitated prior to hospital arrival bull 138 of these patients survived to discharge
bull 44 overall survived to hospital discharge
OHCA with CPR on Arrival
bull 169 children bull 141 deaths bull 69 required cpr on arrival- none survived bull 87 of patients requiring CPR on arrival
expired in the ED bull Of the 28 survivors
ndash 55 of survivors had full neurologic recovery
Pediatric Trauma
bull Fortunately these cases represent only a small fraction of EMS transports
bull Despite a few key differences pediatric trauma care overall is very similar to adult trauma care
Questions
References 1 bull NTDB 2013 pediatric Report bull Monkey bars httpsplaygroundchroniclesfileswordpresscom201307soccerjpg bull Screaming child httpblogsbabycentercomwp-contentuploads201409screaming-child-tantrum-fitjpg bull Pediatric airway image httpwwwcelebritydiagnosiscomwp-contentuploads201003pediatric-airwayjpg bull Child on backboard httpsencrypted-tbn2gstaticcomimagesq=tbnANd9GcQscrDVc8IH4MwkNGF6F1A9p7mSVzik5zrWyNvI-
qSwQT5S3GNyVg bull Elbow fracture httpwwwimageinterpretationcoukimageselbowSUPRACONDYLAR20LAT3jpg bull Bike riding httpsmile-per-daycomwp-contentuploads201412klr03jpg bull Dad and child pic httplaughingsquidcomwp-contentuploads471160jpg bull Weigth estimation inner city Am J Emerg Med 2015 Oct33(10)1364-7 doi 101016jajem201507040 Epub 2015 Jul 29 Weight
estimation in an inner-city pediatric ED the effect of obesity Chavez H1 Peterson RE2 Lo K3 Arel M4
bull Guess weight sign httpmedialiveauctiongroupneti963110572971_1jpgv=8CDDAAF8A5B9E20 bull Broselow tape httpsuploadwikimediaorgwikipediacommons994BTape1jpg bull Parent screaming httpmommyofamonstercomwp-contentuploads201301yellingjpg bull Prehospital pain management Am J Emerg Med 2015 Mar33(3)451-4 doi 101016jajem201412012 Epub 2014 Dec 18
Prehospital pain management of injured children a systematic review of current evidence Samuel N1 Steiner IP2 Shavit I3 bull Prehospital pain ped pain assessment Prehosp Emerg Care 2008 Apr-Jun12(2)182-6 doi 10108010903120801907471 Prehospital
pain assessment in pediatric trauma Izsak E1 Moore JL Stringfellow K Oswanski MF Lindstrom DA Stombaugh HA bull Ped pain management Prehosp Emerg Care 2005 Jan-Mar9(1)40-3 Prehospital pain management in children suffering traumatic
injury Swor R1 McEachin CM Seguin D Grall KH bull Prehospital intervention Allen CJ Teisch LF et al Prehospital care and transportation of pediatric trauma patients J Surg Res 2015
Aug197(2)240-6 JAMA 2000 Feb 9283(6)783-90 bull Effect of out-of-hospital pediatric endotracheal intubation on survival and neurological outcome a controlled clinical trial
Gausche M1 Lewis RJ Stratton SJ Haynes BE Gunter CS Goodrich SM Poore PD McCollough MD Henderson DP Pratt FD Seidel JS
bull Pediatric pain management survey Pediatr Emerg Care 2015 Sep 23 [Epub ahead of print] An Assessment of Newly Identified Barriers to and Enablers for Prehospital Pediatric Pain Management Whitley DE1 Li T Jones CM Cushman JT Williams DM Shah MN
References 2 bull httpwwwuptodatecomcontentsprehospital-pediatrics-and-emergency-medical-services-emsabstract6 bull httpwwwuptodatecomcontentsprehospital-pediatrics-and-emergency-medical-services-emsabstract7 bull Pediatr Crit Care Med 2011 Jul12(4)e166-70 doi 101097PCC0b013e3181f36f6e First responder
performance in pediatric trauma a comparison with an adult cohortBankole S1 Asuncion A Ross S Aghai Z Nollah L Echols H Da-Silva S
bull Drayna pc Browne LR et al Prehospital pediatric care Oppportunities for training treatment and research Prehosp Emerg Care 2015 Jul-Sep 19(3) Epub 2015 Feb 6
bull Pediatr Emerg Care 2001 Feb17(1) 5-9Pediatric pre-hospital advanced life support care in an urban setting Babl FE1 Vinci RJ Bauchner H Mottley L
bull Pediatr Crit Care Med 2015 Oct16(8)e260-7 doi 101097PCC0000000000000505Pediatric Out-of-Hospital Critical Procedures in the United States Carlson JN1 Gannon E Mann NC Jacobson KE Dai M Colleran C Wang HE
bull Pediatr Emerg Care 2009 Aug25(8)508-12 doi 101097PEC0b013e3181b0a0da The efficacy of pediatric advanced life support training in emergency medical service providers Baker TW1 King W Soto W Asher C Stolfi A Rowin ME
bull Sutton RM Case E et al ROC investigators A quantitative analysis of out-of-hospital pediatric and adolescent resuscitation quality A report from the ROC Epistry- Cardiac Arrest Resusciation 201593150-157
bull Resuscitation 2014 Aug85(8)1059-64 doi 101016jresuscitation201403307 Epub 2014 Apr 4 Neurocognitive long term follow-up study on drowned children Suominen PK1 Sutinen N2 Valle S3 Olkkola KT4 Loumlnnqvist T3
bull J Pediatr Surg 2010 Jul45(7)1413-9 doi 101016jjpedsurg200912020 Prehospital cardiopulmonary resuscitation in the pediatric trauma patient Murphy JT1 Jaiswal K Sabella J Vinson L Megison S Maxson RT
References 3 bull Pre atv accident
httpwwwctvnewscapolopoly_fs119871591409741949httpImageimagejpg_genderivativeslandscape_960imagejpg bull atv pic httpswwwutahadvocatescomwp-contentuploads201402atvAccidentLawyerjpg bull Blunt abdominal solid organ injury adult vs pediatric trauma center J Pediatr Surg 2015 Aug 28 pii S0022-3468(15)00526-6 doi
101016jjpedsurg201508012 [Epub ahead of print] Trauma center variation in the management of pediatric patients with blunt abdominal solid organ injury a national trauma data bank analysis Safavi A1 Skarsgard ED2 Rhee P1 Zangbar B1 Kulvatunyou N1 Tang A1 OKeeffe T1 Friese RS1 Joseph B3
bull Pediatric blunt abdominal injury Curr Opin Crit Care 2015 Sep 28 [Epub ahead of print] Pediatric blunt abdominal trauma current management Notrica DM1
bull Pediatric splenic injury management Am J Surg 2015 Jul 31 pii S0002-9610(15)00417-1 doi 101016jamjsurg201506009 [Epub ahead of print] Comparative effectiveness of treatment strategies for severe splenic trauma in the pediatric population Rialon KL1 Englum BR1 Gulack BC1 Guevara CJ2 Bhattacharya SD3 Shapiro ML4 Rice HE5 Scarborough JE4 Adibe OO6
bull Liver pic httpss-media-cache-ak0pinimgcom736x7da50e7da50eb2bb603c99ef6649ff897e26b5jpg bull Solid organ injury non op in peds J Trauma Acute Care Surg 2015 Oct79(4)683-93 doi 101097TA0000000000000808
Nonoperative management of blunt liver and spleen injury in children Evaluation of the ATOMAC guideline using GRADE Notrica DM1 Eubanks JW 3rd Tuggle DW Maxson RT Letton RW Garcia NM Alder AC Lawson KA St Peter SD Megison S Garcia Filion P
bull Pediaric vs nonped trauma ct use J Pediatr 2015 Oct167(4)897-904e3 doi 101016jjpeds201506052 Epub 2015 Jul 29 Variation in Computed Tomography Imaging for Pediatric Injury-Related Emergency Visits Marin JR1 Wang L2 Winger DG2 Mannix RC3
bull Solid organ management in ped population J Trauma Acute Care Surg 2015 Aug79(2)206-14quiz 332 doi 101097TA0000000000000731 Management of children with solid organ injuries after blunt torso trauma Wisner DH1 Kuppermann N Cooper A Menaker J Ehrlich P Kooistra J Mahajan P Lee L Cook LJ Yen K Lillis K Holmes JF
bull Triad of death image httpimageslidesharecdncomdamage-control-resuscitation-1304253390-phpapp0195damage-control-resuscitation-14-728jpgcb=1304235553
bull Tranexamic acid study Eckert MJ Wertin TM Tyner SD et al 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 77852
bull Image care accident httpsuploadwikimediaorgwikipediacommonsthumbee1Car_crash_1jpg1280px-Car_crash_1jpg
References 4 bull httpwwwsurgeryvcuedudivisionsacutesurghtml bull Trauma management Approach to the unstable child
httpwwwuptodatecomcontentstrauma-management-approach-to-the-unstable-childsource=search_resultampsearch=pediatric+trauma+childrenampselectedTitle=17E150
bull Trauma management Unique pediatric considerations httpwwwuptodatecomcontentstrauma-management-unique-pediatric-considerationssource=search_resultampsearch=pediatric+trauma+childrenampselectedTitle=37E150
References 5 bull httpwwwetiquettehellcomsmfindexphptopic=8666360 bull httpwwwstlouischildrensorghealth-care-professionalsems-providers bull httpwwwuchicagokidshospitalorgspecialtiesemergency-medicinespecialhtml bull httpwwwsimsacademyinfoFXpatienthtm bull httptheemtspotcomwp-contentuploads200902another-burn-patient-by-annette-larsonjpg bull httplastangryfancomwp-contentuploads200910Clint-Malarchukjpg bull httpwwwtraumaorgarchiveresusmassivehtml bull httpwwwuptodatecomcontentsimageimageKey=PEDS68694amptopicKey=EM2F6389ampsourc
e=previewampsearch=pediatric+hemorrhagic+shockampselectedTitle=17E150amprank=undefined bull httptheemtspotcomwp-contentuploads200902gcsgif bull httpwwwuptodatecomcontentsimageimageKey=EM2F60409amptopicKey=EM2F6571amprank
=17E150ampsource=see_linkampsearch=traumaamputdPopup=true bull httpwwwuptodatecomcontentsimageimageKey=EM2F80874amptopicKey=EM2F6571amprank
=17E150ampsource=see_linkampsearch=traumaamputdPopup=true bull httpempracticenewswordpresscomcategorynexus-criteria bull httpswwwgooglecomsearchq=pediatric+glasgow+coma+scaleamptbm=ischamptbo=uampsource=uni
vampsa=Xampei=8TiOU7TNC5WuyATp5YG4BQampsqi=2ampved=0CDYQsAQampbiw=1426ampbih=883q=canadian+c-spine+rulesamptbm=ischampfacrc=_ampimgdii=_ampimgrc=WI94QMHgMLTQmM253A3BP5nbsFhNCXK0FM3Bhttp253A252F252Fwwwbmjcom252Fhighwire252Ffilestream252F436003252Ffield_highwire_fragment_image_l252F0jpg3Bhttp253A252F252Fwwwbmjcom252Fcontent252F339252Fbmjb41463B12803B1253
References 5 bull httpwwwuptodatecomcontentsimageimageKey=EM2F76777amptopicKey=EM2F6571amprank
=17E150ampsource=see_linkampsearch=traumaamputdPopup=true bull httpwwwdocumentingrealitycomforumattachmentsf14964898d1246625322-firework-injury-
m80injury1jpg bull httpwwwpediatriceducationorg20050620 bull httpwwwarmstrongmedicalcomindexcfmgoproductdetailsec3ssec19cat61fam515 bull httpwwwuptodatecomcontentsimageimageKey=PEDS61087amptopicKey=ID2F7661ampsource
=outline_linkampsearch=tetanus+prophylaxisamputdPopup=true bull httpwwwafsecafmilsharedmediaphotodbweb110609-F-MJ378-009jpg bull httpwwwuptodatecomcontentsimageimageKey=EM75765amptopicKey= bull EM2F6389ampsource=outline_linkampsearch=massive+transfusion+protocolamputdPopup=true bull httpwwwmotifakecomimagedemotivational-postersmall0910whats-the-question-ignorance-
calvin-and-hobbes-demotivational-poster-1255020127jpg
XXXXBoston study ems peds trauma procedures- limited pediatric procedural exposure (but more adult experience) bull Catchment area 590000
over 1 year bull 555 pediatric ALS
transport ndash 19 blunt trauma ndash 10 penetrating trauma
bull IV 33 bull BMV 5 bull Intubation 3 bull 50 ALS providers average
year ndash IV- 37 ndash Intubation- 03 ndash IO- 006
bull 7 ped ems ndash 13 trauma
bull Critical procedures ndash 101000 peds cases ndash Intubation 671000 ndash IO 51000 ndash 81 successful
Pediatr Emerg Care 2001 Feb17(1)5-9 Pediatric pre-hospital advanced life support care in an urban setting
Babl FE1 Vinci RJ Bauchner H Mottley L
Pediatr Crit Care Med 2015 Oct16(8)e260-7 doi 101097PCC0000000000000505 Pediatric Out-of-Hospital Critical Procedures in the United States
Carlson JN1 Gannon E Mann NC Jacobson KE Dai M Colleran C Wang HE
C-spine bull C-spine injuries rare bull Take pt to closest hospital if over injuries
call for it (ie resuscitation altered mental status) primary guide
bull Mechanism ndash Altered mental status focal neuro change
torticollis substantial torso injury diving high speed auto neck pain underlying predisposing condition Acad Emerg Med 2014 Jan21(1)55-64 doi 101111acem12288
Comparison of outcomes for children with cervical spine injury based on destination hospital from scene of injury Anders JF1 Adelgais K Hoyle JD Jr Olsen C Jaffe DM Leonard JC Pediatric Emergency Care Applied Research Network
(PECARN)
Ann Emerg Med 2011 Aug58(2)145-55 doi 101016jannemergmed201008038 Epub 2010 Oct 29 Factors associated with cervical spine injury in children after blunt trauma
Leonard JC Kuppermann N Olsen C Babcock-Cimpello L Brown K Mahajan P Adelgais KM Anders J Borgialli D Donoghue A Hoyle JD Jr Kim E Leonard JR Lillis KA Nigrovic LE Powell EC Rebella
G Reeves SD Rogers AJ Stankovic C Teshome G Jaffe DM Pediatric Emergency Care Applied Research Network
- Itrsquos Hard to Put a Band-Aid on a Broken Spleen Pediatric Trauma
- Disclosures
- Objectives
- Pediatric Prehospital Care
- Mechanism
- Traumatic Pain Management
- Pediatric Trauma
- Deaths by Mechanism of Injury
- Pediatric Trauma
- Pediatric Trauma
- Airway Differences
- Pediatric-Adult Differences
- Pediatric Challenges
- Prehospital Pediatric Challenges
- Pediatric and Adult Trauma
- Scene Response
- Prehospital Intervention
- Where do you take the patient
- Patient arrives at the EDhellip
- Primary Survey
- Order is critical
- Slide Number 22
- Slide Number 23
- Airway
- Indications for Intubation
- Breathing
- ETT Intubation Basics
- Circulation
- Slide Number 29
- CirculationHemodynamic Changes
- Circulation
- Fluid Resuscitation Algorithm
- Reconsidering Crystalloid Resuscitation
- When to start MTP
- Disability
- Finishing Up the Evaluation
- Bad Scene Responses
- OHCA from Trauma
- Blunt Trauma- No Signs of Life
- OHCA with CPR on Arrival
- Pediatric Trauma
- Questions
- References 1
- References 2
- References 3
- References 4
- References 5
- References 5
- XXXXBoston study ems peds trauma procedures- limited pediatric procedural exposure (but more adult experience)
- C-spine
Breathing bull What are you assessing
ndash ldquoGoodrdquo symmetric chest rise ndash Lung sounds ndash Aeration ndash Basic RR assessment (fast or minimalnone)
bull Interventions ndash Oxygen ndash Albuterolatrovent racemic epi ndash Positive pressure (CPAP BIPAP BMV) ndash Needle decompression ndash Chest tube thoracostomy ndash Intubation ndash Jet ventilation
ETT Intubation Basics bull Size
ndash Age4 + 4 or (Age +16)4 bull Depth
ndash ~ 3 x ETT size when over 1 year of age bull Blade size mac vs miller
ndash 0~ newborn ndash 1~ up to 2 years of life ndash 2~ 2-10 years ndash 3~ 10+ years
bull RSI medications ndash +-Sedation (Always before paralytic) ndash +-Paralytic (May not need it and never wo sedation)
Circulation
bull What do you assess ndash Central and peripheral pulses ndash Heart rate ndash Blood pressure systolic (age x2) +70 ndash Capillary refill ndash Cardiac activity on FAST ndash End organ perfusion
bull Mental status bull Urine output
Circulation Hemodynamic Changes
Percent Blood Volume Loss 0 15 25 35 45
Heart Rate
Blood Pressure
Cardiac Output
Circulation
ndash Access 2 large bore IVrsquos ndash IVFrsquos ndash pRBCrsquos
bull Hgb lt7gdl or ongoing blood losses
ndash Massive Transfusion Protocol
bull (111 ratio of PRBCS FFP Platelets)
ndash Vasopressors (epi norepi dopamine)
ndash Control of Hemorrhage bull Pelvic binders bull Direct pressure bull Indirectproximal pressure bull Tourniquet (only when
absolutely necessary)
ndash Chest Compressions ndash Pericardiocentesis ndash Delayed resuscitation
controlled hypotension (MAP 50 vs 65)
ndash Tranexamic acid in the near future
bull Interventions
Fluid Resuscitation Algorithm 20 mLkg isotonic crystalloid
Reassess
20 mLkg isotonic crystalloid
Reassess
20 mLkg isotonic crystalloid (31 rule)
or consider 10 to 20 mLkg packed red cells
Reconsidering Crystalloid Resuscitation
bull Less fluid ndash Permissive hypotension to
prevent clot rupture (select cases)
bull Too much fluid ndash Excessive Third Spacing ndash Secondary Compartment
Syndrome ndash Greater risk of ARDS ndash Dilutional Coagulopathy
When to start MTP
bull As soon as you believe you will need it ndash Institution specific guidelines
bull gt4 units or 40mlkg of PRBCrsquos expected bull Earlier use of Massive Transfusion Protocol
(pRBC FFP PLT) in ldquoDamage Controlrdquo resuscitations may improve outcome
bull 111 unit ratio bull Risk of TRALI ARDS etc
Disability bull GCS
ndash Range 3-15 ndash We should be 15 ndash Dead are still 3 ndash Less than 8 intubate ndash Eyes- 4 eyes ndash Verbal- most difficult ndash Motor- V6 engine ndash Intubated T
bull AVPU
Finishing Up the Evaluation
bull Airway bull Breathing bull Circulation bull Disability bull Exposure
ndash Expose and examine all parts ndash Cover quickly and keep warm
bull Secondary Survey
Bad Scene Responses
bull What are the outcomes of out-of-hospital cardiac arrest from blunt trauma
bull What are the outcomes of pediatric drowning patients
OHCA from Trauma
bull 2000-2003 bull 123 pts bull Mean age 73 yrs bull Most common
rhythms ndash Asystole 59 ndash PEA 29 ndash V-fib 35
bull 195 rosc in field ndash 98 survived for 24
hrs ndash 57 survived to
discharge ndash Drowning- 19
survival to discharge ndash Bystander CPR tripled
the survivor rate
Blunt Trauma- No Signs of Life
bull Review from 2002-2010 bull No signs of life- 025 of blunt trauma
ndash 25 resuscitated prior to hospital arrival bull 138 of these patients survived to discharge
bull 44 overall survived to hospital discharge
OHCA with CPR on Arrival
bull 169 children bull 141 deaths bull 69 required cpr on arrival- none survived bull 87 of patients requiring CPR on arrival
expired in the ED bull Of the 28 survivors
ndash 55 of survivors had full neurologic recovery
Pediatric Trauma
bull Fortunately these cases represent only a small fraction of EMS transports
bull Despite a few key differences pediatric trauma care overall is very similar to adult trauma care
Questions
References 1 bull NTDB 2013 pediatric Report bull Monkey bars httpsplaygroundchroniclesfileswordpresscom201307soccerjpg bull Screaming child httpblogsbabycentercomwp-contentuploads201409screaming-child-tantrum-fitjpg bull Pediatric airway image httpwwwcelebritydiagnosiscomwp-contentuploads201003pediatric-airwayjpg bull Child on backboard httpsencrypted-tbn2gstaticcomimagesq=tbnANd9GcQscrDVc8IH4MwkNGF6F1A9p7mSVzik5zrWyNvI-
qSwQT5S3GNyVg bull Elbow fracture httpwwwimageinterpretationcoukimageselbowSUPRACONDYLAR20LAT3jpg bull Bike riding httpsmile-per-daycomwp-contentuploads201412klr03jpg bull Dad and child pic httplaughingsquidcomwp-contentuploads471160jpg bull Weigth estimation inner city Am J Emerg Med 2015 Oct33(10)1364-7 doi 101016jajem201507040 Epub 2015 Jul 29 Weight
estimation in an inner-city pediatric ED the effect of obesity Chavez H1 Peterson RE2 Lo K3 Arel M4
bull Guess weight sign httpmedialiveauctiongroupneti963110572971_1jpgv=8CDDAAF8A5B9E20 bull Broselow tape httpsuploadwikimediaorgwikipediacommons994BTape1jpg bull Parent screaming httpmommyofamonstercomwp-contentuploads201301yellingjpg bull Prehospital pain management Am J Emerg Med 2015 Mar33(3)451-4 doi 101016jajem201412012 Epub 2014 Dec 18
Prehospital pain management of injured children a systematic review of current evidence Samuel N1 Steiner IP2 Shavit I3 bull Prehospital pain ped pain assessment Prehosp Emerg Care 2008 Apr-Jun12(2)182-6 doi 10108010903120801907471 Prehospital
pain assessment in pediatric trauma Izsak E1 Moore JL Stringfellow K Oswanski MF Lindstrom DA Stombaugh HA bull Ped pain management Prehosp Emerg Care 2005 Jan-Mar9(1)40-3 Prehospital pain management in children suffering traumatic
injury Swor R1 McEachin CM Seguin D Grall KH bull Prehospital intervention Allen CJ Teisch LF et al Prehospital care and transportation of pediatric trauma patients J Surg Res 2015
Aug197(2)240-6 JAMA 2000 Feb 9283(6)783-90 bull Effect of out-of-hospital pediatric endotracheal intubation on survival and neurological outcome a controlled clinical trial
Gausche M1 Lewis RJ Stratton SJ Haynes BE Gunter CS Goodrich SM Poore PD McCollough MD Henderson DP Pratt FD Seidel JS
bull Pediatric pain management survey Pediatr Emerg Care 2015 Sep 23 [Epub ahead of print] An Assessment of Newly Identified Barriers to and Enablers for Prehospital Pediatric Pain Management Whitley DE1 Li T Jones CM Cushman JT Williams DM Shah MN
References 2 bull httpwwwuptodatecomcontentsprehospital-pediatrics-and-emergency-medical-services-emsabstract6 bull httpwwwuptodatecomcontentsprehospital-pediatrics-and-emergency-medical-services-emsabstract7 bull Pediatr Crit Care Med 2011 Jul12(4)e166-70 doi 101097PCC0b013e3181f36f6e First responder
performance in pediatric trauma a comparison with an adult cohortBankole S1 Asuncion A Ross S Aghai Z Nollah L Echols H Da-Silva S
bull Drayna pc Browne LR et al Prehospital pediatric care Oppportunities for training treatment and research Prehosp Emerg Care 2015 Jul-Sep 19(3) Epub 2015 Feb 6
bull Pediatr Emerg Care 2001 Feb17(1) 5-9Pediatric pre-hospital advanced life support care in an urban setting Babl FE1 Vinci RJ Bauchner H Mottley L
bull Pediatr Crit Care Med 2015 Oct16(8)e260-7 doi 101097PCC0000000000000505Pediatric Out-of-Hospital Critical Procedures in the United States Carlson JN1 Gannon E Mann NC Jacobson KE Dai M Colleran C Wang HE
bull Pediatr Emerg Care 2009 Aug25(8)508-12 doi 101097PEC0b013e3181b0a0da The efficacy of pediatric advanced life support training in emergency medical service providers Baker TW1 King W Soto W Asher C Stolfi A Rowin ME
bull Sutton RM Case E et al ROC investigators A quantitative analysis of out-of-hospital pediatric and adolescent resuscitation quality A report from the ROC Epistry- Cardiac Arrest Resusciation 201593150-157
bull Resuscitation 2014 Aug85(8)1059-64 doi 101016jresuscitation201403307 Epub 2014 Apr 4 Neurocognitive long term follow-up study on drowned children Suominen PK1 Sutinen N2 Valle S3 Olkkola KT4 Loumlnnqvist T3
bull J Pediatr Surg 2010 Jul45(7)1413-9 doi 101016jjpedsurg200912020 Prehospital cardiopulmonary resuscitation in the pediatric trauma patient Murphy JT1 Jaiswal K Sabella J Vinson L Megison S Maxson RT
References 3 bull Pre atv accident
httpwwwctvnewscapolopoly_fs119871591409741949httpImageimagejpg_genderivativeslandscape_960imagejpg bull atv pic httpswwwutahadvocatescomwp-contentuploads201402atvAccidentLawyerjpg bull Blunt abdominal solid organ injury adult vs pediatric trauma center J Pediatr Surg 2015 Aug 28 pii S0022-3468(15)00526-6 doi
101016jjpedsurg201508012 [Epub ahead of print] Trauma center variation in the management of pediatric patients with blunt abdominal solid organ injury a national trauma data bank analysis Safavi A1 Skarsgard ED2 Rhee P1 Zangbar B1 Kulvatunyou N1 Tang A1 OKeeffe T1 Friese RS1 Joseph B3
bull Pediatric blunt abdominal injury Curr Opin Crit Care 2015 Sep 28 [Epub ahead of print] Pediatric blunt abdominal trauma current management Notrica DM1
bull Pediatric splenic injury management Am J Surg 2015 Jul 31 pii S0002-9610(15)00417-1 doi 101016jamjsurg201506009 [Epub ahead of print] Comparative effectiveness of treatment strategies for severe splenic trauma in the pediatric population Rialon KL1 Englum BR1 Gulack BC1 Guevara CJ2 Bhattacharya SD3 Shapiro ML4 Rice HE5 Scarborough JE4 Adibe OO6
bull Liver pic httpss-media-cache-ak0pinimgcom736x7da50e7da50eb2bb603c99ef6649ff897e26b5jpg bull Solid organ injury non op in peds J Trauma Acute Care Surg 2015 Oct79(4)683-93 doi 101097TA0000000000000808
Nonoperative management of blunt liver and spleen injury in children Evaluation of the ATOMAC guideline using GRADE Notrica DM1 Eubanks JW 3rd Tuggle DW Maxson RT Letton RW Garcia NM Alder AC Lawson KA St Peter SD Megison S Garcia Filion P
bull Pediaric vs nonped trauma ct use J Pediatr 2015 Oct167(4)897-904e3 doi 101016jjpeds201506052 Epub 2015 Jul 29 Variation in Computed Tomography Imaging for Pediatric Injury-Related Emergency Visits Marin JR1 Wang L2 Winger DG2 Mannix RC3
bull Solid organ management in ped population J Trauma Acute Care Surg 2015 Aug79(2)206-14quiz 332 doi 101097TA0000000000000731 Management of children with solid organ injuries after blunt torso trauma Wisner DH1 Kuppermann N Cooper A Menaker J Ehrlich P Kooistra J Mahajan P Lee L Cook LJ Yen K Lillis K Holmes JF
bull Triad of death image httpimageslidesharecdncomdamage-control-resuscitation-1304253390-phpapp0195damage-control-resuscitation-14-728jpgcb=1304235553
bull Tranexamic acid study Eckert MJ Wertin TM Tyner SD et al 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 77852
bull Image care accident httpsuploadwikimediaorgwikipediacommonsthumbee1Car_crash_1jpg1280px-Car_crash_1jpg
References 4 bull httpwwwsurgeryvcuedudivisionsacutesurghtml bull Trauma management Approach to the unstable child
httpwwwuptodatecomcontentstrauma-management-approach-to-the-unstable-childsource=search_resultampsearch=pediatric+trauma+childrenampselectedTitle=17E150
bull Trauma management Unique pediatric considerations httpwwwuptodatecomcontentstrauma-management-unique-pediatric-considerationssource=search_resultampsearch=pediatric+trauma+childrenampselectedTitle=37E150
References 5 bull httpwwwetiquettehellcomsmfindexphptopic=8666360 bull httpwwwstlouischildrensorghealth-care-professionalsems-providers bull httpwwwuchicagokidshospitalorgspecialtiesemergency-medicinespecialhtml bull httpwwwsimsacademyinfoFXpatienthtm bull httptheemtspotcomwp-contentuploads200902another-burn-patient-by-annette-larsonjpg bull httplastangryfancomwp-contentuploads200910Clint-Malarchukjpg bull httpwwwtraumaorgarchiveresusmassivehtml bull httpwwwuptodatecomcontentsimageimageKey=PEDS68694amptopicKey=EM2F6389ampsourc
e=previewampsearch=pediatric+hemorrhagic+shockampselectedTitle=17E150amprank=undefined bull httptheemtspotcomwp-contentuploads200902gcsgif bull httpwwwuptodatecomcontentsimageimageKey=EM2F60409amptopicKey=EM2F6571amprank
=17E150ampsource=see_linkampsearch=traumaamputdPopup=true bull httpwwwuptodatecomcontentsimageimageKey=EM2F80874amptopicKey=EM2F6571amprank
=17E150ampsource=see_linkampsearch=traumaamputdPopup=true bull httpempracticenewswordpresscomcategorynexus-criteria bull httpswwwgooglecomsearchq=pediatric+glasgow+coma+scaleamptbm=ischamptbo=uampsource=uni
vampsa=Xampei=8TiOU7TNC5WuyATp5YG4BQampsqi=2ampved=0CDYQsAQampbiw=1426ampbih=883q=canadian+c-spine+rulesamptbm=ischampfacrc=_ampimgdii=_ampimgrc=WI94QMHgMLTQmM253A3BP5nbsFhNCXK0FM3Bhttp253A252F252Fwwwbmjcom252Fhighwire252Ffilestream252F436003252Ffield_highwire_fragment_image_l252F0jpg3Bhttp253A252F252Fwwwbmjcom252Fcontent252F339252Fbmjb41463B12803B1253
References 5 bull httpwwwuptodatecomcontentsimageimageKey=EM2F76777amptopicKey=EM2F6571amprank
=17E150ampsource=see_linkampsearch=traumaamputdPopup=true bull httpwwwdocumentingrealitycomforumattachmentsf14964898d1246625322-firework-injury-
m80injury1jpg bull httpwwwpediatriceducationorg20050620 bull httpwwwarmstrongmedicalcomindexcfmgoproductdetailsec3ssec19cat61fam515 bull httpwwwuptodatecomcontentsimageimageKey=PEDS61087amptopicKey=ID2F7661ampsource
=outline_linkampsearch=tetanus+prophylaxisamputdPopup=true bull httpwwwafsecafmilsharedmediaphotodbweb110609-F-MJ378-009jpg bull httpwwwuptodatecomcontentsimageimageKey=EM75765amptopicKey= bull EM2F6389ampsource=outline_linkampsearch=massive+transfusion+protocolamputdPopup=true bull httpwwwmotifakecomimagedemotivational-postersmall0910whats-the-question-ignorance-
calvin-and-hobbes-demotivational-poster-1255020127jpg
XXXXBoston study ems peds trauma procedures- limited pediatric procedural exposure (but more adult experience) bull Catchment area 590000
over 1 year bull 555 pediatric ALS
transport ndash 19 blunt trauma ndash 10 penetrating trauma
bull IV 33 bull BMV 5 bull Intubation 3 bull 50 ALS providers average
year ndash IV- 37 ndash Intubation- 03 ndash IO- 006
bull 7 ped ems ndash 13 trauma
bull Critical procedures ndash 101000 peds cases ndash Intubation 671000 ndash IO 51000 ndash 81 successful
Pediatr Emerg Care 2001 Feb17(1)5-9 Pediatric pre-hospital advanced life support care in an urban setting
Babl FE1 Vinci RJ Bauchner H Mottley L
Pediatr Crit Care Med 2015 Oct16(8)e260-7 doi 101097PCC0000000000000505 Pediatric Out-of-Hospital Critical Procedures in the United States
Carlson JN1 Gannon E Mann NC Jacobson KE Dai M Colleran C Wang HE
C-spine bull C-spine injuries rare bull Take pt to closest hospital if over injuries
call for it (ie resuscitation altered mental status) primary guide
bull Mechanism ndash Altered mental status focal neuro change
torticollis substantial torso injury diving high speed auto neck pain underlying predisposing condition Acad Emerg Med 2014 Jan21(1)55-64 doi 101111acem12288
Comparison of outcomes for children with cervical spine injury based on destination hospital from scene of injury Anders JF1 Adelgais K Hoyle JD Jr Olsen C Jaffe DM Leonard JC Pediatric Emergency Care Applied Research Network
(PECARN)
Ann Emerg Med 2011 Aug58(2)145-55 doi 101016jannemergmed201008038 Epub 2010 Oct 29 Factors associated with cervical spine injury in children after blunt trauma
Leonard JC Kuppermann N Olsen C Babcock-Cimpello L Brown K Mahajan P Adelgais KM Anders J Borgialli D Donoghue A Hoyle JD Jr Kim E Leonard JR Lillis KA Nigrovic LE Powell EC Rebella
G Reeves SD Rogers AJ Stankovic C Teshome G Jaffe DM Pediatric Emergency Care Applied Research Network
- Itrsquos Hard to Put a Band-Aid on a Broken Spleen Pediatric Trauma
- Disclosures
- Objectives
- Pediatric Prehospital Care
- Mechanism
- Traumatic Pain Management
- Pediatric Trauma
- Deaths by Mechanism of Injury
- Pediatric Trauma
- Pediatric Trauma
- Airway Differences
- Pediatric-Adult Differences
- Pediatric Challenges
- Prehospital Pediatric Challenges
- Pediatric and Adult Trauma
- Scene Response
- Prehospital Intervention
- Where do you take the patient
- Patient arrives at the EDhellip
- Primary Survey
- Order is critical
- Slide Number 22
- Slide Number 23
- Airway
- Indications for Intubation
- Breathing
- ETT Intubation Basics
- Circulation
- Slide Number 29
- CirculationHemodynamic Changes
- Circulation
- Fluid Resuscitation Algorithm
- Reconsidering Crystalloid Resuscitation
- When to start MTP
- Disability
- Finishing Up the Evaluation
- Bad Scene Responses
- OHCA from Trauma
- Blunt Trauma- No Signs of Life
- OHCA with CPR on Arrival
- Pediatric Trauma
- Questions
- References 1
- References 2
- References 3
- References 4
- References 5
- References 5
- XXXXBoston study ems peds trauma procedures- limited pediatric procedural exposure (but more adult experience)
- C-spine
ETT Intubation Basics bull Size
ndash Age4 + 4 or (Age +16)4 bull Depth
ndash ~ 3 x ETT size when over 1 year of age bull Blade size mac vs miller
ndash 0~ newborn ndash 1~ up to 2 years of life ndash 2~ 2-10 years ndash 3~ 10+ years
bull RSI medications ndash +-Sedation (Always before paralytic) ndash +-Paralytic (May not need it and never wo sedation)
Circulation
bull What do you assess ndash Central and peripheral pulses ndash Heart rate ndash Blood pressure systolic (age x2) +70 ndash Capillary refill ndash Cardiac activity on FAST ndash End organ perfusion
bull Mental status bull Urine output
Circulation Hemodynamic Changes
Percent Blood Volume Loss 0 15 25 35 45
Heart Rate
Blood Pressure
Cardiac Output
Circulation
ndash Access 2 large bore IVrsquos ndash IVFrsquos ndash pRBCrsquos
bull Hgb lt7gdl or ongoing blood losses
ndash Massive Transfusion Protocol
bull (111 ratio of PRBCS FFP Platelets)
ndash Vasopressors (epi norepi dopamine)
ndash Control of Hemorrhage bull Pelvic binders bull Direct pressure bull Indirectproximal pressure bull Tourniquet (only when
absolutely necessary)
ndash Chest Compressions ndash Pericardiocentesis ndash Delayed resuscitation
controlled hypotension (MAP 50 vs 65)
ndash Tranexamic acid in the near future
bull Interventions
Fluid Resuscitation Algorithm 20 mLkg isotonic crystalloid
Reassess
20 mLkg isotonic crystalloid
Reassess
20 mLkg isotonic crystalloid (31 rule)
or consider 10 to 20 mLkg packed red cells
Reconsidering Crystalloid Resuscitation
bull Less fluid ndash Permissive hypotension to
prevent clot rupture (select cases)
bull Too much fluid ndash Excessive Third Spacing ndash Secondary Compartment
Syndrome ndash Greater risk of ARDS ndash Dilutional Coagulopathy
When to start MTP
bull As soon as you believe you will need it ndash Institution specific guidelines
bull gt4 units or 40mlkg of PRBCrsquos expected bull Earlier use of Massive Transfusion Protocol
(pRBC FFP PLT) in ldquoDamage Controlrdquo resuscitations may improve outcome
bull 111 unit ratio bull Risk of TRALI ARDS etc
Disability bull GCS
ndash Range 3-15 ndash We should be 15 ndash Dead are still 3 ndash Less than 8 intubate ndash Eyes- 4 eyes ndash Verbal- most difficult ndash Motor- V6 engine ndash Intubated T
bull AVPU
Finishing Up the Evaluation
bull Airway bull Breathing bull Circulation bull Disability bull Exposure
ndash Expose and examine all parts ndash Cover quickly and keep warm
bull Secondary Survey
Bad Scene Responses
bull What are the outcomes of out-of-hospital cardiac arrest from blunt trauma
bull What are the outcomes of pediatric drowning patients
OHCA from Trauma
bull 2000-2003 bull 123 pts bull Mean age 73 yrs bull Most common
rhythms ndash Asystole 59 ndash PEA 29 ndash V-fib 35
bull 195 rosc in field ndash 98 survived for 24
hrs ndash 57 survived to
discharge ndash Drowning- 19
survival to discharge ndash Bystander CPR tripled
the survivor rate
Blunt Trauma- No Signs of Life
bull Review from 2002-2010 bull No signs of life- 025 of blunt trauma
ndash 25 resuscitated prior to hospital arrival bull 138 of these patients survived to discharge
bull 44 overall survived to hospital discharge
OHCA with CPR on Arrival
bull 169 children bull 141 deaths bull 69 required cpr on arrival- none survived bull 87 of patients requiring CPR on arrival
expired in the ED bull Of the 28 survivors
ndash 55 of survivors had full neurologic recovery
Pediatric Trauma
bull Fortunately these cases represent only a small fraction of EMS transports
bull Despite a few key differences pediatric trauma care overall is very similar to adult trauma care
Questions
References 1 bull NTDB 2013 pediatric Report bull Monkey bars httpsplaygroundchroniclesfileswordpresscom201307soccerjpg bull Screaming child httpblogsbabycentercomwp-contentuploads201409screaming-child-tantrum-fitjpg bull Pediatric airway image httpwwwcelebritydiagnosiscomwp-contentuploads201003pediatric-airwayjpg bull Child on backboard httpsencrypted-tbn2gstaticcomimagesq=tbnANd9GcQscrDVc8IH4MwkNGF6F1A9p7mSVzik5zrWyNvI-
qSwQT5S3GNyVg bull Elbow fracture httpwwwimageinterpretationcoukimageselbowSUPRACONDYLAR20LAT3jpg bull Bike riding httpsmile-per-daycomwp-contentuploads201412klr03jpg bull Dad and child pic httplaughingsquidcomwp-contentuploads471160jpg bull Weigth estimation inner city Am J Emerg Med 2015 Oct33(10)1364-7 doi 101016jajem201507040 Epub 2015 Jul 29 Weight
estimation in an inner-city pediatric ED the effect of obesity Chavez H1 Peterson RE2 Lo K3 Arel M4
bull Guess weight sign httpmedialiveauctiongroupneti963110572971_1jpgv=8CDDAAF8A5B9E20 bull Broselow tape httpsuploadwikimediaorgwikipediacommons994BTape1jpg bull Parent screaming httpmommyofamonstercomwp-contentuploads201301yellingjpg bull Prehospital pain management Am J Emerg Med 2015 Mar33(3)451-4 doi 101016jajem201412012 Epub 2014 Dec 18
Prehospital pain management of injured children a systematic review of current evidence Samuel N1 Steiner IP2 Shavit I3 bull Prehospital pain ped pain assessment Prehosp Emerg Care 2008 Apr-Jun12(2)182-6 doi 10108010903120801907471 Prehospital
pain assessment in pediatric trauma Izsak E1 Moore JL Stringfellow K Oswanski MF Lindstrom DA Stombaugh HA bull Ped pain management Prehosp Emerg Care 2005 Jan-Mar9(1)40-3 Prehospital pain management in children suffering traumatic
injury Swor R1 McEachin CM Seguin D Grall KH bull Prehospital intervention Allen CJ Teisch LF et al Prehospital care and transportation of pediatric trauma patients J Surg Res 2015
Aug197(2)240-6 JAMA 2000 Feb 9283(6)783-90 bull Effect of out-of-hospital pediatric endotracheal intubation on survival and neurological outcome a controlled clinical trial
Gausche M1 Lewis RJ Stratton SJ Haynes BE Gunter CS Goodrich SM Poore PD McCollough MD Henderson DP Pratt FD Seidel JS
bull Pediatric pain management survey Pediatr Emerg Care 2015 Sep 23 [Epub ahead of print] An Assessment of Newly Identified Barriers to and Enablers for Prehospital Pediatric Pain Management Whitley DE1 Li T Jones CM Cushman JT Williams DM Shah MN
References 2 bull httpwwwuptodatecomcontentsprehospital-pediatrics-and-emergency-medical-services-emsabstract6 bull httpwwwuptodatecomcontentsprehospital-pediatrics-and-emergency-medical-services-emsabstract7 bull Pediatr Crit Care Med 2011 Jul12(4)e166-70 doi 101097PCC0b013e3181f36f6e First responder
performance in pediatric trauma a comparison with an adult cohortBankole S1 Asuncion A Ross S Aghai Z Nollah L Echols H Da-Silva S
bull Drayna pc Browne LR et al Prehospital pediatric care Oppportunities for training treatment and research Prehosp Emerg Care 2015 Jul-Sep 19(3) Epub 2015 Feb 6
bull Pediatr Emerg Care 2001 Feb17(1) 5-9Pediatric pre-hospital advanced life support care in an urban setting Babl FE1 Vinci RJ Bauchner H Mottley L
bull Pediatr Crit Care Med 2015 Oct16(8)e260-7 doi 101097PCC0000000000000505Pediatric Out-of-Hospital Critical Procedures in the United States Carlson JN1 Gannon E Mann NC Jacobson KE Dai M Colleran C Wang HE
bull Pediatr Emerg Care 2009 Aug25(8)508-12 doi 101097PEC0b013e3181b0a0da The efficacy of pediatric advanced life support training in emergency medical service providers Baker TW1 King W Soto W Asher C Stolfi A Rowin ME
bull Sutton RM Case E et al ROC investigators A quantitative analysis of out-of-hospital pediatric and adolescent resuscitation quality A report from the ROC Epistry- Cardiac Arrest Resusciation 201593150-157
bull Resuscitation 2014 Aug85(8)1059-64 doi 101016jresuscitation201403307 Epub 2014 Apr 4 Neurocognitive long term follow-up study on drowned children Suominen PK1 Sutinen N2 Valle S3 Olkkola KT4 Loumlnnqvist T3
bull J Pediatr Surg 2010 Jul45(7)1413-9 doi 101016jjpedsurg200912020 Prehospital cardiopulmonary resuscitation in the pediatric trauma patient Murphy JT1 Jaiswal K Sabella J Vinson L Megison S Maxson RT
References 3 bull Pre atv accident
httpwwwctvnewscapolopoly_fs119871591409741949httpImageimagejpg_genderivativeslandscape_960imagejpg bull atv pic httpswwwutahadvocatescomwp-contentuploads201402atvAccidentLawyerjpg bull Blunt abdominal solid organ injury adult vs pediatric trauma center J Pediatr Surg 2015 Aug 28 pii S0022-3468(15)00526-6 doi
101016jjpedsurg201508012 [Epub ahead of print] Trauma center variation in the management of pediatric patients with blunt abdominal solid organ injury a national trauma data bank analysis Safavi A1 Skarsgard ED2 Rhee P1 Zangbar B1 Kulvatunyou N1 Tang A1 OKeeffe T1 Friese RS1 Joseph B3
bull Pediatric blunt abdominal injury Curr Opin Crit Care 2015 Sep 28 [Epub ahead of print] Pediatric blunt abdominal trauma current management Notrica DM1
bull Pediatric splenic injury management Am J Surg 2015 Jul 31 pii S0002-9610(15)00417-1 doi 101016jamjsurg201506009 [Epub ahead of print] Comparative effectiveness of treatment strategies for severe splenic trauma in the pediatric population Rialon KL1 Englum BR1 Gulack BC1 Guevara CJ2 Bhattacharya SD3 Shapiro ML4 Rice HE5 Scarborough JE4 Adibe OO6
bull Liver pic httpss-media-cache-ak0pinimgcom736x7da50e7da50eb2bb603c99ef6649ff897e26b5jpg bull Solid organ injury non op in peds J Trauma Acute Care Surg 2015 Oct79(4)683-93 doi 101097TA0000000000000808
Nonoperative management of blunt liver and spleen injury in children Evaluation of the ATOMAC guideline using GRADE Notrica DM1 Eubanks JW 3rd Tuggle DW Maxson RT Letton RW Garcia NM Alder AC Lawson KA St Peter SD Megison S Garcia Filion P
bull Pediaric vs nonped trauma ct use J Pediatr 2015 Oct167(4)897-904e3 doi 101016jjpeds201506052 Epub 2015 Jul 29 Variation in Computed Tomography Imaging for Pediatric Injury-Related Emergency Visits Marin JR1 Wang L2 Winger DG2 Mannix RC3
bull Solid organ management in ped population J Trauma Acute Care Surg 2015 Aug79(2)206-14quiz 332 doi 101097TA0000000000000731 Management of children with solid organ injuries after blunt torso trauma Wisner DH1 Kuppermann N Cooper A Menaker J Ehrlich P Kooistra J Mahajan P Lee L Cook LJ Yen K Lillis K Holmes JF
bull Triad of death image httpimageslidesharecdncomdamage-control-resuscitation-1304253390-phpapp0195damage-control-resuscitation-14-728jpgcb=1304235553
bull Tranexamic acid study Eckert MJ Wertin TM Tyner SD et al 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 77852
bull Image care accident httpsuploadwikimediaorgwikipediacommonsthumbee1Car_crash_1jpg1280px-Car_crash_1jpg
References 4 bull httpwwwsurgeryvcuedudivisionsacutesurghtml bull Trauma management Approach to the unstable child
httpwwwuptodatecomcontentstrauma-management-approach-to-the-unstable-childsource=search_resultampsearch=pediatric+trauma+childrenampselectedTitle=17E150
bull Trauma management Unique pediatric considerations httpwwwuptodatecomcontentstrauma-management-unique-pediatric-considerationssource=search_resultampsearch=pediatric+trauma+childrenampselectedTitle=37E150
References 5 bull httpwwwetiquettehellcomsmfindexphptopic=8666360 bull httpwwwstlouischildrensorghealth-care-professionalsems-providers bull httpwwwuchicagokidshospitalorgspecialtiesemergency-medicinespecialhtml bull httpwwwsimsacademyinfoFXpatienthtm bull httptheemtspotcomwp-contentuploads200902another-burn-patient-by-annette-larsonjpg bull httplastangryfancomwp-contentuploads200910Clint-Malarchukjpg bull httpwwwtraumaorgarchiveresusmassivehtml bull httpwwwuptodatecomcontentsimageimageKey=PEDS68694amptopicKey=EM2F6389ampsourc
e=previewampsearch=pediatric+hemorrhagic+shockampselectedTitle=17E150amprank=undefined bull httptheemtspotcomwp-contentuploads200902gcsgif bull httpwwwuptodatecomcontentsimageimageKey=EM2F60409amptopicKey=EM2F6571amprank
=17E150ampsource=see_linkampsearch=traumaamputdPopup=true bull httpwwwuptodatecomcontentsimageimageKey=EM2F80874amptopicKey=EM2F6571amprank
=17E150ampsource=see_linkampsearch=traumaamputdPopup=true bull httpempracticenewswordpresscomcategorynexus-criteria bull httpswwwgooglecomsearchq=pediatric+glasgow+coma+scaleamptbm=ischamptbo=uampsource=uni
vampsa=Xampei=8TiOU7TNC5WuyATp5YG4BQampsqi=2ampved=0CDYQsAQampbiw=1426ampbih=883q=canadian+c-spine+rulesamptbm=ischampfacrc=_ampimgdii=_ampimgrc=WI94QMHgMLTQmM253A3BP5nbsFhNCXK0FM3Bhttp253A252F252Fwwwbmjcom252Fhighwire252Ffilestream252F436003252Ffield_highwire_fragment_image_l252F0jpg3Bhttp253A252F252Fwwwbmjcom252Fcontent252F339252Fbmjb41463B12803B1253
References 5 bull httpwwwuptodatecomcontentsimageimageKey=EM2F76777amptopicKey=EM2F6571amprank
=17E150ampsource=see_linkampsearch=traumaamputdPopup=true bull httpwwwdocumentingrealitycomforumattachmentsf14964898d1246625322-firework-injury-
m80injury1jpg bull httpwwwpediatriceducationorg20050620 bull httpwwwarmstrongmedicalcomindexcfmgoproductdetailsec3ssec19cat61fam515 bull httpwwwuptodatecomcontentsimageimageKey=PEDS61087amptopicKey=ID2F7661ampsource
=outline_linkampsearch=tetanus+prophylaxisamputdPopup=true bull httpwwwafsecafmilsharedmediaphotodbweb110609-F-MJ378-009jpg bull httpwwwuptodatecomcontentsimageimageKey=EM75765amptopicKey= bull EM2F6389ampsource=outline_linkampsearch=massive+transfusion+protocolamputdPopup=true bull httpwwwmotifakecomimagedemotivational-postersmall0910whats-the-question-ignorance-
calvin-and-hobbes-demotivational-poster-1255020127jpg
XXXXBoston study ems peds trauma procedures- limited pediatric procedural exposure (but more adult experience) bull Catchment area 590000
over 1 year bull 555 pediatric ALS
transport ndash 19 blunt trauma ndash 10 penetrating trauma
bull IV 33 bull BMV 5 bull Intubation 3 bull 50 ALS providers average
year ndash IV- 37 ndash Intubation- 03 ndash IO- 006
bull 7 ped ems ndash 13 trauma
bull Critical procedures ndash 101000 peds cases ndash Intubation 671000 ndash IO 51000 ndash 81 successful
Pediatr Emerg Care 2001 Feb17(1)5-9 Pediatric pre-hospital advanced life support care in an urban setting
Babl FE1 Vinci RJ Bauchner H Mottley L
Pediatr Crit Care Med 2015 Oct16(8)e260-7 doi 101097PCC0000000000000505 Pediatric Out-of-Hospital Critical Procedures in the United States
Carlson JN1 Gannon E Mann NC Jacobson KE Dai M Colleran C Wang HE
C-spine bull C-spine injuries rare bull Take pt to closest hospital if over injuries
call for it (ie resuscitation altered mental status) primary guide
bull Mechanism ndash Altered mental status focal neuro change
torticollis substantial torso injury diving high speed auto neck pain underlying predisposing condition Acad Emerg Med 2014 Jan21(1)55-64 doi 101111acem12288
Comparison of outcomes for children with cervical spine injury based on destination hospital from scene of injury Anders JF1 Adelgais K Hoyle JD Jr Olsen C Jaffe DM Leonard JC Pediatric Emergency Care Applied Research Network
(PECARN)
Ann Emerg Med 2011 Aug58(2)145-55 doi 101016jannemergmed201008038 Epub 2010 Oct 29 Factors associated with cervical spine injury in children after blunt trauma
Leonard JC Kuppermann N Olsen C Babcock-Cimpello L Brown K Mahajan P Adelgais KM Anders J Borgialli D Donoghue A Hoyle JD Jr Kim E Leonard JR Lillis KA Nigrovic LE Powell EC Rebella
G Reeves SD Rogers AJ Stankovic C Teshome G Jaffe DM Pediatric Emergency Care Applied Research Network
- Itrsquos Hard to Put a Band-Aid on a Broken Spleen Pediatric Trauma
- Disclosures
- Objectives
- Pediatric Prehospital Care
- Mechanism
- Traumatic Pain Management
- Pediatric Trauma
- Deaths by Mechanism of Injury
- Pediatric Trauma
- Pediatric Trauma
- Airway Differences
- Pediatric-Adult Differences
- Pediatric Challenges
- Prehospital Pediatric Challenges
- Pediatric and Adult Trauma
- Scene Response
- Prehospital Intervention
- Where do you take the patient
- Patient arrives at the EDhellip
- Primary Survey
- Order is critical
- Slide Number 22
- Slide Number 23
- Airway
- Indications for Intubation
- Breathing
- ETT Intubation Basics
- Circulation
- Slide Number 29
- CirculationHemodynamic Changes
- Circulation
- Fluid Resuscitation Algorithm
- Reconsidering Crystalloid Resuscitation
- When to start MTP
- Disability
- Finishing Up the Evaluation
- Bad Scene Responses
- OHCA from Trauma
- Blunt Trauma- No Signs of Life
- OHCA with CPR on Arrival
- Pediatric Trauma
- Questions
- References 1
- References 2
- References 3
- References 4
- References 5
- References 5
- XXXXBoston study ems peds trauma procedures- limited pediatric procedural exposure (but more adult experience)
- C-spine
Circulation
bull What do you assess ndash Central and peripheral pulses ndash Heart rate ndash Blood pressure systolic (age x2) +70 ndash Capillary refill ndash Cardiac activity on FAST ndash End organ perfusion
bull Mental status bull Urine output
Circulation Hemodynamic Changes
Percent Blood Volume Loss 0 15 25 35 45
Heart Rate
Blood Pressure
Cardiac Output
Circulation
ndash Access 2 large bore IVrsquos ndash IVFrsquos ndash pRBCrsquos
bull Hgb lt7gdl or ongoing blood losses
ndash Massive Transfusion Protocol
bull (111 ratio of PRBCS FFP Platelets)
ndash Vasopressors (epi norepi dopamine)
ndash Control of Hemorrhage bull Pelvic binders bull Direct pressure bull Indirectproximal pressure bull Tourniquet (only when
absolutely necessary)
ndash Chest Compressions ndash Pericardiocentesis ndash Delayed resuscitation
controlled hypotension (MAP 50 vs 65)
ndash Tranexamic acid in the near future
bull Interventions
Fluid Resuscitation Algorithm 20 mLkg isotonic crystalloid
Reassess
20 mLkg isotonic crystalloid
Reassess
20 mLkg isotonic crystalloid (31 rule)
or consider 10 to 20 mLkg packed red cells
Reconsidering Crystalloid Resuscitation
bull Less fluid ndash Permissive hypotension to
prevent clot rupture (select cases)
bull Too much fluid ndash Excessive Third Spacing ndash Secondary Compartment
Syndrome ndash Greater risk of ARDS ndash Dilutional Coagulopathy
When to start MTP
bull As soon as you believe you will need it ndash Institution specific guidelines
bull gt4 units or 40mlkg of PRBCrsquos expected bull Earlier use of Massive Transfusion Protocol
(pRBC FFP PLT) in ldquoDamage Controlrdquo resuscitations may improve outcome
bull 111 unit ratio bull Risk of TRALI ARDS etc
Disability bull GCS
ndash Range 3-15 ndash We should be 15 ndash Dead are still 3 ndash Less than 8 intubate ndash Eyes- 4 eyes ndash Verbal- most difficult ndash Motor- V6 engine ndash Intubated T
bull AVPU
Finishing Up the Evaluation
bull Airway bull Breathing bull Circulation bull Disability bull Exposure
ndash Expose and examine all parts ndash Cover quickly and keep warm
bull Secondary Survey
Bad Scene Responses
bull What are the outcomes of out-of-hospital cardiac arrest from blunt trauma
bull What are the outcomes of pediatric drowning patients
OHCA from Trauma
bull 2000-2003 bull 123 pts bull Mean age 73 yrs bull Most common
rhythms ndash Asystole 59 ndash PEA 29 ndash V-fib 35
bull 195 rosc in field ndash 98 survived for 24
hrs ndash 57 survived to
discharge ndash Drowning- 19
survival to discharge ndash Bystander CPR tripled
the survivor rate
Blunt Trauma- No Signs of Life
bull Review from 2002-2010 bull No signs of life- 025 of blunt trauma
ndash 25 resuscitated prior to hospital arrival bull 138 of these patients survived to discharge
bull 44 overall survived to hospital discharge
OHCA with CPR on Arrival
bull 169 children bull 141 deaths bull 69 required cpr on arrival- none survived bull 87 of patients requiring CPR on arrival
expired in the ED bull Of the 28 survivors
ndash 55 of survivors had full neurologic recovery
Pediatric Trauma
bull Fortunately these cases represent only a small fraction of EMS transports
bull Despite a few key differences pediatric trauma care overall is very similar to adult trauma care
Questions
References 1 bull NTDB 2013 pediatric Report bull Monkey bars httpsplaygroundchroniclesfileswordpresscom201307soccerjpg bull Screaming child httpblogsbabycentercomwp-contentuploads201409screaming-child-tantrum-fitjpg bull Pediatric airway image httpwwwcelebritydiagnosiscomwp-contentuploads201003pediatric-airwayjpg bull Child on backboard httpsencrypted-tbn2gstaticcomimagesq=tbnANd9GcQscrDVc8IH4MwkNGF6F1A9p7mSVzik5zrWyNvI-
qSwQT5S3GNyVg bull Elbow fracture httpwwwimageinterpretationcoukimageselbowSUPRACONDYLAR20LAT3jpg bull Bike riding httpsmile-per-daycomwp-contentuploads201412klr03jpg bull Dad and child pic httplaughingsquidcomwp-contentuploads471160jpg bull Weigth estimation inner city Am J Emerg Med 2015 Oct33(10)1364-7 doi 101016jajem201507040 Epub 2015 Jul 29 Weight
estimation in an inner-city pediatric ED the effect of obesity Chavez H1 Peterson RE2 Lo K3 Arel M4
bull Guess weight sign httpmedialiveauctiongroupneti963110572971_1jpgv=8CDDAAF8A5B9E20 bull Broselow tape httpsuploadwikimediaorgwikipediacommons994BTape1jpg bull Parent screaming httpmommyofamonstercomwp-contentuploads201301yellingjpg bull Prehospital pain management Am J Emerg Med 2015 Mar33(3)451-4 doi 101016jajem201412012 Epub 2014 Dec 18
Prehospital pain management of injured children a systematic review of current evidence Samuel N1 Steiner IP2 Shavit I3 bull Prehospital pain ped pain assessment Prehosp Emerg Care 2008 Apr-Jun12(2)182-6 doi 10108010903120801907471 Prehospital
pain assessment in pediatric trauma Izsak E1 Moore JL Stringfellow K Oswanski MF Lindstrom DA Stombaugh HA bull Ped pain management Prehosp Emerg Care 2005 Jan-Mar9(1)40-3 Prehospital pain management in children suffering traumatic
injury Swor R1 McEachin CM Seguin D Grall KH bull Prehospital intervention Allen CJ Teisch LF et al Prehospital care and transportation of pediatric trauma patients J Surg Res 2015
Aug197(2)240-6 JAMA 2000 Feb 9283(6)783-90 bull Effect of out-of-hospital pediatric endotracheal intubation on survival and neurological outcome a controlled clinical trial
Gausche M1 Lewis RJ Stratton SJ Haynes BE Gunter CS Goodrich SM Poore PD McCollough MD Henderson DP Pratt FD Seidel JS
bull Pediatric pain management survey Pediatr Emerg Care 2015 Sep 23 [Epub ahead of print] An Assessment of Newly Identified Barriers to and Enablers for Prehospital Pediatric Pain Management Whitley DE1 Li T Jones CM Cushman JT Williams DM Shah MN
References 2 bull httpwwwuptodatecomcontentsprehospital-pediatrics-and-emergency-medical-services-emsabstract6 bull httpwwwuptodatecomcontentsprehospital-pediatrics-and-emergency-medical-services-emsabstract7 bull Pediatr Crit Care Med 2011 Jul12(4)e166-70 doi 101097PCC0b013e3181f36f6e First responder
performance in pediatric trauma a comparison with an adult cohortBankole S1 Asuncion A Ross S Aghai Z Nollah L Echols H Da-Silva S
bull Drayna pc Browne LR et al Prehospital pediatric care Oppportunities for training treatment and research Prehosp Emerg Care 2015 Jul-Sep 19(3) Epub 2015 Feb 6
bull Pediatr Emerg Care 2001 Feb17(1) 5-9Pediatric pre-hospital advanced life support care in an urban setting Babl FE1 Vinci RJ Bauchner H Mottley L
bull Pediatr Crit Care Med 2015 Oct16(8)e260-7 doi 101097PCC0000000000000505Pediatric Out-of-Hospital Critical Procedures in the United States Carlson JN1 Gannon E Mann NC Jacobson KE Dai M Colleran C Wang HE
bull Pediatr Emerg Care 2009 Aug25(8)508-12 doi 101097PEC0b013e3181b0a0da The efficacy of pediatric advanced life support training in emergency medical service providers Baker TW1 King W Soto W Asher C Stolfi A Rowin ME
bull Sutton RM Case E et al ROC investigators A quantitative analysis of out-of-hospital pediatric and adolescent resuscitation quality A report from the ROC Epistry- Cardiac Arrest Resusciation 201593150-157
bull Resuscitation 2014 Aug85(8)1059-64 doi 101016jresuscitation201403307 Epub 2014 Apr 4 Neurocognitive long term follow-up study on drowned children Suominen PK1 Sutinen N2 Valle S3 Olkkola KT4 Loumlnnqvist T3
bull J Pediatr Surg 2010 Jul45(7)1413-9 doi 101016jjpedsurg200912020 Prehospital cardiopulmonary resuscitation in the pediatric trauma patient Murphy JT1 Jaiswal K Sabella J Vinson L Megison S Maxson RT
References 3 bull Pre atv accident
httpwwwctvnewscapolopoly_fs119871591409741949httpImageimagejpg_genderivativeslandscape_960imagejpg bull atv pic httpswwwutahadvocatescomwp-contentuploads201402atvAccidentLawyerjpg bull Blunt abdominal solid organ injury adult vs pediatric trauma center J Pediatr Surg 2015 Aug 28 pii S0022-3468(15)00526-6 doi
101016jjpedsurg201508012 [Epub ahead of print] Trauma center variation in the management of pediatric patients with blunt abdominal solid organ injury a national trauma data bank analysis Safavi A1 Skarsgard ED2 Rhee P1 Zangbar B1 Kulvatunyou N1 Tang A1 OKeeffe T1 Friese RS1 Joseph B3
bull Pediatric blunt abdominal injury Curr Opin Crit Care 2015 Sep 28 [Epub ahead of print] Pediatric blunt abdominal trauma current management Notrica DM1
bull Pediatric splenic injury management Am J Surg 2015 Jul 31 pii S0002-9610(15)00417-1 doi 101016jamjsurg201506009 [Epub ahead of print] Comparative effectiveness of treatment strategies for severe splenic trauma in the pediatric population Rialon KL1 Englum BR1 Gulack BC1 Guevara CJ2 Bhattacharya SD3 Shapiro ML4 Rice HE5 Scarborough JE4 Adibe OO6
bull Liver pic httpss-media-cache-ak0pinimgcom736x7da50e7da50eb2bb603c99ef6649ff897e26b5jpg bull Solid organ injury non op in peds J Trauma Acute Care Surg 2015 Oct79(4)683-93 doi 101097TA0000000000000808
Nonoperative management of blunt liver and spleen injury in children Evaluation of the ATOMAC guideline using GRADE Notrica DM1 Eubanks JW 3rd Tuggle DW Maxson RT Letton RW Garcia NM Alder AC Lawson KA St Peter SD Megison S Garcia Filion P
bull Pediaric vs nonped trauma ct use J Pediatr 2015 Oct167(4)897-904e3 doi 101016jjpeds201506052 Epub 2015 Jul 29 Variation in Computed Tomography Imaging for Pediatric Injury-Related Emergency Visits Marin JR1 Wang L2 Winger DG2 Mannix RC3
bull Solid organ management in ped population J Trauma Acute Care Surg 2015 Aug79(2)206-14quiz 332 doi 101097TA0000000000000731 Management of children with solid organ injuries after blunt torso trauma Wisner DH1 Kuppermann N Cooper A Menaker J Ehrlich P Kooistra J Mahajan P Lee L Cook LJ Yen K Lillis K Holmes JF
bull Triad of death image httpimageslidesharecdncomdamage-control-resuscitation-1304253390-phpapp0195damage-control-resuscitation-14-728jpgcb=1304235553
bull Tranexamic acid study Eckert MJ Wertin TM Tyner SD et al 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 77852
bull Image care accident httpsuploadwikimediaorgwikipediacommonsthumbee1Car_crash_1jpg1280px-Car_crash_1jpg
References 4 bull httpwwwsurgeryvcuedudivisionsacutesurghtml bull Trauma management Approach to the unstable child
httpwwwuptodatecomcontentstrauma-management-approach-to-the-unstable-childsource=search_resultampsearch=pediatric+trauma+childrenampselectedTitle=17E150
bull Trauma management Unique pediatric considerations httpwwwuptodatecomcontentstrauma-management-unique-pediatric-considerationssource=search_resultampsearch=pediatric+trauma+childrenampselectedTitle=37E150
References 5 bull httpwwwetiquettehellcomsmfindexphptopic=8666360 bull httpwwwstlouischildrensorghealth-care-professionalsems-providers bull httpwwwuchicagokidshospitalorgspecialtiesemergency-medicinespecialhtml bull httpwwwsimsacademyinfoFXpatienthtm bull httptheemtspotcomwp-contentuploads200902another-burn-patient-by-annette-larsonjpg bull httplastangryfancomwp-contentuploads200910Clint-Malarchukjpg bull httpwwwtraumaorgarchiveresusmassivehtml bull httpwwwuptodatecomcontentsimageimageKey=PEDS68694amptopicKey=EM2F6389ampsourc
e=previewampsearch=pediatric+hemorrhagic+shockampselectedTitle=17E150amprank=undefined bull httptheemtspotcomwp-contentuploads200902gcsgif bull httpwwwuptodatecomcontentsimageimageKey=EM2F60409amptopicKey=EM2F6571amprank
=17E150ampsource=see_linkampsearch=traumaamputdPopup=true bull httpwwwuptodatecomcontentsimageimageKey=EM2F80874amptopicKey=EM2F6571amprank
=17E150ampsource=see_linkampsearch=traumaamputdPopup=true bull httpempracticenewswordpresscomcategorynexus-criteria bull httpswwwgooglecomsearchq=pediatric+glasgow+coma+scaleamptbm=ischamptbo=uampsource=uni
vampsa=Xampei=8TiOU7TNC5WuyATp5YG4BQampsqi=2ampved=0CDYQsAQampbiw=1426ampbih=883q=canadian+c-spine+rulesamptbm=ischampfacrc=_ampimgdii=_ampimgrc=WI94QMHgMLTQmM253A3BP5nbsFhNCXK0FM3Bhttp253A252F252Fwwwbmjcom252Fhighwire252Ffilestream252F436003252Ffield_highwire_fragment_image_l252F0jpg3Bhttp253A252F252Fwwwbmjcom252Fcontent252F339252Fbmjb41463B12803B1253
References 5 bull httpwwwuptodatecomcontentsimageimageKey=EM2F76777amptopicKey=EM2F6571amprank
=17E150ampsource=see_linkampsearch=traumaamputdPopup=true bull httpwwwdocumentingrealitycomforumattachmentsf14964898d1246625322-firework-injury-
m80injury1jpg bull httpwwwpediatriceducationorg20050620 bull httpwwwarmstrongmedicalcomindexcfmgoproductdetailsec3ssec19cat61fam515 bull httpwwwuptodatecomcontentsimageimageKey=PEDS61087amptopicKey=ID2F7661ampsource
=outline_linkampsearch=tetanus+prophylaxisamputdPopup=true bull httpwwwafsecafmilsharedmediaphotodbweb110609-F-MJ378-009jpg bull httpwwwuptodatecomcontentsimageimageKey=EM75765amptopicKey= bull EM2F6389ampsource=outline_linkampsearch=massive+transfusion+protocolamputdPopup=true bull httpwwwmotifakecomimagedemotivational-postersmall0910whats-the-question-ignorance-
calvin-and-hobbes-demotivational-poster-1255020127jpg
XXXXBoston study ems peds trauma procedures- limited pediatric procedural exposure (but more adult experience) bull Catchment area 590000
over 1 year bull 555 pediatric ALS
transport ndash 19 blunt trauma ndash 10 penetrating trauma
bull IV 33 bull BMV 5 bull Intubation 3 bull 50 ALS providers average
year ndash IV- 37 ndash Intubation- 03 ndash IO- 006
bull 7 ped ems ndash 13 trauma
bull Critical procedures ndash 101000 peds cases ndash Intubation 671000 ndash IO 51000 ndash 81 successful
Pediatr Emerg Care 2001 Feb17(1)5-9 Pediatric pre-hospital advanced life support care in an urban setting
Babl FE1 Vinci RJ Bauchner H Mottley L
Pediatr Crit Care Med 2015 Oct16(8)e260-7 doi 101097PCC0000000000000505 Pediatric Out-of-Hospital Critical Procedures in the United States
Carlson JN1 Gannon E Mann NC Jacobson KE Dai M Colleran C Wang HE
C-spine bull C-spine injuries rare bull Take pt to closest hospital if over injuries
call for it (ie resuscitation altered mental status) primary guide
bull Mechanism ndash Altered mental status focal neuro change
torticollis substantial torso injury diving high speed auto neck pain underlying predisposing condition Acad Emerg Med 2014 Jan21(1)55-64 doi 101111acem12288
Comparison of outcomes for children with cervical spine injury based on destination hospital from scene of injury Anders JF1 Adelgais K Hoyle JD Jr Olsen C Jaffe DM Leonard JC Pediatric Emergency Care Applied Research Network
(PECARN)
Ann Emerg Med 2011 Aug58(2)145-55 doi 101016jannemergmed201008038 Epub 2010 Oct 29 Factors associated with cervical spine injury in children after blunt trauma
Leonard JC Kuppermann N Olsen C Babcock-Cimpello L Brown K Mahajan P Adelgais KM Anders J Borgialli D Donoghue A Hoyle JD Jr Kim E Leonard JR Lillis KA Nigrovic LE Powell EC Rebella
G Reeves SD Rogers AJ Stankovic C Teshome G Jaffe DM Pediatric Emergency Care Applied Research Network
- Itrsquos Hard to Put a Band-Aid on a Broken Spleen Pediatric Trauma
- Disclosures
- Objectives
- Pediatric Prehospital Care
- Mechanism
- Traumatic Pain Management
- Pediatric Trauma
- Deaths by Mechanism of Injury
- Pediatric Trauma
- Pediatric Trauma
- Airway Differences
- Pediatric-Adult Differences
- Pediatric Challenges
- Prehospital Pediatric Challenges
- Pediatric and Adult Trauma
- Scene Response
- Prehospital Intervention
- Where do you take the patient
- Patient arrives at the EDhellip
- Primary Survey
- Order is critical
- Slide Number 22
- Slide Number 23
- Airway
- Indications for Intubation
- Breathing
- ETT Intubation Basics
- Circulation
- Slide Number 29
- CirculationHemodynamic Changes
- Circulation
- Fluid Resuscitation Algorithm
- Reconsidering Crystalloid Resuscitation
- When to start MTP
- Disability
- Finishing Up the Evaluation
- Bad Scene Responses
- OHCA from Trauma
- Blunt Trauma- No Signs of Life
- OHCA with CPR on Arrival
- Pediatric Trauma
- Questions
- References 1
- References 2
- References 3
- References 4
- References 5
- References 5
- XXXXBoston study ems peds trauma procedures- limited pediatric procedural exposure (but more adult experience)
- C-spine
Circulation Hemodynamic Changes
Percent Blood Volume Loss 0 15 25 35 45
Heart Rate
Blood Pressure
Cardiac Output
Circulation
ndash Access 2 large bore IVrsquos ndash IVFrsquos ndash pRBCrsquos
bull Hgb lt7gdl or ongoing blood losses
ndash Massive Transfusion Protocol
bull (111 ratio of PRBCS FFP Platelets)
ndash Vasopressors (epi norepi dopamine)
ndash Control of Hemorrhage bull Pelvic binders bull Direct pressure bull Indirectproximal pressure bull Tourniquet (only when
absolutely necessary)
ndash Chest Compressions ndash Pericardiocentesis ndash Delayed resuscitation
controlled hypotension (MAP 50 vs 65)
ndash Tranexamic acid in the near future
bull Interventions
Fluid Resuscitation Algorithm 20 mLkg isotonic crystalloid
Reassess
20 mLkg isotonic crystalloid
Reassess
20 mLkg isotonic crystalloid (31 rule)
or consider 10 to 20 mLkg packed red cells
Reconsidering Crystalloid Resuscitation
bull Less fluid ndash Permissive hypotension to
prevent clot rupture (select cases)
bull Too much fluid ndash Excessive Third Spacing ndash Secondary Compartment
Syndrome ndash Greater risk of ARDS ndash Dilutional Coagulopathy
When to start MTP
bull As soon as you believe you will need it ndash Institution specific guidelines
bull gt4 units or 40mlkg of PRBCrsquos expected bull Earlier use of Massive Transfusion Protocol
(pRBC FFP PLT) in ldquoDamage Controlrdquo resuscitations may improve outcome
bull 111 unit ratio bull Risk of TRALI ARDS etc
Disability bull GCS
ndash Range 3-15 ndash We should be 15 ndash Dead are still 3 ndash Less than 8 intubate ndash Eyes- 4 eyes ndash Verbal- most difficult ndash Motor- V6 engine ndash Intubated T
bull AVPU
Finishing Up the Evaluation
bull Airway bull Breathing bull Circulation bull Disability bull Exposure
ndash Expose and examine all parts ndash Cover quickly and keep warm
bull Secondary Survey
Bad Scene Responses
bull What are the outcomes of out-of-hospital cardiac arrest from blunt trauma
bull What are the outcomes of pediatric drowning patients
OHCA from Trauma
bull 2000-2003 bull 123 pts bull Mean age 73 yrs bull Most common
rhythms ndash Asystole 59 ndash PEA 29 ndash V-fib 35
bull 195 rosc in field ndash 98 survived for 24
hrs ndash 57 survived to
discharge ndash Drowning- 19
survival to discharge ndash Bystander CPR tripled
the survivor rate
Blunt Trauma- No Signs of Life
bull Review from 2002-2010 bull No signs of life- 025 of blunt trauma
ndash 25 resuscitated prior to hospital arrival bull 138 of these patients survived to discharge
bull 44 overall survived to hospital discharge
OHCA with CPR on Arrival
bull 169 children bull 141 deaths bull 69 required cpr on arrival- none survived bull 87 of patients requiring CPR on arrival
expired in the ED bull Of the 28 survivors
ndash 55 of survivors had full neurologic recovery
Pediatric Trauma
bull Fortunately these cases represent only a small fraction of EMS transports
bull Despite a few key differences pediatric trauma care overall is very similar to adult trauma care
Questions
References 1 bull NTDB 2013 pediatric Report bull Monkey bars httpsplaygroundchroniclesfileswordpresscom201307soccerjpg bull Screaming child httpblogsbabycentercomwp-contentuploads201409screaming-child-tantrum-fitjpg bull Pediatric airway image httpwwwcelebritydiagnosiscomwp-contentuploads201003pediatric-airwayjpg bull Child on backboard httpsencrypted-tbn2gstaticcomimagesq=tbnANd9GcQscrDVc8IH4MwkNGF6F1A9p7mSVzik5zrWyNvI-
qSwQT5S3GNyVg bull Elbow fracture httpwwwimageinterpretationcoukimageselbowSUPRACONDYLAR20LAT3jpg bull Bike riding httpsmile-per-daycomwp-contentuploads201412klr03jpg bull Dad and child pic httplaughingsquidcomwp-contentuploads471160jpg bull Weigth estimation inner city Am J Emerg Med 2015 Oct33(10)1364-7 doi 101016jajem201507040 Epub 2015 Jul 29 Weight
estimation in an inner-city pediatric ED the effect of obesity Chavez H1 Peterson RE2 Lo K3 Arel M4
bull Guess weight sign httpmedialiveauctiongroupneti963110572971_1jpgv=8CDDAAF8A5B9E20 bull Broselow tape httpsuploadwikimediaorgwikipediacommons994BTape1jpg bull Parent screaming httpmommyofamonstercomwp-contentuploads201301yellingjpg bull Prehospital pain management Am J Emerg Med 2015 Mar33(3)451-4 doi 101016jajem201412012 Epub 2014 Dec 18
Prehospital pain management of injured children a systematic review of current evidence Samuel N1 Steiner IP2 Shavit I3 bull Prehospital pain ped pain assessment Prehosp Emerg Care 2008 Apr-Jun12(2)182-6 doi 10108010903120801907471 Prehospital
pain assessment in pediatric trauma Izsak E1 Moore JL Stringfellow K Oswanski MF Lindstrom DA Stombaugh HA bull Ped pain management Prehosp Emerg Care 2005 Jan-Mar9(1)40-3 Prehospital pain management in children suffering traumatic
injury Swor R1 McEachin CM Seguin D Grall KH bull Prehospital intervention Allen CJ Teisch LF et al Prehospital care and transportation of pediatric trauma patients J Surg Res 2015
Aug197(2)240-6 JAMA 2000 Feb 9283(6)783-90 bull Effect of out-of-hospital pediatric endotracheal intubation on survival and neurological outcome a controlled clinical trial
Gausche M1 Lewis RJ Stratton SJ Haynes BE Gunter CS Goodrich SM Poore PD McCollough MD Henderson DP Pratt FD Seidel JS
bull Pediatric pain management survey Pediatr Emerg Care 2015 Sep 23 [Epub ahead of print] An Assessment of Newly Identified Barriers to and Enablers for Prehospital Pediatric Pain Management Whitley DE1 Li T Jones CM Cushman JT Williams DM Shah MN
References 2 bull httpwwwuptodatecomcontentsprehospital-pediatrics-and-emergency-medical-services-emsabstract6 bull httpwwwuptodatecomcontentsprehospital-pediatrics-and-emergency-medical-services-emsabstract7 bull Pediatr Crit Care Med 2011 Jul12(4)e166-70 doi 101097PCC0b013e3181f36f6e First responder
performance in pediatric trauma a comparison with an adult cohortBankole S1 Asuncion A Ross S Aghai Z Nollah L Echols H Da-Silva S
bull Drayna pc Browne LR et al Prehospital pediatric care Oppportunities for training treatment and research Prehosp Emerg Care 2015 Jul-Sep 19(3) Epub 2015 Feb 6
bull Pediatr Emerg Care 2001 Feb17(1) 5-9Pediatric pre-hospital advanced life support care in an urban setting Babl FE1 Vinci RJ Bauchner H Mottley L
bull Pediatr Crit Care Med 2015 Oct16(8)e260-7 doi 101097PCC0000000000000505Pediatric Out-of-Hospital Critical Procedures in the United States Carlson JN1 Gannon E Mann NC Jacobson KE Dai M Colleran C Wang HE
bull Pediatr Emerg Care 2009 Aug25(8)508-12 doi 101097PEC0b013e3181b0a0da The efficacy of pediatric advanced life support training in emergency medical service providers Baker TW1 King W Soto W Asher C Stolfi A Rowin ME
bull Sutton RM Case E et al ROC investigators A quantitative analysis of out-of-hospital pediatric and adolescent resuscitation quality A report from the ROC Epistry- Cardiac Arrest Resusciation 201593150-157
bull Resuscitation 2014 Aug85(8)1059-64 doi 101016jresuscitation201403307 Epub 2014 Apr 4 Neurocognitive long term follow-up study on drowned children Suominen PK1 Sutinen N2 Valle S3 Olkkola KT4 Loumlnnqvist T3
bull J Pediatr Surg 2010 Jul45(7)1413-9 doi 101016jjpedsurg200912020 Prehospital cardiopulmonary resuscitation in the pediatric trauma patient Murphy JT1 Jaiswal K Sabella J Vinson L Megison S Maxson RT
References 3 bull Pre atv accident
httpwwwctvnewscapolopoly_fs119871591409741949httpImageimagejpg_genderivativeslandscape_960imagejpg bull atv pic httpswwwutahadvocatescomwp-contentuploads201402atvAccidentLawyerjpg bull Blunt abdominal solid organ injury adult vs pediatric trauma center J Pediatr Surg 2015 Aug 28 pii S0022-3468(15)00526-6 doi
101016jjpedsurg201508012 [Epub ahead of print] Trauma center variation in the management of pediatric patients with blunt abdominal solid organ injury a national trauma data bank analysis Safavi A1 Skarsgard ED2 Rhee P1 Zangbar B1 Kulvatunyou N1 Tang A1 OKeeffe T1 Friese RS1 Joseph B3
bull Pediatric blunt abdominal injury Curr Opin Crit Care 2015 Sep 28 [Epub ahead of print] Pediatric blunt abdominal trauma current management Notrica DM1
bull Pediatric splenic injury management Am J Surg 2015 Jul 31 pii S0002-9610(15)00417-1 doi 101016jamjsurg201506009 [Epub ahead of print] Comparative effectiveness of treatment strategies for severe splenic trauma in the pediatric population Rialon KL1 Englum BR1 Gulack BC1 Guevara CJ2 Bhattacharya SD3 Shapiro ML4 Rice HE5 Scarborough JE4 Adibe OO6
bull Liver pic httpss-media-cache-ak0pinimgcom736x7da50e7da50eb2bb603c99ef6649ff897e26b5jpg bull Solid organ injury non op in peds J Trauma Acute Care Surg 2015 Oct79(4)683-93 doi 101097TA0000000000000808
Nonoperative management of blunt liver and spleen injury in children Evaluation of the ATOMAC guideline using GRADE Notrica DM1 Eubanks JW 3rd Tuggle DW Maxson RT Letton RW Garcia NM Alder AC Lawson KA St Peter SD Megison S Garcia Filion P
bull Pediaric vs nonped trauma ct use J Pediatr 2015 Oct167(4)897-904e3 doi 101016jjpeds201506052 Epub 2015 Jul 29 Variation in Computed Tomography Imaging for Pediatric Injury-Related Emergency Visits Marin JR1 Wang L2 Winger DG2 Mannix RC3
bull Solid organ management in ped population J Trauma Acute Care Surg 2015 Aug79(2)206-14quiz 332 doi 101097TA0000000000000731 Management of children with solid organ injuries after blunt torso trauma Wisner DH1 Kuppermann N Cooper A Menaker J Ehrlich P Kooistra J Mahajan P Lee L Cook LJ Yen K Lillis K Holmes JF
bull Triad of death image httpimageslidesharecdncomdamage-control-resuscitation-1304253390-phpapp0195damage-control-resuscitation-14-728jpgcb=1304235553
bull Tranexamic acid study Eckert MJ Wertin TM Tyner SD et al 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 77852
bull Image care accident httpsuploadwikimediaorgwikipediacommonsthumbee1Car_crash_1jpg1280px-Car_crash_1jpg
References 4 bull httpwwwsurgeryvcuedudivisionsacutesurghtml bull Trauma management Approach to the unstable child
httpwwwuptodatecomcontentstrauma-management-approach-to-the-unstable-childsource=search_resultampsearch=pediatric+trauma+childrenampselectedTitle=17E150
bull Trauma management Unique pediatric considerations httpwwwuptodatecomcontentstrauma-management-unique-pediatric-considerationssource=search_resultampsearch=pediatric+trauma+childrenampselectedTitle=37E150
References 5 bull httpwwwetiquettehellcomsmfindexphptopic=8666360 bull httpwwwstlouischildrensorghealth-care-professionalsems-providers bull httpwwwuchicagokidshospitalorgspecialtiesemergency-medicinespecialhtml bull httpwwwsimsacademyinfoFXpatienthtm bull httptheemtspotcomwp-contentuploads200902another-burn-patient-by-annette-larsonjpg bull httplastangryfancomwp-contentuploads200910Clint-Malarchukjpg bull httpwwwtraumaorgarchiveresusmassivehtml bull httpwwwuptodatecomcontentsimageimageKey=PEDS68694amptopicKey=EM2F6389ampsourc
e=previewampsearch=pediatric+hemorrhagic+shockampselectedTitle=17E150amprank=undefined bull httptheemtspotcomwp-contentuploads200902gcsgif bull httpwwwuptodatecomcontentsimageimageKey=EM2F60409amptopicKey=EM2F6571amprank
=17E150ampsource=see_linkampsearch=traumaamputdPopup=true bull httpwwwuptodatecomcontentsimageimageKey=EM2F80874amptopicKey=EM2F6571amprank
=17E150ampsource=see_linkampsearch=traumaamputdPopup=true bull httpempracticenewswordpresscomcategorynexus-criteria bull httpswwwgooglecomsearchq=pediatric+glasgow+coma+scaleamptbm=ischamptbo=uampsource=uni
vampsa=Xampei=8TiOU7TNC5WuyATp5YG4BQampsqi=2ampved=0CDYQsAQampbiw=1426ampbih=883q=canadian+c-spine+rulesamptbm=ischampfacrc=_ampimgdii=_ampimgrc=WI94QMHgMLTQmM253A3BP5nbsFhNCXK0FM3Bhttp253A252F252Fwwwbmjcom252Fhighwire252Ffilestream252F436003252Ffield_highwire_fragment_image_l252F0jpg3Bhttp253A252F252Fwwwbmjcom252Fcontent252F339252Fbmjb41463B12803B1253
References 5 bull httpwwwuptodatecomcontentsimageimageKey=EM2F76777amptopicKey=EM2F6571amprank
=17E150ampsource=see_linkampsearch=traumaamputdPopup=true bull httpwwwdocumentingrealitycomforumattachmentsf14964898d1246625322-firework-injury-
m80injury1jpg bull httpwwwpediatriceducationorg20050620 bull httpwwwarmstrongmedicalcomindexcfmgoproductdetailsec3ssec19cat61fam515 bull httpwwwuptodatecomcontentsimageimageKey=PEDS61087amptopicKey=ID2F7661ampsource
=outline_linkampsearch=tetanus+prophylaxisamputdPopup=true bull httpwwwafsecafmilsharedmediaphotodbweb110609-F-MJ378-009jpg bull httpwwwuptodatecomcontentsimageimageKey=EM75765amptopicKey= bull EM2F6389ampsource=outline_linkampsearch=massive+transfusion+protocolamputdPopup=true bull httpwwwmotifakecomimagedemotivational-postersmall0910whats-the-question-ignorance-
calvin-and-hobbes-demotivational-poster-1255020127jpg
XXXXBoston study ems peds trauma procedures- limited pediatric procedural exposure (but more adult experience) bull Catchment area 590000
over 1 year bull 555 pediatric ALS
transport ndash 19 blunt trauma ndash 10 penetrating trauma
bull IV 33 bull BMV 5 bull Intubation 3 bull 50 ALS providers average
year ndash IV- 37 ndash Intubation- 03 ndash IO- 006
bull 7 ped ems ndash 13 trauma
bull Critical procedures ndash 101000 peds cases ndash Intubation 671000 ndash IO 51000 ndash 81 successful
Pediatr Emerg Care 2001 Feb17(1)5-9 Pediatric pre-hospital advanced life support care in an urban setting
Babl FE1 Vinci RJ Bauchner H Mottley L
Pediatr Crit Care Med 2015 Oct16(8)e260-7 doi 101097PCC0000000000000505 Pediatric Out-of-Hospital Critical Procedures in the United States
Carlson JN1 Gannon E Mann NC Jacobson KE Dai M Colleran C Wang HE
C-spine bull C-spine injuries rare bull Take pt to closest hospital if over injuries
call for it (ie resuscitation altered mental status) primary guide
bull Mechanism ndash Altered mental status focal neuro change
torticollis substantial torso injury diving high speed auto neck pain underlying predisposing condition Acad Emerg Med 2014 Jan21(1)55-64 doi 101111acem12288
Comparison of outcomes for children with cervical spine injury based on destination hospital from scene of injury Anders JF1 Adelgais K Hoyle JD Jr Olsen C Jaffe DM Leonard JC Pediatric Emergency Care Applied Research Network
(PECARN)
Ann Emerg Med 2011 Aug58(2)145-55 doi 101016jannemergmed201008038 Epub 2010 Oct 29 Factors associated with cervical spine injury in children after blunt trauma
Leonard JC Kuppermann N Olsen C Babcock-Cimpello L Brown K Mahajan P Adelgais KM Anders J Borgialli D Donoghue A Hoyle JD Jr Kim E Leonard JR Lillis KA Nigrovic LE Powell EC Rebella
G Reeves SD Rogers AJ Stankovic C Teshome G Jaffe DM Pediatric Emergency Care Applied Research Network
- Itrsquos Hard to Put a Band-Aid on a Broken Spleen Pediatric Trauma
- Disclosures
- Objectives
- Pediatric Prehospital Care
- Mechanism
- Traumatic Pain Management
- Pediatric Trauma
- Deaths by Mechanism of Injury
- Pediatric Trauma
- Pediatric Trauma
- Airway Differences
- Pediatric-Adult Differences
- Pediatric Challenges
- Prehospital Pediatric Challenges
- Pediatric and Adult Trauma
- Scene Response
- Prehospital Intervention
- Where do you take the patient
- Patient arrives at the EDhellip
- Primary Survey
- Order is critical
- Slide Number 22
- Slide Number 23
- Airway
- Indications for Intubation
- Breathing
- ETT Intubation Basics
- Circulation
- Slide Number 29
- CirculationHemodynamic Changes
- Circulation
- Fluid Resuscitation Algorithm
- Reconsidering Crystalloid Resuscitation
- When to start MTP
- Disability
- Finishing Up the Evaluation
- Bad Scene Responses
- OHCA from Trauma
- Blunt Trauma- No Signs of Life
- OHCA with CPR on Arrival
- Pediatric Trauma
- Questions
- References 1
- References 2
- References 3
- References 4
- References 5
- References 5
- XXXXBoston study ems peds trauma procedures- limited pediatric procedural exposure (but more adult experience)
- C-spine
Circulation
ndash Access 2 large bore IVrsquos ndash IVFrsquos ndash pRBCrsquos
bull Hgb lt7gdl or ongoing blood losses
ndash Massive Transfusion Protocol
bull (111 ratio of PRBCS FFP Platelets)
ndash Vasopressors (epi norepi dopamine)
ndash Control of Hemorrhage bull Pelvic binders bull Direct pressure bull Indirectproximal pressure bull Tourniquet (only when
absolutely necessary)
ndash Chest Compressions ndash Pericardiocentesis ndash Delayed resuscitation
controlled hypotension (MAP 50 vs 65)
ndash Tranexamic acid in the near future
bull Interventions
Fluid Resuscitation Algorithm 20 mLkg isotonic crystalloid
Reassess
20 mLkg isotonic crystalloid
Reassess
20 mLkg isotonic crystalloid (31 rule)
or consider 10 to 20 mLkg packed red cells
Reconsidering Crystalloid Resuscitation
bull Less fluid ndash Permissive hypotension to
prevent clot rupture (select cases)
bull Too much fluid ndash Excessive Third Spacing ndash Secondary Compartment
Syndrome ndash Greater risk of ARDS ndash Dilutional Coagulopathy
When to start MTP
bull As soon as you believe you will need it ndash Institution specific guidelines
bull gt4 units or 40mlkg of PRBCrsquos expected bull Earlier use of Massive Transfusion Protocol
(pRBC FFP PLT) in ldquoDamage Controlrdquo resuscitations may improve outcome
bull 111 unit ratio bull Risk of TRALI ARDS etc
Disability bull GCS
ndash Range 3-15 ndash We should be 15 ndash Dead are still 3 ndash Less than 8 intubate ndash Eyes- 4 eyes ndash Verbal- most difficult ndash Motor- V6 engine ndash Intubated T
bull AVPU
Finishing Up the Evaluation
bull Airway bull Breathing bull Circulation bull Disability bull Exposure
ndash Expose and examine all parts ndash Cover quickly and keep warm
bull Secondary Survey
Bad Scene Responses
bull What are the outcomes of out-of-hospital cardiac arrest from blunt trauma
bull What are the outcomes of pediatric drowning patients
OHCA from Trauma
bull 2000-2003 bull 123 pts bull Mean age 73 yrs bull Most common
rhythms ndash Asystole 59 ndash PEA 29 ndash V-fib 35
bull 195 rosc in field ndash 98 survived for 24
hrs ndash 57 survived to
discharge ndash Drowning- 19
survival to discharge ndash Bystander CPR tripled
the survivor rate
Blunt Trauma- No Signs of Life
bull Review from 2002-2010 bull No signs of life- 025 of blunt trauma
ndash 25 resuscitated prior to hospital arrival bull 138 of these patients survived to discharge
bull 44 overall survived to hospital discharge
OHCA with CPR on Arrival
bull 169 children bull 141 deaths bull 69 required cpr on arrival- none survived bull 87 of patients requiring CPR on arrival
expired in the ED bull Of the 28 survivors
ndash 55 of survivors had full neurologic recovery
Pediatric Trauma
bull Fortunately these cases represent only a small fraction of EMS transports
bull Despite a few key differences pediatric trauma care overall is very similar to adult trauma care
Questions
References 1 bull NTDB 2013 pediatric Report bull Monkey bars httpsplaygroundchroniclesfileswordpresscom201307soccerjpg bull Screaming child httpblogsbabycentercomwp-contentuploads201409screaming-child-tantrum-fitjpg bull Pediatric airway image httpwwwcelebritydiagnosiscomwp-contentuploads201003pediatric-airwayjpg bull Child on backboard httpsencrypted-tbn2gstaticcomimagesq=tbnANd9GcQscrDVc8IH4MwkNGF6F1A9p7mSVzik5zrWyNvI-
qSwQT5S3GNyVg bull Elbow fracture httpwwwimageinterpretationcoukimageselbowSUPRACONDYLAR20LAT3jpg bull Bike riding httpsmile-per-daycomwp-contentuploads201412klr03jpg bull Dad and child pic httplaughingsquidcomwp-contentuploads471160jpg bull Weigth estimation inner city Am J Emerg Med 2015 Oct33(10)1364-7 doi 101016jajem201507040 Epub 2015 Jul 29 Weight
estimation in an inner-city pediatric ED the effect of obesity Chavez H1 Peterson RE2 Lo K3 Arel M4
bull Guess weight sign httpmedialiveauctiongroupneti963110572971_1jpgv=8CDDAAF8A5B9E20 bull Broselow tape httpsuploadwikimediaorgwikipediacommons994BTape1jpg bull Parent screaming httpmommyofamonstercomwp-contentuploads201301yellingjpg bull Prehospital pain management Am J Emerg Med 2015 Mar33(3)451-4 doi 101016jajem201412012 Epub 2014 Dec 18
Prehospital pain management of injured children a systematic review of current evidence Samuel N1 Steiner IP2 Shavit I3 bull Prehospital pain ped pain assessment Prehosp Emerg Care 2008 Apr-Jun12(2)182-6 doi 10108010903120801907471 Prehospital
pain assessment in pediatric trauma Izsak E1 Moore JL Stringfellow K Oswanski MF Lindstrom DA Stombaugh HA bull Ped pain management Prehosp Emerg Care 2005 Jan-Mar9(1)40-3 Prehospital pain management in children suffering traumatic
injury Swor R1 McEachin CM Seguin D Grall KH bull Prehospital intervention Allen CJ Teisch LF et al Prehospital care and transportation of pediatric trauma patients J Surg Res 2015
Aug197(2)240-6 JAMA 2000 Feb 9283(6)783-90 bull Effect of out-of-hospital pediatric endotracheal intubation on survival and neurological outcome a controlled clinical trial
Gausche M1 Lewis RJ Stratton SJ Haynes BE Gunter CS Goodrich SM Poore PD McCollough MD Henderson DP Pratt FD Seidel JS
bull Pediatric pain management survey Pediatr Emerg Care 2015 Sep 23 [Epub ahead of print] An Assessment of Newly Identified Barriers to and Enablers for Prehospital Pediatric Pain Management Whitley DE1 Li T Jones CM Cushman JT Williams DM Shah MN
References 2 bull httpwwwuptodatecomcontentsprehospital-pediatrics-and-emergency-medical-services-emsabstract6 bull httpwwwuptodatecomcontentsprehospital-pediatrics-and-emergency-medical-services-emsabstract7 bull Pediatr Crit Care Med 2011 Jul12(4)e166-70 doi 101097PCC0b013e3181f36f6e First responder
performance in pediatric trauma a comparison with an adult cohortBankole S1 Asuncion A Ross S Aghai Z Nollah L Echols H Da-Silva S
bull Drayna pc Browne LR et al Prehospital pediatric care Oppportunities for training treatment and research Prehosp Emerg Care 2015 Jul-Sep 19(3) Epub 2015 Feb 6
bull Pediatr Emerg Care 2001 Feb17(1) 5-9Pediatric pre-hospital advanced life support care in an urban setting Babl FE1 Vinci RJ Bauchner H Mottley L
bull Pediatr Crit Care Med 2015 Oct16(8)e260-7 doi 101097PCC0000000000000505Pediatric Out-of-Hospital Critical Procedures in the United States Carlson JN1 Gannon E Mann NC Jacobson KE Dai M Colleran C Wang HE
bull Pediatr Emerg Care 2009 Aug25(8)508-12 doi 101097PEC0b013e3181b0a0da The efficacy of pediatric advanced life support training in emergency medical service providers Baker TW1 King W Soto W Asher C Stolfi A Rowin ME
bull Sutton RM Case E et al ROC investigators A quantitative analysis of out-of-hospital pediatric and adolescent resuscitation quality A report from the ROC Epistry- Cardiac Arrest Resusciation 201593150-157
bull Resuscitation 2014 Aug85(8)1059-64 doi 101016jresuscitation201403307 Epub 2014 Apr 4 Neurocognitive long term follow-up study on drowned children Suominen PK1 Sutinen N2 Valle S3 Olkkola KT4 Loumlnnqvist T3
bull J Pediatr Surg 2010 Jul45(7)1413-9 doi 101016jjpedsurg200912020 Prehospital cardiopulmonary resuscitation in the pediatric trauma patient Murphy JT1 Jaiswal K Sabella J Vinson L Megison S Maxson RT
References 3 bull Pre atv accident
httpwwwctvnewscapolopoly_fs119871591409741949httpImageimagejpg_genderivativeslandscape_960imagejpg bull atv pic httpswwwutahadvocatescomwp-contentuploads201402atvAccidentLawyerjpg bull Blunt abdominal solid organ injury adult vs pediatric trauma center J Pediatr Surg 2015 Aug 28 pii S0022-3468(15)00526-6 doi
101016jjpedsurg201508012 [Epub ahead of print] Trauma center variation in the management of pediatric patients with blunt abdominal solid organ injury a national trauma data bank analysis Safavi A1 Skarsgard ED2 Rhee P1 Zangbar B1 Kulvatunyou N1 Tang A1 OKeeffe T1 Friese RS1 Joseph B3
bull Pediatric blunt abdominal injury Curr Opin Crit Care 2015 Sep 28 [Epub ahead of print] Pediatric blunt abdominal trauma current management Notrica DM1
bull Pediatric splenic injury management Am J Surg 2015 Jul 31 pii S0002-9610(15)00417-1 doi 101016jamjsurg201506009 [Epub ahead of print] Comparative effectiveness of treatment strategies for severe splenic trauma in the pediatric population Rialon KL1 Englum BR1 Gulack BC1 Guevara CJ2 Bhattacharya SD3 Shapiro ML4 Rice HE5 Scarborough JE4 Adibe OO6
bull Liver pic httpss-media-cache-ak0pinimgcom736x7da50e7da50eb2bb603c99ef6649ff897e26b5jpg bull Solid organ injury non op in peds J Trauma Acute Care Surg 2015 Oct79(4)683-93 doi 101097TA0000000000000808
Nonoperative management of blunt liver and spleen injury in children Evaluation of the ATOMAC guideline using GRADE Notrica DM1 Eubanks JW 3rd Tuggle DW Maxson RT Letton RW Garcia NM Alder AC Lawson KA St Peter SD Megison S Garcia Filion P
bull Pediaric vs nonped trauma ct use J Pediatr 2015 Oct167(4)897-904e3 doi 101016jjpeds201506052 Epub 2015 Jul 29 Variation in Computed Tomography Imaging for Pediatric Injury-Related Emergency Visits Marin JR1 Wang L2 Winger DG2 Mannix RC3
bull Solid organ management in ped population J Trauma Acute Care Surg 2015 Aug79(2)206-14quiz 332 doi 101097TA0000000000000731 Management of children with solid organ injuries after blunt torso trauma Wisner DH1 Kuppermann N Cooper A Menaker J Ehrlich P Kooistra J Mahajan P Lee L Cook LJ Yen K Lillis K Holmes JF
bull Triad of death image httpimageslidesharecdncomdamage-control-resuscitation-1304253390-phpapp0195damage-control-resuscitation-14-728jpgcb=1304235553
bull Tranexamic acid study Eckert MJ Wertin TM Tyner SD et al 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 77852
bull Image care accident httpsuploadwikimediaorgwikipediacommonsthumbee1Car_crash_1jpg1280px-Car_crash_1jpg
References 4 bull httpwwwsurgeryvcuedudivisionsacutesurghtml bull Trauma management Approach to the unstable child
httpwwwuptodatecomcontentstrauma-management-approach-to-the-unstable-childsource=search_resultampsearch=pediatric+trauma+childrenampselectedTitle=17E150
bull Trauma management Unique pediatric considerations httpwwwuptodatecomcontentstrauma-management-unique-pediatric-considerationssource=search_resultampsearch=pediatric+trauma+childrenampselectedTitle=37E150
References 5 bull httpwwwetiquettehellcomsmfindexphptopic=8666360 bull httpwwwstlouischildrensorghealth-care-professionalsems-providers bull httpwwwuchicagokidshospitalorgspecialtiesemergency-medicinespecialhtml bull httpwwwsimsacademyinfoFXpatienthtm bull httptheemtspotcomwp-contentuploads200902another-burn-patient-by-annette-larsonjpg bull httplastangryfancomwp-contentuploads200910Clint-Malarchukjpg bull httpwwwtraumaorgarchiveresusmassivehtml bull httpwwwuptodatecomcontentsimageimageKey=PEDS68694amptopicKey=EM2F6389ampsourc
e=previewampsearch=pediatric+hemorrhagic+shockampselectedTitle=17E150amprank=undefined bull httptheemtspotcomwp-contentuploads200902gcsgif bull httpwwwuptodatecomcontentsimageimageKey=EM2F60409amptopicKey=EM2F6571amprank
=17E150ampsource=see_linkampsearch=traumaamputdPopup=true bull httpwwwuptodatecomcontentsimageimageKey=EM2F80874amptopicKey=EM2F6571amprank
=17E150ampsource=see_linkampsearch=traumaamputdPopup=true bull httpempracticenewswordpresscomcategorynexus-criteria bull httpswwwgooglecomsearchq=pediatric+glasgow+coma+scaleamptbm=ischamptbo=uampsource=uni
vampsa=Xampei=8TiOU7TNC5WuyATp5YG4BQampsqi=2ampved=0CDYQsAQampbiw=1426ampbih=883q=canadian+c-spine+rulesamptbm=ischampfacrc=_ampimgdii=_ampimgrc=WI94QMHgMLTQmM253A3BP5nbsFhNCXK0FM3Bhttp253A252F252Fwwwbmjcom252Fhighwire252Ffilestream252F436003252Ffield_highwire_fragment_image_l252F0jpg3Bhttp253A252F252Fwwwbmjcom252Fcontent252F339252Fbmjb41463B12803B1253
References 5 bull httpwwwuptodatecomcontentsimageimageKey=EM2F76777amptopicKey=EM2F6571amprank
=17E150ampsource=see_linkampsearch=traumaamputdPopup=true bull httpwwwdocumentingrealitycomforumattachmentsf14964898d1246625322-firework-injury-
m80injury1jpg bull httpwwwpediatriceducationorg20050620 bull httpwwwarmstrongmedicalcomindexcfmgoproductdetailsec3ssec19cat61fam515 bull httpwwwuptodatecomcontentsimageimageKey=PEDS61087amptopicKey=ID2F7661ampsource
=outline_linkampsearch=tetanus+prophylaxisamputdPopup=true bull httpwwwafsecafmilsharedmediaphotodbweb110609-F-MJ378-009jpg bull httpwwwuptodatecomcontentsimageimageKey=EM75765amptopicKey= bull EM2F6389ampsource=outline_linkampsearch=massive+transfusion+protocolamputdPopup=true bull httpwwwmotifakecomimagedemotivational-postersmall0910whats-the-question-ignorance-
calvin-and-hobbes-demotivational-poster-1255020127jpg
XXXXBoston study ems peds trauma procedures- limited pediatric procedural exposure (but more adult experience) bull Catchment area 590000
over 1 year bull 555 pediatric ALS
transport ndash 19 blunt trauma ndash 10 penetrating trauma
bull IV 33 bull BMV 5 bull Intubation 3 bull 50 ALS providers average
year ndash IV- 37 ndash Intubation- 03 ndash IO- 006
bull 7 ped ems ndash 13 trauma
bull Critical procedures ndash 101000 peds cases ndash Intubation 671000 ndash IO 51000 ndash 81 successful
Pediatr Emerg Care 2001 Feb17(1)5-9 Pediatric pre-hospital advanced life support care in an urban setting
Babl FE1 Vinci RJ Bauchner H Mottley L
Pediatr Crit Care Med 2015 Oct16(8)e260-7 doi 101097PCC0000000000000505 Pediatric Out-of-Hospital Critical Procedures in the United States
Carlson JN1 Gannon E Mann NC Jacobson KE Dai M Colleran C Wang HE
C-spine bull C-spine injuries rare bull Take pt to closest hospital if over injuries
call for it (ie resuscitation altered mental status) primary guide
bull Mechanism ndash Altered mental status focal neuro change
torticollis substantial torso injury diving high speed auto neck pain underlying predisposing condition Acad Emerg Med 2014 Jan21(1)55-64 doi 101111acem12288
Comparison of outcomes for children with cervical spine injury based on destination hospital from scene of injury Anders JF1 Adelgais K Hoyle JD Jr Olsen C Jaffe DM Leonard JC Pediatric Emergency Care Applied Research Network
(PECARN)
Ann Emerg Med 2011 Aug58(2)145-55 doi 101016jannemergmed201008038 Epub 2010 Oct 29 Factors associated with cervical spine injury in children after blunt trauma
Leonard JC Kuppermann N Olsen C Babcock-Cimpello L Brown K Mahajan P Adelgais KM Anders J Borgialli D Donoghue A Hoyle JD Jr Kim E Leonard JR Lillis KA Nigrovic LE Powell EC Rebella
G Reeves SD Rogers AJ Stankovic C Teshome G Jaffe DM Pediatric Emergency Care Applied Research Network
- Itrsquos Hard to Put a Band-Aid on a Broken Spleen Pediatric Trauma
- Disclosures
- Objectives
- Pediatric Prehospital Care
- Mechanism
- Traumatic Pain Management
- Pediatric Trauma
- Deaths by Mechanism of Injury
- Pediatric Trauma
- Pediatric Trauma
- Airway Differences
- Pediatric-Adult Differences
- Pediatric Challenges
- Prehospital Pediatric Challenges
- Pediatric and Adult Trauma
- Scene Response
- Prehospital Intervention
- Where do you take the patient
- Patient arrives at the EDhellip
- Primary Survey
- Order is critical
- Slide Number 22
- Slide Number 23
- Airway
- Indications for Intubation
- Breathing
- ETT Intubation Basics
- Circulation
- Slide Number 29
- CirculationHemodynamic Changes
- Circulation
- Fluid Resuscitation Algorithm
- Reconsidering Crystalloid Resuscitation
- When to start MTP
- Disability
- Finishing Up the Evaluation
- Bad Scene Responses
- OHCA from Trauma
- Blunt Trauma- No Signs of Life
- OHCA with CPR on Arrival
- Pediatric Trauma
- Questions
- References 1
- References 2
- References 3
- References 4
- References 5
- References 5
- XXXXBoston study ems peds trauma procedures- limited pediatric procedural exposure (but more adult experience)
- C-spine
Fluid Resuscitation Algorithm 20 mLkg isotonic crystalloid
Reassess
20 mLkg isotonic crystalloid
Reassess
20 mLkg isotonic crystalloid (31 rule)
or consider 10 to 20 mLkg packed red cells
Reconsidering Crystalloid Resuscitation
bull Less fluid ndash Permissive hypotension to
prevent clot rupture (select cases)
bull Too much fluid ndash Excessive Third Spacing ndash Secondary Compartment
Syndrome ndash Greater risk of ARDS ndash Dilutional Coagulopathy
When to start MTP
bull As soon as you believe you will need it ndash Institution specific guidelines
bull gt4 units or 40mlkg of PRBCrsquos expected bull Earlier use of Massive Transfusion Protocol
(pRBC FFP PLT) in ldquoDamage Controlrdquo resuscitations may improve outcome
bull 111 unit ratio bull Risk of TRALI ARDS etc
Disability bull GCS
ndash Range 3-15 ndash We should be 15 ndash Dead are still 3 ndash Less than 8 intubate ndash Eyes- 4 eyes ndash Verbal- most difficult ndash Motor- V6 engine ndash Intubated T
bull AVPU
Finishing Up the Evaluation
bull Airway bull Breathing bull Circulation bull Disability bull Exposure
ndash Expose and examine all parts ndash Cover quickly and keep warm
bull Secondary Survey
Bad Scene Responses
bull What are the outcomes of out-of-hospital cardiac arrest from blunt trauma
bull What are the outcomes of pediatric drowning patients
OHCA from Trauma
bull 2000-2003 bull 123 pts bull Mean age 73 yrs bull Most common
rhythms ndash Asystole 59 ndash PEA 29 ndash V-fib 35
bull 195 rosc in field ndash 98 survived for 24
hrs ndash 57 survived to
discharge ndash Drowning- 19
survival to discharge ndash Bystander CPR tripled
the survivor rate
Blunt Trauma- No Signs of Life
bull Review from 2002-2010 bull No signs of life- 025 of blunt trauma
ndash 25 resuscitated prior to hospital arrival bull 138 of these patients survived to discharge
bull 44 overall survived to hospital discharge
OHCA with CPR on Arrival
bull 169 children bull 141 deaths bull 69 required cpr on arrival- none survived bull 87 of patients requiring CPR on arrival
expired in the ED bull Of the 28 survivors
ndash 55 of survivors had full neurologic recovery
Pediatric Trauma
bull Fortunately these cases represent only a small fraction of EMS transports
bull Despite a few key differences pediatric trauma care overall is very similar to adult trauma care
Questions
References 1 bull NTDB 2013 pediatric Report bull Monkey bars httpsplaygroundchroniclesfileswordpresscom201307soccerjpg bull Screaming child httpblogsbabycentercomwp-contentuploads201409screaming-child-tantrum-fitjpg bull Pediatric airway image httpwwwcelebritydiagnosiscomwp-contentuploads201003pediatric-airwayjpg bull Child on backboard httpsencrypted-tbn2gstaticcomimagesq=tbnANd9GcQscrDVc8IH4MwkNGF6F1A9p7mSVzik5zrWyNvI-
qSwQT5S3GNyVg bull Elbow fracture httpwwwimageinterpretationcoukimageselbowSUPRACONDYLAR20LAT3jpg bull Bike riding httpsmile-per-daycomwp-contentuploads201412klr03jpg bull Dad and child pic httplaughingsquidcomwp-contentuploads471160jpg bull Weigth estimation inner city Am J Emerg Med 2015 Oct33(10)1364-7 doi 101016jajem201507040 Epub 2015 Jul 29 Weight
estimation in an inner-city pediatric ED the effect of obesity Chavez H1 Peterson RE2 Lo K3 Arel M4
bull Guess weight sign httpmedialiveauctiongroupneti963110572971_1jpgv=8CDDAAF8A5B9E20 bull Broselow tape httpsuploadwikimediaorgwikipediacommons994BTape1jpg bull Parent screaming httpmommyofamonstercomwp-contentuploads201301yellingjpg bull Prehospital pain management Am J Emerg Med 2015 Mar33(3)451-4 doi 101016jajem201412012 Epub 2014 Dec 18
Prehospital pain management of injured children a systematic review of current evidence Samuel N1 Steiner IP2 Shavit I3 bull Prehospital pain ped pain assessment Prehosp Emerg Care 2008 Apr-Jun12(2)182-6 doi 10108010903120801907471 Prehospital
pain assessment in pediatric trauma Izsak E1 Moore JL Stringfellow K Oswanski MF Lindstrom DA Stombaugh HA bull Ped pain management Prehosp Emerg Care 2005 Jan-Mar9(1)40-3 Prehospital pain management in children suffering traumatic
injury Swor R1 McEachin CM Seguin D Grall KH bull Prehospital intervention Allen CJ Teisch LF et al Prehospital care and transportation of pediatric trauma patients J Surg Res 2015
Aug197(2)240-6 JAMA 2000 Feb 9283(6)783-90 bull Effect of out-of-hospital pediatric endotracheal intubation on survival and neurological outcome a controlled clinical trial
Gausche M1 Lewis RJ Stratton SJ Haynes BE Gunter CS Goodrich SM Poore PD McCollough MD Henderson DP Pratt FD Seidel JS
bull Pediatric pain management survey Pediatr Emerg Care 2015 Sep 23 [Epub ahead of print] An Assessment of Newly Identified Barriers to and Enablers for Prehospital Pediatric Pain Management Whitley DE1 Li T Jones CM Cushman JT Williams DM Shah MN
References 2 bull httpwwwuptodatecomcontentsprehospital-pediatrics-and-emergency-medical-services-emsabstract6 bull httpwwwuptodatecomcontentsprehospital-pediatrics-and-emergency-medical-services-emsabstract7 bull Pediatr Crit Care Med 2011 Jul12(4)e166-70 doi 101097PCC0b013e3181f36f6e First responder
performance in pediatric trauma a comparison with an adult cohortBankole S1 Asuncion A Ross S Aghai Z Nollah L Echols H Da-Silva S
bull Drayna pc Browne LR et al Prehospital pediatric care Oppportunities for training treatment and research Prehosp Emerg Care 2015 Jul-Sep 19(3) Epub 2015 Feb 6
bull Pediatr Emerg Care 2001 Feb17(1) 5-9Pediatric pre-hospital advanced life support care in an urban setting Babl FE1 Vinci RJ Bauchner H Mottley L
bull Pediatr Crit Care Med 2015 Oct16(8)e260-7 doi 101097PCC0000000000000505Pediatric Out-of-Hospital Critical Procedures in the United States Carlson JN1 Gannon E Mann NC Jacobson KE Dai M Colleran C Wang HE
bull Pediatr Emerg Care 2009 Aug25(8)508-12 doi 101097PEC0b013e3181b0a0da The efficacy of pediatric advanced life support training in emergency medical service providers Baker TW1 King W Soto W Asher C Stolfi A Rowin ME
bull Sutton RM Case E et al ROC investigators A quantitative analysis of out-of-hospital pediatric and adolescent resuscitation quality A report from the ROC Epistry- Cardiac Arrest Resusciation 201593150-157
bull Resuscitation 2014 Aug85(8)1059-64 doi 101016jresuscitation201403307 Epub 2014 Apr 4 Neurocognitive long term follow-up study on drowned children Suominen PK1 Sutinen N2 Valle S3 Olkkola KT4 Loumlnnqvist T3
bull J Pediatr Surg 2010 Jul45(7)1413-9 doi 101016jjpedsurg200912020 Prehospital cardiopulmonary resuscitation in the pediatric trauma patient Murphy JT1 Jaiswal K Sabella J Vinson L Megison S Maxson RT
References 3 bull Pre atv accident
httpwwwctvnewscapolopoly_fs119871591409741949httpImageimagejpg_genderivativeslandscape_960imagejpg bull atv pic httpswwwutahadvocatescomwp-contentuploads201402atvAccidentLawyerjpg bull Blunt abdominal solid organ injury adult vs pediatric trauma center J Pediatr Surg 2015 Aug 28 pii S0022-3468(15)00526-6 doi
101016jjpedsurg201508012 [Epub ahead of print] Trauma center variation in the management of pediatric patients with blunt abdominal solid organ injury a national trauma data bank analysis Safavi A1 Skarsgard ED2 Rhee P1 Zangbar B1 Kulvatunyou N1 Tang A1 OKeeffe T1 Friese RS1 Joseph B3
bull Pediatric blunt abdominal injury Curr Opin Crit Care 2015 Sep 28 [Epub ahead of print] Pediatric blunt abdominal trauma current management Notrica DM1
bull Pediatric splenic injury management Am J Surg 2015 Jul 31 pii S0002-9610(15)00417-1 doi 101016jamjsurg201506009 [Epub ahead of print] Comparative effectiveness of treatment strategies for severe splenic trauma in the pediatric population Rialon KL1 Englum BR1 Gulack BC1 Guevara CJ2 Bhattacharya SD3 Shapiro ML4 Rice HE5 Scarborough JE4 Adibe OO6
bull Liver pic httpss-media-cache-ak0pinimgcom736x7da50e7da50eb2bb603c99ef6649ff897e26b5jpg bull Solid organ injury non op in peds J Trauma Acute Care Surg 2015 Oct79(4)683-93 doi 101097TA0000000000000808
Nonoperative management of blunt liver and spleen injury in children Evaluation of the ATOMAC guideline using GRADE Notrica DM1 Eubanks JW 3rd Tuggle DW Maxson RT Letton RW Garcia NM Alder AC Lawson KA St Peter SD Megison S Garcia Filion P
bull Pediaric vs nonped trauma ct use J Pediatr 2015 Oct167(4)897-904e3 doi 101016jjpeds201506052 Epub 2015 Jul 29 Variation in Computed Tomography Imaging for Pediatric Injury-Related Emergency Visits Marin JR1 Wang L2 Winger DG2 Mannix RC3
bull Solid organ management in ped population J Trauma Acute Care Surg 2015 Aug79(2)206-14quiz 332 doi 101097TA0000000000000731 Management of children with solid organ injuries after blunt torso trauma Wisner DH1 Kuppermann N Cooper A Menaker J Ehrlich P Kooistra J Mahajan P Lee L Cook LJ Yen K Lillis K Holmes JF
bull Triad of death image httpimageslidesharecdncomdamage-control-resuscitation-1304253390-phpapp0195damage-control-resuscitation-14-728jpgcb=1304235553
bull Tranexamic acid study Eckert MJ Wertin TM Tyner SD et al 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 77852
bull Image care accident httpsuploadwikimediaorgwikipediacommonsthumbee1Car_crash_1jpg1280px-Car_crash_1jpg
References 4 bull httpwwwsurgeryvcuedudivisionsacutesurghtml bull Trauma management Approach to the unstable child
httpwwwuptodatecomcontentstrauma-management-approach-to-the-unstable-childsource=search_resultampsearch=pediatric+trauma+childrenampselectedTitle=17E150
bull Trauma management Unique pediatric considerations httpwwwuptodatecomcontentstrauma-management-unique-pediatric-considerationssource=search_resultampsearch=pediatric+trauma+childrenampselectedTitle=37E150
References 5 bull httpwwwetiquettehellcomsmfindexphptopic=8666360 bull httpwwwstlouischildrensorghealth-care-professionalsems-providers bull httpwwwuchicagokidshospitalorgspecialtiesemergency-medicinespecialhtml bull httpwwwsimsacademyinfoFXpatienthtm bull httptheemtspotcomwp-contentuploads200902another-burn-patient-by-annette-larsonjpg bull httplastangryfancomwp-contentuploads200910Clint-Malarchukjpg bull httpwwwtraumaorgarchiveresusmassivehtml bull httpwwwuptodatecomcontentsimageimageKey=PEDS68694amptopicKey=EM2F6389ampsourc
e=previewampsearch=pediatric+hemorrhagic+shockampselectedTitle=17E150amprank=undefined bull httptheemtspotcomwp-contentuploads200902gcsgif bull httpwwwuptodatecomcontentsimageimageKey=EM2F60409amptopicKey=EM2F6571amprank
=17E150ampsource=see_linkampsearch=traumaamputdPopup=true bull httpwwwuptodatecomcontentsimageimageKey=EM2F80874amptopicKey=EM2F6571amprank
=17E150ampsource=see_linkampsearch=traumaamputdPopup=true bull httpempracticenewswordpresscomcategorynexus-criteria bull httpswwwgooglecomsearchq=pediatric+glasgow+coma+scaleamptbm=ischamptbo=uampsource=uni
vampsa=Xampei=8TiOU7TNC5WuyATp5YG4BQampsqi=2ampved=0CDYQsAQampbiw=1426ampbih=883q=canadian+c-spine+rulesamptbm=ischampfacrc=_ampimgdii=_ampimgrc=WI94QMHgMLTQmM253A3BP5nbsFhNCXK0FM3Bhttp253A252F252Fwwwbmjcom252Fhighwire252Ffilestream252F436003252Ffield_highwire_fragment_image_l252F0jpg3Bhttp253A252F252Fwwwbmjcom252Fcontent252F339252Fbmjb41463B12803B1253
References 5 bull httpwwwuptodatecomcontentsimageimageKey=EM2F76777amptopicKey=EM2F6571amprank
=17E150ampsource=see_linkampsearch=traumaamputdPopup=true bull httpwwwdocumentingrealitycomforumattachmentsf14964898d1246625322-firework-injury-
m80injury1jpg bull httpwwwpediatriceducationorg20050620 bull httpwwwarmstrongmedicalcomindexcfmgoproductdetailsec3ssec19cat61fam515 bull httpwwwuptodatecomcontentsimageimageKey=PEDS61087amptopicKey=ID2F7661ampsource
=outline_linkampsearch=tetanus+prophylaxisamputdPopup=true bull httpwwwafsecafmilsharedmediaphotodbweb110609-F-MJ378-009jpg bull httpwwwuptodatecomcontentsimageimageKey=EM75765amptopicKey= bull EM2F6389ampsource=outline_linkampsearch=massive+transfusion+protocolamputdPopup=true bull httpwwwmotifakecomimagedemotivational-postersmall0910whats-the-question-ignorance-
calvin-and-hobbes-demotivational-poster-1255020127jpg
XXXXBoston study ems peds trauma procedures- limited pediatric procedural exposure (but more adult experience) bull Catchment area 590000
over 1 year bull 555 pediatric ALS
transport ndash 19 blunt trauma ndash 10 penetrating trauma
bull IV 33 bull BMV 5 bull Intubation 3 bull 50 ALS providers average
year ndash IV- 37 ndash Intubation- 03 ndash IO- 006
bull 7 ped ems ndash 13 trauma
bull Critical procedures ndash 101000 peds cases ndash Intubation 671000 ndash IO 51000 ndash 81 successful
Pediatr Emerg Care 2001 Feb17(1)5-9 Pediatric pre-hospital advanced life support care in an urban setting
Babl FE1 Vinci RJ Bauchner H Mottley L
Pediatr Crit Care Med 2015 Oct16(8)e260-7 doi 101097PCC0000000000000505 Pediatric Out-of-Hospital Critical Procedures in the United States
Carlson JN1 Gannon E Mann NC Jacobson KE Dai M Colleran C Wang HE
C-spine bull C-spine injuries rare bull Take pt to closest hospital if over injuries
call for it (ie resuscitation altered mental status) primary guide
bull Mechanism ndash Altered mental status focal neuro change
torticollis substantial torso injury diving high speed auto neck pain underlying predisposing condition Acad Emerg Med 2014 Jan21(1)55-64 doi 101111acem12288
Comparison of outcomes for children with cervical spine injury based on destination hospital from scene of injury Anders JF1 Adelgais K Hoyle JD Jr Olsen C Jaffe DM Leonard JC Pediatric Emergency Care Applied Research Network
(PECARN)
Ann Emerg Med 2011 Aug58(2)145-55 doi 101016jannemergmed201008038 Epub 2010 Oct 29 Factors associated with cervical spine injury in children after blunt trauma
Leonard JC Kuppermann N Olsen C Babcock-Cimpello L Brown K Mahajan P Adelgais KM Anders J Borgialli D Donoghue A Hoyle JD Jr Kim E Leonard JR Lillis KA Nigrovic LE Powell EC Rebella
G Reeves SD Rogers AJ Stankovic C Teshome G Jaffe DM Pediatric Emergency Care Applied Research Network
- Itrsquos Hard to Put a Band-Aid on a Broken Spleen Pediatric Trauma
- Disclosures
- Objectives
- Pediatric Prehospital Care
- Mechanism
- Traumatic Pain Management
- Pediatric Trauma
- Deaths by Mechanism of Injury
- Pediatric Trauma
- Pediatric Trauma
- Airway Differences
- Pediatric-Adult Differences
- Pediatric Challenges
- Prehospital Pediatric Challenges
- Pediatric and Adult Trauma
- Scene Response
- Prehospital Intervention
- Where do you take the patient
- Patient arrives at the EDhellip
- Primary Survey
- Order is critical
- Slide Number 22
- Slide Number 23
- Airway
- Indications for Intubation
- Breathing
- ETT Intubation Basics
- Circulation
- Slide Number 29
- CirculationHemodynamic Changes
- Circulation
- Fluid Resuscitation Algorithm
- Reconsidering Crystalloid Resuscitation
- When to start MTP
- Disability
- Finishing Up the Evaluation
- Bad Scene Responses
- OHCA from Trauma
- Blunt Trauma- No Signs of Life
- OHCA with CPR on Arrival
- Pediatric Trauma
- Questions
- References 1
- References 2
- References 3
- References 4
- References 5
- References 5
- XXXXBoston study ems peds trauma procedures- limited pediatric procedural exposure (but more adult experience)
- C-spine
Reconsidering Crystalloid Resuscitation
bull Less fluid ndash Permissive hypotension to
prevent clot rupture (select cases)
bull Too much fluid ndash Excessive Third Spacing ndash Secondary Compartment
Syndrome ndash Greater risk of ARDS ndash Dilutional Coagulopathy
When to start MTP
bull As soon as you believe you will need it ndash Institution specific guidelines
bull gt4 units or 40mlkg of PRBCrsquos expected bull Earlier use of Massive Transfusion Protocol
(pRBC FFP PLT) in ldquoDamage Controlrdquo resuscitations may improve outcome
bull 111 unit ratio bull Risk of TRALI ARDS etc
Disability bull GCS
ndash Range 3-15 ndash We should be 15 ndash Dead are still 3 ndash Less than 8 intubate ndash Eyes- 4 eyes ndash Verbal- most difficult ndash Motor- V6 engine ndash Intubated T
bull AVPU
Finishing Up the Evaluation
bull Airway bull Breathing bull Circulation bull Disability bull Exposure
ndash Expose and examine all parts ndash Cover quickly and keep warm
bull Secondary Survey
Bad Scene Responses
bull What are the outcomes of out-of-hospital cardiac arrest from blunt trauma
bull What are the outcomes of pediatric drowning patients
OHCA from Trauma
bull 2000-2003 bull 123 pts bull Mean age 73 yrs bull Most common
rhythms ndash Asystole 59 ndash PEA 29 ndash V-fib 35
bull 195 rosc in field ndash 98 survived for 24
hrs ndash 57 survived to
discharge ndash Drowning- 19
survival to discharge ndash Bystander CPR tripled
the survivor rate
Blunt Trauma- No Signs of Life
bull Review from 2002-2010 bull No signs of life- 025 of blunt trauma
ndash 25 resuscitated prior to hospital arrival bull 138 of these patients survived to discharge
bull 44 overall survived to hospital discharge
OHCA with CPR on Arrival
bull 169 children bull 141 deaths bull 69 required cpr on arrival- none survived bull 87 of patients requiring CPR on arrival
expired in the ED bull Of the 28 survivors
ndash 55 of survivors had full neurologic recovery
Pediatric Trauma
bull Fortunately these cases represent only a small fraction of EMS transports
bull Despite a few key differences pediatric trauma care overall is very similar to adult trauma care
Questions
References 1 bull NTDB 2013 pediatric Report bull Monkey bars httpsplaygroundchroniclesfileswordpresscom201307soccerjpg bull Screaming child httpblogsbabycentercomwp-contentuploads201409screaming-child-tantrum-fitjpg bull Pediatric airway image httpwwwcelebritydiagnosiscomwp-contentuploads201003pediatric-airwayjpg bull Child on backboard httpsencrypted-tbn2gstaticcomimagesq=tbnANd9GcQscrDVc8IH4MwkNGF6F1A9p7mSVzik5zrWyNvI-
qSwQT5S3GNyVg bull Elbow fracture httpwwwimageinterpretationcoukimageselbowSUPRACONDYLAR20LAT3jpg bull Bike riding httpsmile-per-daycomwp-contentuploads201412klr03jpg bull Dad and child pic httplaughingsquidcomwp-contentuploads471160jpg bull Weigth estimation inner city Am J Emerg Med 2015 Oct33(10)1364-7 doi 101016jajem201507040 Epub 2015 Jul 29 Weight
estimation in an inner-city pediatric ED the effect of obesity Chavez H1 Peterson RE2 Lo K3 Arel M4
bull Guess weight sign httpmedialiveauctiongroupneti963110572971_1jpgv=8CDDAAF8A5B9E20 bull Broselow tape httpsuploadwikimediaorgwikipediacommons994BTape1jpg bull Parent screaming httpmommyofamonstercomwp-contentuploads201301yellingjpg bull Prehospital pain management Am J Emerg Med 2015 Mar33(3)451-4 doi 101016jajem201412012 Epub 2014 Dec 18
Prehospital pain management of injured children a systematic review of current evidence Samuel N1 Steiner IP2 Shavit I3 bull Prehospital pain ped pain assessment Prehosp Emerg Care 2008 Apr-Jun12(2)182-6 doi 10108010903120801907471 Prehospital
pain assessment in pediatric trauma Izsak E1 Moore JL Stringfellow K Oswanski MF Lindstrom DA Stombaugh HA bull Ped pain management Prehosp Emerg Care 2005 Jan-Mar9(1)40-3 Prehospital pain management in children suffering traumatic
injury Swor R1 McEachin CM Seguin D Grall KH bull Prehospital intervention Allen CJ Teisch LF et al Prehospital care and transportation of pediatric trauma patients J Surg Res 2015
Aug197(2)240-6 JAMA 2000 Feb 9283(6)783-90 bull Effect of out-of-hospital pediatric endotracheal intubation on survival and neurological outcome a controlled clinical trial
Gausche M1 Lewis RJ Stratton SJ Haynes BE Gunter CS Goodrich SM Poore PD McCollough MD Henderson DP Pratt FD Seidel JS
bull Pediatric pain management survey Pediatr Emerg Care 2015 Sep 23 [Epub ahead of print] An Assessment of Newly Identified Barriers to and Enablers for Prehospital Pediatric Pain Management Whitley DE1 Li T Jones CM Cushman JT Williams DM Shah MN
References 2 bull httpwwwuptodatecomcontentsprehospital-pediatrics-and-emergency-medical-services-emsabstract6 bull httpwwwuptodatecomcontentsprehospital-pediatrics-and-emergency-medical-services-emsabstract7 bull Pediatr Crit Care Med 2011 Jul12(4)e166-70 doi 101097PCC0b013e3181f36f6e First responder
performance in pediatric trauma a comparison with an adult cohortBankole S1 Asuncion A Ross S Aghai Z Nollah L Echols H Da-Silva S
bull Drayna pc Browne LR et al Prehospital pediatric care Oppportunities for training treatment and research Prehosp Emerg Care 2015 Jul-Sep 19(3) Epub 2015 Feb 6
bull Pediatr Emerg Care 2001 Feb17(1) 5-9Pediatric pre-hospital advanced life support care in an urban setting Babl FE1 Vinci RJ Bauchner H Mottley L
bull Pediatr Crit Care Med 2015 Oct16(8)e260-7 doi 101097PCC0000000000000505Pediatric Out-of-Hospital Critical Procedures in the United States Carlson JN1 Gannon E Mann NC Jacobson KE Dai M Colleran C Wang HE
bull Pediatr Emerg Care 2009 Aug25(8)508-12 doi 101097PEC0b013e3181b0a0da The efficacy of pediatric advanced life support training in emergency medical service providers Baker TW1 King W Soto W Asher C Stolfi A Rowin ME
bull Sutton RM Case E et al ROC investigators A quantitative analysis of out-of-hospital pediatric and adolescent resuscitation quality A report from the ROC Epistry- Cardiac Arrest Resusciation 201593150-157
bull Resuscitation 2014 Aug85(8)1059-64 doi 101016jresuscitation201403307 Epub 2014 Apr 4 Neurocognitive long term follow-up study on drowned children Suominen PK1 Sutinen N2 Valle S3 Olkkola KT4 Loumlnnqvist T3
bull J Pediatr Surg 2010 Jul45(7)1413-9 doi 101016jjpedsurg200912020 Prehospital cardiopulmonary resuscitation in the pediatric trauma patient Murphy JT1 Jaiswal K Sabella J Vinson L Megison S Maxson RT
References 3 bull Pre atv accident
httpwwwctvnewscapolopoly_fs119871591409741949httpImageimagejpg_genderivativeslandscape_960imagejpg bull atv pic httpswwwutahadvocatescomwp-contentuploads201402atvAccidentLawyerjpg bull Blunt abdominal solid organ injury adult vs pediatric trauma center J Pediatr Surg 2015 Aug 28 pii S0022-3468(15)00526-6 doi
101016jjpedsurg201508012 [Epub ahead of print] Trauma center variation in the management of pediatric patients with blunt abdominal solid organ injury a national trauma data bank analysis Safavi A1 Skarsgard ED2 Rhee P1 Zangbar B1 Kulvatunyou N1 Tang A1 OKeeffe T1 Friese RS1 Joseph B3
bull Pediatric blunt abdominal injury Curr Opin Crit Care 2015 Sep 28 [Epub ahead of print] Pediatric blunt abdominal trauma current management Notrica DM1
bull Pediatric splenic injury management Am J Surg 2015 Jul 31 pii S0002-9610(15)00417-1 doi 101016jamjsurg201506009 [Epub ahead of print] Comparative effectiveness of treatment strategies for severe splenic trauma in the pediatric population Rialon KL1 Englum BR1 Gulack BC1 Guevara CJ2 Bhattacharya SD3 Shapiro ML4 Rice HE5 Scarborough JE4 Adibe OO6
bull Liver pic httpss-media-cache-ak0pinimgcom736x7da50e7da50eb2bb603c99ef6649ff897e26b5jpg bull Solid organ injury non op in peds J Trauma Acute Care Surg 2015 Oct79(4)683-93 doi 101097TA0000000000000808
Nonoperative management of blunt liver and spleen injury in children Evaluation of the ATOMAC guideline using GRADE Notrica DM1 Eubanks JW 3rd Tuggle DW Maxson RT Letton RW Garcia NM Alder AC Lawson KA St Peter SD Megison S Garcia Filion P
bull Pediaric vs nonped trauma ct use J Pediatr 2015 Oct167(4)897-904e3 doi 101016jjpeds201506052 Epub 2015 Jul 29 Variation in Computed Tomography Imaging for Pediatric Injury-Related Emergency Visits Marin JR1 Wang L2 Winger DG2 Mannix RC3
bull Solid organ management in ped population J Trauma Acute Care Surg 2015 Aug79(2)206-14quiz 332 doi 101097TA0000000000000731 Management of children with solid organ injuries after blunt torso trauma Wisner DH1 Kuppermann N Cooper A Menaker J Ehrlich P Kooistra J Mahajan P Lee L Cook LJ Yen K Lillis K Holmes JF
bull Triad of death image httpimageslidesharecdncomdamage-control-resuscitation-1304253390-phpapp0195damage-control-resuscitation-14-728jpgcb=1304235553
bull Tranexamic acid study Eckert MJ Wertin TM Tyner SD et al 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 77852
bull Image care accident httpsuploadwikimediaorgwikipediacommonsthumbee1Car_crash_1jpg1280px-Car_crash_1jpg
References 4 bull httpwwwsurgeryvcuedudivisionsacutesurghtml bull Trauma management Approach to the unstable child
httpwwwuptodatecomcontentstrauma-management-approach-to-the-unstable-childsource=search_resultampsearch=pediatric+trauma+childrenampselectedTitle=17E150
bull Trauma management Unique pediatric considerations httpwwwuptodatecomcontentstrauma-management-unique-pediatric-considerationssource=search_resultampsearch=pediatric+trauma+childrenampselectedTitle=37E150
References 5 bull httpwwwetiquettehellcomsmfindexphptopic=8666360 bull httpwwwstlouischildrensorghealth-care-professionalsems-providers bull httpwwwuchicagokidshospitalorgspecialtiesemergency-medicinespecialhtml bull httpwwwsimsacademyinfoFXpatienthtm bull httptheemtspotcomwp-contentuploads200902another-burn-patient-by-annette-larsonjpg bull httplastangryfancomwp-contentuploads200910Clint-Malarchukjpg bull httpwwwtraumaorgarchiveresusmassivehtml bull httpwwwuptodatecomcontentsimageimageKey=PEDS68694amptopicKey=EM2F6389ampsourc
e=previewampsearch=pediatric+hemorrhagic+shockampselectedTitle=17E150amprank=undefined bull httptheemtspotcomwp-contentuploads200902gcsgif bull httpwwwuptodatecomcontentsimageimageKey=EM2F60409amptopicKey=EM2F6571amprank
=17E150ampsource=see_linkampsearch=traumaamputdPopup=true bull httpwwwuptodatecomcontentsimageimageKey=EM2F80874amptopicKey=EM2F6571amprank
=17E150ampsource=see_linkampsearch=traumaamputdPopup=true bull httpempracticenewswordpresscomcategorynexus-criteria bull httpswwwgooglecomsearchq=pediatric+glasgow+coma+scaleamptbm=ischamptbo=uampsource=uni
vampsa=Xampei=8TiOU7TNC5WuyATp5YG4BQampsqi=2ampved=0CDYQsAQampbiw=1426ampbih=883q=canadian+c-spine+rulesamptbm=ischampfacrc=_ampimgdii=_ampimgrc=WI94QMHgMLTQmM253A3BP5nbsFhNCXK0FM3Bhttp253A252F252Fwwwbmjcom252Fhighwire252Ffilestream252F436003252Ffield_highwire_fragment_image_l252F0jpg3Bhttp253A252F252Fwwwbmjcom252Fcontent252F339252Fbmjb41463B12803B1253
References 5 bull httpwwwuptodatecomcontentsimageimageKey=EM2F76777amptopicKey=EM2F6571amprank
=17E150ampsource=see_linkampsearch=traumaamputdPopup=true bull httpwwwdocumentingrealitycomforumattachmentsf14964898d1246625322-firework-injury-
m80injury1jpg bull httpwwwpediatriceducationorg20050620 bull httpwwwarmstrongmedicalcomindexcfmgoproductdetailsec3ssec19cat61fam515 bull httpwwwuptodatecomcontentsimageimageKey=PEDS61087amptopicKey=ID2F7661ampsource
=outline_linkampsearch=tetanus+prophylaxisamputdPopup=true bull httpwwwafsecafmilsharedmediaphotodbweb110609-F-MJ378-009jpg bull httpwwwuptodatecomcontentsimageimageKey=EM75765amptopicKey= bull EM2F6389ampsource=outline_linkampsearch=massive+transfusion+protocolamputdPopup=true bull httpwwwmotifakecomimagedemotivational-postersmall0910whats-the-question-ignorance-
calvin-and-hobbes-demotivational-poster-1255020127jpg
XXXXBoston study ems peds trauma procedures- limited pediatric procedural exposure (but more adult experience) bull Catchment area 590000
over 1 year bull 555 pediatric ALS
transport ndash 19 blunt trauma ndash 10 penetrating trauma
bull IV 33 bull BMV 5 bull Intubation 3 bull 50 ALS providers average
year ndash IV- 37 ndash Intubation- 03 ndash IO- 006
bull 7 ped ems ndash 13 trauma
bull Critical procedures ndash 101000 peds cases ndash Intubation 671000 ndash IO 51000 ndash 81 successful
Pediatr Emerg Care 2001 Feb17(1)5-9 Pediatric pre-hospital advanced life support care in an urban setting
Babl FE1 Vinci RJ Bauchner H Mottley L
Pediatr Crit Care Med 2015 Oct16(8)e260-7 doi 101097PCC0000000000000505 Pediatric Out-of-Hospital Critical Procedures in the United States
Carlson JN1 Gannon E Mann NC Jacobson KE Dai M Colleran C Wang HE
C-spine bull C-spine injuries rare bull Take pt to closest hospital if over injuries
call for it (ie resuscitation altered mental status) primary guide
bull Mechanism ndash Altered mental status focal neuro change
torticollis substantial torso injury diving high speed auto neck pain underlying predisposing condition Acad Emerg Med 2014 Jan21(1)55-64 doi 101111acem12288
Comparison of outcomes for children with cervical spine injury based on destination hospital from scene of injury Anders JF1 Adelgais K Hoyle JD Jr Olsen C Jaffe DM Leonard JC Pediatric Emergency Care Applied Research Network
(PECARN)
Ann Emerg Med 2011 Aug58(2)145-55 doi 101016jannemergmed201008038 Epub 2010 Oct 29 Factors associated with cervical spine injury in children after blunt trauma
Leonard JC Kuppermann N Olsen C Babcock-Cimpello L Brown K Mahajan P Adelgais KM Anders J Borgialli D Donoghue A Hoyle JD Jr Kim E Leonard JR Lillis KA Nigrovic LE Powell EC Rebella
G Reeves SD Rogers AJ Stankovic C Teshome G Jaffe DM Pediatric Emergency Care Applied Research Network
- Itrsquos Hard to Put a Band-Aid on a Broken Spleen Pediatric Trauma
- Disclosures
- Objectives
- Pediatric Prehospital Care
- Mechanism
- Traumatic Pain Management
- Pediatric Trauma
- Deaths by Mechanism of Injury
- Pediatric Trauma
- Pediatric Trauma
- Airway Differences
- Pediatric-Adult Differences
- Pediatric Challenges
- Prehospital Pediatric Challenges
- Pediatric and Adult Trauma
- Scene Response
- Prehospital Intervention
- Where do you take the patient
- Patient arrives at the EDhellip
- Primary Survey
- Order is critical
- Slide Number 22
- Slide Number 23
- Airway
- Indications for Intubation
- Breathing
- ETT Intubation Basics
- Circulation
- Slide Number 29
- CirculationHemodynamic Changes
- Circulation
- Fluid Resuscitation Algorithm
- Reconsidering Crystalloid Resuscitation
- When to start MTP
- Disability
- Finishing Up the Evaluation
- Bad Scene Responses
- OHCA from Trauma
- Blunt Trauma- No Signs of Life
- OHCA with CPR on Arrival
- Pediatric Trauma
- Questions
- References 1
- References 2
- References 3
- References 4
- References 5
- References 5
- XXXXBoston study ems peds trauma procedures- limited pediatric procedural exposure (but more adult experience)
- C-spine
When to start MTP
bull As soon as you believe you will need it ndash Institution specific guidelines
bull gt4 units or 40mlkg of PRBCrsquos expected bull Earlier use of Massive Transfusion Protocol
(pRBC FFP PLT) in ldquoDamage Controlrdquo resuscitations may improve outcome
bull 111 unit ratio bull Risk of TRALI ARDS etc
Disability bull GCS
ndash Range 3-15 ndash We should be 15 ndash Dead are still 3 ndash Less than 8 intubate ndash Eyes- 4 eyes ndash Verbal- most difficult ndash Motor- V6 engine ndash Intubated T
bull AVPU
Finishing Up the Evaluation
bull Airway bull Breathing bull Circulation bull Disability bull Exposure
ndash Expose and examine all parts ndash Cover quickly and keep warm
bull Secondary Survey
Bad Scene Responses
bull What are the outcomes of out-of-hospital cardiac arrest from blunt trauma
bull What are the outcomes of pediatric drowning patients
OHCA from Trauma
bull 2000-2003 bull 123 pts bull Mean age 73 yrs bull Most common
rhythms ndash Asystole 59 ndash PEA 29 ndash V-fib 35
bull 195 rosc in field ndash 98 survived for 24
hrs ndash 57 survived to
discharge ndash Drowning- 19
survival to discharge ndash Bystander CPR tripled
the survivor rate
Blunt Trauma- No Signs of Life
bull Review from 2002-2010 bull No signs of life- 025 of blunt trauma
ndash 25 resuscitated prior to hospital arrival bull 138 of these patients survived to discharge
bull 44 overall survived to hospital discharge
OHCA with CPR on Arrival
bull 169 children bull 141 deaths bull 69 required cpr on arrival- none survived bull 87 of patients requiring CPR on arrival
expired in the ED bull Of the 28 survivors
ndash 55 of survivors had full neurologic recovery
Pediatric Trauma
bull Fortunately these cases represent only a small fraction of EMS transports
bull Despite a few key differences pediatric trauma care overall is very similar to adult trauma care
Questions
References 1 bull NTDB 2013 pediatric Report bull Monkey bars httpsplaygroundchroniclesfileswordpresscom201307soccerjpg bull Screaming child httpblogsbabycentercomwp-contentuploads201409screaming-child-tantrum-fitjpg bull Pediatric airway image httpwwwcelebritydiagnosiscomwp-contentuploads201003pediatric-airwayjpg bull Child on backboard httpsencrypted-tbn2gstaticcomimagesq=tbnANd9GcQscrDVc8IH4MwkNGF6F1A9p7mSVzik5zrWyNvI-
qSwQT5S3GNyVg bull Elbow fracture httpwwwimageinterpretationcoukimageselbowSUPRACONDYLAR20LAT3jpg bull Bike riding httpsmile-per-daycomwp-contentuploads201412klr03jpg bull Dad and child pic httplaughingsquidcomwp-contentuploads471160jpg bull Weigth estimation inner city Am J Emerg Med 2015 Oct33(10)1364-7 doi 101016jajem201507040 Epub 2015 Jul 29 Weight
estimation in an inner-city pediatric ED the effect of obesity Chavez H1 Peterson RE2 Lo K3 Arel M4
bull Guess weight sign httpmedialiveauctiongroupneti963110572971_1jpgv=8CDDAAF8A5B9E20 bull Broselow tape httpsuploadwikimediaorgwikipediacommons994BTape1jpg bull Parent screaming httpmommyofamonstercomwp-contentuploads201301yellingjpg bull Prehospital pain management Am J Emerg Med 2015 Mar33(3)451-4 doi 101016jajem201412012 Epub 2014 Dec 18
Prehospital pain management of injured children a systematic review of current evidence Samuel N1 Steiner IP2 Shavit I3 bull Prehospital pain ped pain assessment Prehosp Emerg Care 2008 Apr-Jun12(2)182-6 doi 10108010903120801907471 Prehospital
pain assessment in pediatric trauma Izsak E1 Moore JL Stringfellow K Oswanski MF Lindstrom DA Stombaugh HA bull Ped pain management Prehosp Emerg Care 2005 Jan-Mar9(1)40-3 Prehospital pain management in children suffering traumatic
injury Swor R1 McEachin CM Seguin D Grall KH bull Prehospital intervention Allen CJ Teisch LF et al Prehospital care and transportation of pediatric trauma patients J Surg Res 2015
Aug197(2)240-6 JAMA 2000 Feb 9283(6)783-90 bull Effect of out-of-hospital pediatric endotracheal intubation on survival and neurological outcome a controlled clinical trial
Gausche M1 Lewis RJ Stratton SJ Haynes BE Gunter CS Goodrich SM Poore PD McCollough MD Henderson DP Pratt FD Seidel JS
bull Pediatric pain management survey Pediatr Emerg Care 2015 Sep 23 [Epub ahead of print] An Assessment of Newly Identified Barriers to and Enablers for Prehospital Pediatric Pain Management Whitley DE1 Li T Jones CM Cushman JT Williams DM Shah MN
References 2 bull httpwwwuptodatecomcontentsprehospital-pediatrics-and-emergency-medical-services-emsabstract6 bull httpwwwuptodatecomcontentsprehospital-pediatrics-and-emergency-medical-services-emsabstract7 bull Pediatr Crit Care Med 2011 Jul12(4)e166-70 doi 101097PCC0b013e3181f36f6e First responder
performance in pediatric trauma a comparison with an adult cohortBankole S1 Asuncion A Ross S Aghai Z Nollah L Echols H Da-Silva S
bull Drayna pc Browne LR et al Prehospital pediatric care Oppportunities for training treatment and research Prehosp Emerg Care 2015 Jul-Sep 19(3) Epub 2015 Feb 6
bull Pediatr Emerg Care 2001 Feb17(1) 5-9Pediatric pre-hospital advanced life support care in an urban setting Babl FE1 Vinci RJ Bauchner H Mottley L
bull Pediatr Crit Care Med 2015 Oct16(8)e260-7 doi 101097PCC0000000000000505Pediatric Out-of-Hospital Critical Procedures in the United States Carlson JN1 Gannon E Mann NC Jacobson KE Dai M Colleran C Wang HE
bull Pediatr Emerg Care 2009 Aug25(8)508-12 doi 101097PEC0b013e3181b0a0da The efficacy of pediatric advanced life support training in emergency medical service providers Baker TW1 King W Soto W Asher C Stolfi A Rowin ME
bull Sutton RM Case E et al ROC investigators A quantitative analysis of out-of-hospital pediatric and adolescent resuscitation quality A report from the ROC Epistry- Cardiac Arrest Resusciation 201593150-157
bull Resuscitation 2014 Aug85(8)1059-64 doi 101016jresuscitation201403307 Epub 2014 Apr 4 Neurocognitive long term follow-up study on drowned children Suominen PK1 Sutinen N2 Valle S3 Olkkola KT4 Loumlnnqvist T3
bull J Pediatr Surg 2010 Jul45(7)1413-9 doi 101016jjpedsurg200912020 Prehospital cardiopulmonary resuscitation in the pediatric trauma patient Murphy JT1 Jaiswal K Sabella J Vinson L Megison S Maxson RT
References 3 bull Pre atv accident
httpwwwctvnewscapolopoly_fs119871591409741949httpImageimagejpg_genderivativeslandscape_960imagejpg bull atv pic httpswwwutahadvocatescomwp-contentuploads201402atvAccidentLawyerjpg bull Blunt abdominal solid organ injury adult vs pediatric trauma center J Pediatr Surg 2015 Aug 28 pii S0022-3468(15)00526-6 doi
101016jjpedsurg201508012 [Epub ahead of print] Trauma center variation in the management of pediatric patients with blunt abdominal solid organ injury a national trauma data bank analysis Safavi A1 Skarsgard ED2 Rhee P1 Zangbar B1 Kulvatunyou N1 Tang A1 OKeeffe T1 Friese RS1 Joseph B3
bull Pediatric blunt abdominal injury Curr Opin Crit Care 2015 Sep 28 [Epub ahead of print] Pediatric blunt abdominal trauma current management Notrica DM1
bull Pediatric splenic injury management Am J Surg 2015 Jul 31 pii S0002-9610(15)00417-1 doi 101016jamjsurg201506009 [Epub ahead of print] Comparative effectiveness of treatment strategies for severe splenic trauma in the pediatric population Rialon KL1 Englum BR1 Gulack BC1 Guevara CJ2 Bhattacharya SD3 Shapiro ML4 Rice HE5 Scarborough JE4 Adibe OO6
bull Liver pic httpss-media-cache-ak0pinimgcom736x7da50e7da50eb2bb603c99ef6649ff897e26b5jpg bull Solid organ injury non op in peds J Trauma Acute Care Surg 2015 Oct79(4)683-93 doi 101097TA0000000000000808
Nonoperative management of blunt liver and spleen injury in children Evaluation of the ATOMAC guideline using GRADE Notrica DM1 Eubanks JW 3rd Tuggle DW Maxson RT Letton RW Garcia NM Alder AC Lawson KA St Peter SD Megison S Garcia Filion P
bull Pediaric vs nonped trauma ct use J Pediatr 2015 Oct167(4)897-904e3 doi 101016jjpeds201506052 Epub 2015 Jul 29 Variation in Computed Tomography Imaging for Pediatric Injury-Related Emergency Visits Marin JR1 Wang L2 Winger DG2 Mannix RC3
bull Solid organ management in ped population J Trauma Acute Care Surg 2015 Aug79(2)206-14quiz 332 doi 101097TA0000000000000731 Management of children with solid organ injuries after blunt torso trauma Wisner DH1 Kuppermann N Cooper A Menaker J Ehrlich P Kooistra J Mahajan P Lee L Cook LJ Yen K Lillis K Holmes JF
bull Triad of death image httpimageslidesharecdncomdamage-control-resuscitation-1304253390-phpapp0195damage-control-resuscitation-14-728jpgcb=1304235553
bull Tranexamic acid study Eckert MJ Wertin TM Tyner SD et al 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 77852
bull Image care accident httpsuploadwikimediaorgwikipediacommonsthumbee1Car_crash_1jpg1280px-Car_crash_1jpg
References 4 bull httpwwwsurgeryvcuedudivisionsacutesurghtml bull Trauma management Approach to the unstable child
httpwwwuptodatecomcontentstrauma-management-approach-to-the-unstable-childsource=search_resultampsearch=pediatric+trauma+childrenampselectedTitle=17E150
bull Trauma management Unique pediatric considerations httpwwwuptodatecomcontentstrauma-management-unique-pediatric-considerationssource=search_resultampsearch=pediatric+trauma+childrenampselectedTitle=37E150
References 5 bull httpwwwetiquettehellcomsmfindexphptopic=8666360 bull httpwwwstlouischildrensorghealth-care-professionalsems-providers bull httpwwwuchicagokidshospitalorgspecialtiesemergency-medicinespecialhtml bull httpwwwsimsacademyinfoFXpatienthtm bull httptheemtspotcomwp-contentuploads200902another-burn-patient-by-annette-larsonjpg bull httplastangryfancomwp-contentuploads200910Clint-Malarchukjpg bull httpwwwtraumaorgarchiveresusmassivehtml bull httpwwwuptodatecomcontentsimageimageKey=PEDS68694amptopicKey=EM2F6389ampsourc
e=previewampsearch=pediatric+hemorrhagic+shockampselectedTitle=17E150amprank=undefined bull httptheemtspotcomwp-contentuploads200902gcsgif bull httpwwwuptodatecomcontentsimageimageKey=EM2F60409amptopicKey=EM2F6571amprank
=17E150ampsource=see_linkampsearch=traumaamputdPopup=true bull httpwwwuptodatecomcontentsimageimageKey=EM2F80874amptopicKey=EM2F6571amprank
=17E150ampsource=see_linkampsearch=traumaamputdPopup=true bull httpempracticenewswordpresscomcategorynexus-criteria bull httpswwwgooglecomsearchq=pediatric+glasgow+coma+scaleamptbm=ischamptbo=uampsource=uni
vampsa=Xampei=8TiOU7TNC5WuyATp5YG4BQampsqi=2ampved=0CDYQsAQampbiw=1426ampbih=883q=canadian+c-spine+rulesamptbm=ischampfacrc=_ampimgdii=_ampimgrc=WI94QMHgMLTQmM253A3BP5nbsFhNCXK0FM3Bhttp253A252F252Fwwwbmjcom252Fhighwire252Ffilestream252F436003252Ffield_highwire_fragment_image_l252F0jpg3Bhttp253A252F252Fwwwbmjcom252Fcontent252F339252Fbmjb41463B12803B1253
References 5 bull httpwwwuptodatecomcontentsimageimageKey=EM2F76777amptopicKey=EM2F6571amprank
=17E150ampsource=see_linkampsearch=traumaamputdPopup=true bull httpwwwdocumentingrealitycomforumattachmentsf14964898d1246625322-firework-injury-
m80injury1jpg bull httpwwwpediatriceducationorg20050620 bull httpwwwarmstrongmedicalcomindexcfmgoproductdetailsec3ssec19cat61fam515 bull httpwwwuptodatecomcontentsimageimageKey=PEDS61087amptopicKey=ID2F7661ampsource
=outline_linkampsearch=tetanus+prophylaxisamputdPopup=true bull httpwwwafsecafmilsharedmediaphotodbweb110609-F-MJ378-009jpg bull httpwwwuptodatecomcontentsimageimageKey=EM75765amptopicKey= bull EM2F6389ampsource=outline_linkampsearch=massive+transfusion+protocolamputdPopup=true bull httpwwwmotifakecomimagedemotivational-postersmall0910whats-the-question-ignorance-
calvin-and-hobbes-demotivational-poster-1255020127jpg
XXXXBoston study ems peds trauma procedures- limited pediatric procedural exposure (but more adult experience) bull Catchment area 590000
over 1 year bull 555 pediatric ALS
transport ndash 19 blunt trauma ndash 10 penetrating trauma
bull IV 33 bull BMV 5 bull Intubation 3 bull 50 ALS providers average
year ndash IV- 37 ndash Intubation- 03 ndash IO- 006
bull 7 ped ems ndash 13 trauma
bull Critical procedures ndash 101000 peds cases ndash Intubation 671000 ndash IO 51000 ndash 81 successful
Pediatr Emerg Care 2001 Feb17(1)5-9 Pediatric pre-hospital advanced life support care in an urban setting
Babl FE1 Vinci RJ Bauchner H Mottley L
Pediatr Crit Care Med 2015 Oct16(8)e260-7 doi 101097PCC0000000000000505 Pediatric Out-of-Hospital Critical Procedures in the United States
Carlson JN1 Gannon E Mann NC Jacobson KE Dai M Colleran C Wang HE
C-spine bull C-spine injuries rare bull Take pt to closest hospital if over injuries
call for it (ie resuscitation altered mental status) primary guide
bull Mechanism ndash Altered mental status focal neuro change
torticollis substantial torso injury diving high speed auto neck pain underlying predisposing condition Acad Emerg Med 2014 Jan21(1)55-64 doi 101111acem12288
Comparison of outcomes for children with cervical spine injury based on destination hospital from scene of injury Anders JF1 Adelgais K Hoyle JD Jr Olsen C Jaffe DM Leonard JC Pediatric Emergency Care Applied Research Network
(PECARN)
Ann Emerg Med 2011 Aug58(2)145-55 doi 101016jannemergmed201008038 Epub 2010 Oct 29 Factors associated with cervical spine injury in children after blunt trauma
Leonard JC Kuppermann N Olsen C Babcock-Cimpello L Brown K Mahajan P Adelgais KM Anders J Borgialli D Donoghue A Hoyle JD Jr Kim E Leonard JR Lillis KA Nigrovic LE Powell EC Rebella
G Reeves SD Rogers AJ Stankovic C Teshome G Jaffe DM Pediatric Emergency Care Applied Research Network
- Itrsquos Hard to Put a Band-Aid on a Broken Spleen Pediatric Trauma
- Disclosures
- Objectives
- Pediatric Prehospital Care
- Mechanism
- Traumatic Pain Management
- Pediatric Trauma
- Deaths by Mechanism of Injury
- Pediatric Trauma
- Pediatric Trauma
- Airway Differences
- Pediatric-Adult Differences
- Pediatric Challenges
- Prehospital Pediatric Challenges
- Pediatric and Adult Trauma
- Scene Response
- Prehospital Intervention
- Where do you take the patient
- Patient arrives at the EDhellip
- Primary Survey
- Order is critical
- Slide Number 22
- Slide Number 23
- Airway
- Indications for Intubation
- Breathing
- ETT Intubation Basics
- Circulation
- Slide Number 29
- CirculationHemodynamic Changes
- Circulation
- Fluid Resuscitation Algorithm
- Reconsidering Crystalloid Resuscitation
- When to start MTP
- Disability
- Finishing Up the Evaluation
- Bad Scene Responses
- OHCA from Trauma
- Blunt Trauma- No Signs of Life
- OHCA with CPR on Arrival
- Pediatric Trauma
- Questions
- References 1
- References 2
- References 3
- References 4
- References 5
- References 5
- XXXXBoston study ems peds trauma procedures- limited pediatric procedural exposure (but more adult experience)
- C-spine
Disability bull GCS
ndash Range 3-15 ndash We should be 15 ndash Dead are still 3 ndash Less than 8 intubate ndash Eyes- 4 eyes ndash Verbal- most difficult ndash Motor- V6 engine ndash Intubated T
bull AVPU
Finishing Up the Evaluation
bull Airway bull Breathing bull Circulation bull Disability bull Exposure
ndash Expose and examine all parts ndash Cover quickly and keep warm
bull Secondary Survey
Bad Scene Responses
bull What are the outcomes of out-of-hospital cardiac arrest from blunt trauma
bull What are the outcomes of pediatric drowning patients
OHCA from Trauma
bull 2000-2003 bull 123 pts bull Mean age 73 yrs bull Most common
rhythms ndash Asystole 59 ndash PEA 29 ndash V-fib 35
bull 195 rosc in field ndash 98 survived for 24
hrs ndash 57 survived to
discharge ndash Drowning- 19
survival to discharge ndash Bystander CPR tripled
the survivor rate
Blunt Trauma- No Signs of Life
bull Review from 2002-2010 bull No signs of life- 025 of blunt trauma
ndash 25 resuscitated prior to hospital arrival bull 138 of these patients survived to discharge
bull 44 overall survived to hospital discharge
OHCA with CPR on Arrival
bull 169 children bull 141 deaths bull 69 required cpr on arrival- none survived bull 87 of patients requiring CPR on arrival
expired in the ED bull Of the 28 survivors
ndash 55 of survivors had full neurologic recovery
Pediatric Trauma
bull Fortunately these cases represent only a small fraction of EMS transports
bull Despite a few key differences pediatric trauma care overall is very similar to adult trauma care
Questions
References 1 bull NTDB 2013 pediatric Report bull Monkey bars httpsplaygroundchroniclesfileswordpresscom201307soccerjpg bull Screaming child httpblogsbabycentercomwp-contentuploads201409screaming-child-tantrum-fitjpg bull Pediatric airway image httpwwwcelebritydiagnosiscomwp-contentuploads201003pediatric-airwayjpg bull Child on backboard httpsencrypted-tbn2gstaticcomimagesq=tbnANd9GcQscrDVc8IH4MwkNGF6F1A9p7mSVzik5zrWyNvI-
qSwQT5S3GNyVg bull Elbow fracture httpwwwimageinterpretationcoukimageselbowSUPRACONDYLAR20LAT3jpg bull Bike riding httpsmile-per-daycomwp-contentuploads201412klr03jpg bull Dad and child pic httplaughingsquidcomwp-contentuploads471160jpg bull Weigth estimation inner city Am J Emerg Med 2015 Oct33(10)1364-7 doi 101016jajem201507040 Epub 2015 Jul 29 Weight
estimation in an inner-city pediatric ED the effect of obesity Chavez H1 Peterson RE2 Lo K3 Arel M4
bull Guess weight sign httpmedialiveauctiongroupneti963110572971_1jpgv=8CDDAAF8A5B9E20 bull Broselow tape httpsuploadwikimediaorgwikipediacommons994BTape1jpg bull Parent screaming httpmommyofamonstercomwp-contentuploads201301yellingjpg bull Prehospital pain management Am J Emerg Med 2015 Mar33(3)451-4 doi 101016jajem201412012 Epub 2014 Dec 18
Prehospital pain management of injured children a systematic review of current evidence Samuel N1 Steiner IP2 Shavit I3 bull Prehospital pain ped pain assessment Prehosp Emerg Care 2008 Apr-Jun12(2)182-6 doi 10108010903120801907471 Prehospital
pain assessment in pediatric trauma Izsak E1 Moore JL Stringfellow K Oswanski MF Lindstrom DA Stombaugh HA bull Ped pain management Prehosp Emerg Care 2005 Jan-Mar9(1)40-3 Prehospital pain management in children suffering traumatic
injury Swor R1 McEachin CM Seguin D Grall KH bull Prehospital intervention Allen CJ Teisch LF et al Prehospital care and transportation of pediatric trauma patients J Surg Res 2015
Aug197(2)240-6 JAMA 2000 Feb 9283(6)783-90 bull Effect of out-of-hospital pediatric endotracheal intubation on survival and neurological outcome a controlled clinical trial
Gausche M1 Lewis RJ Stratton SJ Haynes BE Gunter CS Goodrich SM Poore PD McCollough MD Henderson DP Pratt FD Seidel JS
bull Pediatric pain management survey Pediatr Emerg Care 2015 Sep 23 [Epub ahead of print] An Assessment of Newly Identified Barriers to and Enablers for Prehospital Pediatric Pain Management Whitley DE1 Li T Jones CM Cushman JT Williams DM Shah MN
References 2 bull httpwwwuptodatecomcontentsprehospital-pediatrics-and-emergency-medical-services-emsabstract6 bull httpwwwuptodatecomcontentsprehospital-pediatrics-and-emergency-medical-services-emsabstract7 bull Pediatr Crit Care Med 2011 Jul12(4)e166-70 doi 101097PCC0b013e3181f36f6e First responder
performance in pediatric trauma a comparison with an adult cohortBankole S1 Asuncion A Ross S Aghai Z Nollah L Echols H Da-Silva S
bull Drayna pc Browne LR et al Prehospital pediatric care Oppportunities for training treatment and research Prehosp Emerg Care 2015 Jul-Sep 19(3) Epub 2015 Feb 6
bull Pediatr Emerg Care 2001 Feb17(1) 5-9Pediatric pre-hospital advanced life support care in an urban setting Babl FE1 Vinci RJ Bauchner H Mottley L
bull Pediatr Crit Care Med 2015 Oct16(8)e260-7 doi 101097PCC0000000000000505Pediatric Out-of-Hospital Critical Procedures in the United States Carlson JN1 Gannon E Mann NC Jacobson KE Dai M Colleran C Wang HE
bull Pediatr Emerg Care 2009 Aug25(8)508-12 doi 101097PEC0b013e3181b0a0da The efficacy of pediatric advanced life support training in emergency medical service providers Baker TW1 King W Soto W Asher C Stolfi A Rowin ME
bull Sutton RM Case E et al ROC investigators A quantitative analysis of out-of-hospital pediatric and adolescent resuscitation quality A report from the ROC Epistry- Cardiac Arrest Resusciation 201593150-157
bull Resuscitation 2014 Aug85(8)1059-64 doi 101016jresuscitation201403307 Epub 2014 Apr 4 Neurocognitive long term follow-up study on drowned children Suominen PK1 Sutinen N2 Valle S3 Olkkola KT4 Loumlnnqvist T3
bull J Pediatr Surg 2010 Jul45(7)1413-9 doi 101016jjpedsurg200912020 Prehospital cardiopulmonary resuscitation in the pediatric trauma patient Murphy JT1 Jaiswal K Sabella J Vinson L Megison S Maxson RT
References 3 bull Pre atv accident
httpwwwctvnewscapolopoly_fs119871591409741949httpImageimagejpg_genderivativeslandscape_960imagejpg bull atv pic httpswwwutahadvocatescomwp-contentuploads201402atvAccidentLawyerjpg bull Blunt abdominal solid organ injury adult vs pediatric trauma center J Pediatr Surg 2015 Aug 28 pii S0022-3468(15)00526-6 doi
101016jjpedsurg201508012 [Epub ahead of print] Trauma center variation in the management of pediatric patients with blunt abdominal solid organ injury a national trauma data bank analysis Safavi A1 Skarsgard ED2 Rhee P1 Zangbar B1 Kulvatunyou N1 Tang A1 OKeeffe T1 Friese RS1 Joseph B3
bull Pediatric blunt abdominal injury Curr Opin Crit Care 2015 Sep 28 [Epub ahead of print] Pediatric blunt abdominal trauma current management Notrica DM1
bull Pediatric splenic injury management Am J Surg 2015 Jul 31 pii S0002-9610(15)00417-1 doi 101016jamjsurg201506009 [Epub ahead of print] Comparative effectiveness of treatment strategies for severe splenic trauma in the pediatric population Rialon KL1 Englum BR1 Gulack BC1 Guevara CJ2 Bhattacharya SD3 Shapiro ML4 Rice HE5 Scarborough JE4 Adibe OO6
bull Liver pic httpss-media-cache-ak0pinimgcom736x7da50e7da50eb2bb603c99ef6649ff897e26b5jpg bull Solid organ injury non op in peds J Trauma Acute Care Surg 2015 Oct79(4)683-93 doi 101097TA0000000000000808
Nonoperative management of blunt liver and spleen injury in children Evaluation of the ATOMAC guideline using GRADE Notrica DM1 Eubanks JW 3rd Tuggle DW Maxson RT Letton RW Garcia NM Alder AC Lawson KA St Peter SD Megison S Garcia Filion P
bull Pediaric vs nonped trauma ct use J Pediatr 2015 Oct167(4)897-904e3 doi 101016jjpeds201506052 Epub 2015 Jul 29 Variation in Computed Tomography Imaging for Pediatric Injury-Related Emergency Visits Marin JR1 Wang L2 Winger DG2 Mannix RC3
bull Solid organ management in ped population J Trauma Acute Care Surg 2015 Aug79(2)206-14quiz 332 doi 101097TA0000000000000731 Management of children with solid organ injuries after blunt torso trauma Wisner DH1 Kuppermann N Cooper A Menaker J Ehrlich P Kooistra J Mahajan P Lee L Cook LJ Yen K Lillis K Holmes JF
bull Triad of death image httpimageslidesharecdncomdamage-control-resuscitation-1304253390-phpapp0195damage-control-resuscitation-14-728jpgcb=1304235553
bull Tranexamic acid study Eckert MJ Wertin TM Tyner SD et al 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 77852
bull Image care accident httpsuploadwikimediaorgwikipediacommonsthumbee1Car_crash_1jpg1280px-Car_crash_1jpg
References 4 bull httpwwwsurgeryvcuedudivisionsacutesurghtml bull Trauma management Approach to the unstable child
httpwwwuptodatecomcontentstrauma-management-approach-to-the-unstable-childsource=search_resultampsearch=pediatric+trauma+childrenampselectedTitle=17E150
bull Trauma management Unique pediatric considerations httpwwwuptodatecomcontentstrauma-management-unique-pediatric-considerationssource=search_resultampsearch=pediatric+trauma+childrenampselectedTitle=37E150
References 5 bull httpwwwetiquettehellcomsmfindexphptopic=8666360 bull httpwwwstlouischildrensorghealth-care-professionalsems-providers bull httpwwwuchicagokidshospitalorgspecialtiesemergency-medicinespecialhtml bull httpwwwsimsacademyinfoFXpatienthtm bull httptheemtspotcomwp-contentuploads200902another-burn-patient-by-annette-larsonjpg bull httplastangryfancomwp-contentuploads200910Clint-Malarchukjpg bull httpwwwtraumaorgarchiveresusmassivehtml bull httpwwwuptodatecomcontentsimageimageKey=PEDS68694amptopicKey=EM2F6389ampsourc
e=previewampsearch=pediatric+hemorrhagic+shockampselectedTitle=17E150amprank=undefined bull httptheemtspotcomwp-contentuploads200902gcsgif bull httpwwwuptodatecomcontentsimageimageKey=EM2F60409amptopicKey=EM2F6571amprank
=17E150ampsource=see_linkampsearch=traumaamputdPopup=true bull httpwwwuptodatecomcontentsimageimageKey=EM2F80874amptopicKey=EM2F6571amprank
=17E150ampsource=see_linkampsearch=traumaamputdPopup=true bull httpempracticenewswordpresscomcategorynexus-criteria bull httpswwwgooglecomsearchq=pediatric+glasgow+coma+scaleamptbm=ischamptbo=uampsource=uni
vampsa=Xampei=8TiOU7TNC5WuyATp5YG4BQampsqi=2ampved=0CDYQsAQampbiw=1426ampbih=883q=canadian+c-spine+rulesamptbm=ischampfacrc=_ampimgdii=_ampimgrc=WI94QMHgMLTQmM253A3BP5nbsFhNCXK0FM3Bhttp253A252F252Fwwwbmjcom252Fhighwire252Ffilestream252F436003252Ffield_highwire_fragment_image_l252F0jpg3Bhttp253A252F252Fwwwbmjcom252Fcontent252F339252Fbmjb41463B12803B1253
References 5 bull httpwwwuptodatecomcontentsimageimageKey=EM2F76777amptopicKey=EM2F6571amprank
=17E150ampsource=see_linkampsearch=traumaamputdPopup=true bull httpwwwdocumentingrealitycomforumattachmentsf14964898d1246625322-firework-injury-
m80injury1jpg bull httpwwwpediatriceducationorg20050620 bull httpwwwarmstrongmedicalcomindexcfmgoproductdetailsec3ssec19cat61fam515 bull httpwwwuptodatecomcontentsimageimageKey=PEDS61087amptopicKey=ID2F7661ampsource
=outline_linkampsearch=tetanus+prophylaxisamputdPopup=true bull httpwwwafsecafmilsharedmediaphotodbweb110609-F-MJ378-009jpg bull httpwwwuptodatecomcontentsimageimageKey=EM75765amptopicKey= bull EM2F6389ampsource=outline_linkampsearch=massive+transfusion+protocolamputdPopup=true bull httpwwwmotifakecomimagedemotivational-postersmall0910whats-the-question-ignorance-
calvin-and-hobbes-demotivational-poster-1255020127jpg
XXXXBoston study ems peds trauma procedures- limited pediatric procedural exposure (but more adult experience) bull Catchment area 590000
over 1 year bull 555 pediatric ALS
transport ndash 19 blunt trauma ndash 10 penetrating trauma
bull IV 33 bull BMV 5 bull Intubation 3 bull 50 ALS providers average
year ndash IV- 37 ndash Intubation- 03 ndash IO- 006
bull 7 ped ems ndash 13 trauma
bull Critical procedures ndash 101000 peds cases ndash Intubation 671000 ndash IO 51000 ndash 81 successful
Pediatr Emerg Care 2001 Feb17(1)5-9 Pediatric pre-hospital advanced life support care in an urban setting
Babl FE1 Vinci RJ Bauchner H Mottley L
Pediatr Crit Care Med 2015 Oct16(8)e260-7 doi 101097PCC0000000000000505 Pediatric Out-of-Hospital Critical Procedures in the United States
Carlson JN1 Gannon E Mann NC Jacobson KE Dai M Colleran C Wang HE
C-spine bull C-spine injuries rare bull Take pt to closest hospital if over injuries
call for it (ie resuscitation altered mental status) primary guide
bull Mechanism ndash Altered mental status focal neuro change
torticollis substantial torso injury diving high speed auto neck pain underlying predisposing condition Acad Emerg Med 2014 Jan21(1)55-64 doi 101111acem12288
Comparison of outcomes for children with cervical spine injury based on destination hospital from scene of injury Anders JF1 Adelgais K Hoyle JD Jr Olsen C Jaffe DM Leonard JC Pediatric Emergency Care Applied Research Network
(PECARN)
Ann Emerg Med 2011 Aug58(2)145-55 doi 101016jannemergmed201008038 Epub 2010 Oct 29 Factors associated with cervical spine injury in children after blunt trauma
Leonard JC Kuppermann N Olsen C Babcock-Cimpello L Brown K Mahajan P Adelgais KM Anders J Borgialli D Donoghue A Hoyle JD Jr Kim E Leonard JR Lillis KA Nigrovic LE Powell EC Rebella
G Reeves SD Rogers AJ Stankovic C Teshome G Jaffe DM Pediatric Emergency Care Applied Research Network
- Itrsquos Hard to Put a Band-Aid on a Broken Spleen Pediatric Trauma
- Disclosures
- Objectives
- Pediatric Prehospital Care
- Mechanism
- Traumatic Pain Management
- Pediatric Trauma
- Deaths by Mechanism of Injury
- Pediatric Trauma
- Pediatric Trauma
- Airway Differences
- Pediatric-Adult Differences
- Pediatric Challenges
- Prehospital Pediatric Challenges
- Pediatric and Adult Trauma
- Scene Response
- Prehospital Intervention
- Where do you take the patient
- Patient arrives at the EDhellip
- Primary Survey
- Order is critical
- Slide Number 22
- Slide Number 23
- Airway
- Indications for Intubation
- Breathing
- ETT Intubation Basics
- Circulation
- Slide Number 29
- CirculationHemodynamic Changes
- Circulation
- Fluid Resuscitation Algorithm
- Reconsidering Crystalloid Resuscitation
- When to start MTP
- Disability
- Finishing Up the Evaluation
- Bad Scene Responses
- OHCA from Trauma
- Blunt Trauma- No Signs of Life
- OHCA with CPR on Arrival
- Pediatric Trauma
- Questions
- References 1
- References 2
- References 3
- References 4
- References 5
- References 5
- XXXXBoston study ems peds trauma procedures- limited pediatric procedural exposure (but more adult experience)
- C-spine
Finishing Up the Evaluation
bull Airway bull Breathing bull Circulation bull Disability bull Exposure
ndash Expose and examine all parts ndash Cover quickly and keep warm
bull Secondary Survey
Bad Scene Responses
bull What are the outcomes of out-of-hospital cardiac arrest from blunt trauma
bull What are the outcomes of pediatric drowning patients
OHCA from Trauma
bull 2000-2003 bull 123 pts bull Mean age 73 yrs bull Most common
rhythms ndash Asystole 59 ndash PEA 29 ndash V-fib 35
bull 195 rosc in field ndash 98 survived for 24
hrs ndash 57 survived to
discharge ndash Drowning- 19
survival to discharge ndash Bystander CPR tripled
the survivor rate
Blunt Trauma- No Signs of Life
bull Review from 2002-2010 bull No signs of life- 025 of blunt trauma
ndash 25 resuscitated prior to hospital arrival bull 138 of these patients survived to discharge
bull 44 overall survived to hospital discharge
OHCA with CPR on Arrival
bull 169 children bull 141 deaths bull 69 required cpr on arrival- none survived bull 87 of patients requiring CPR on arrival
expired in the ED bull Of the 28 survivors
ndash 55 of survivors had full neurologic recovery
Pediatric Trauma
bull Fortunately these cases represent only a small fraction of EMS transports
bull Despite a few key differences pediatric trauma care overall is very similar to adult trauma care
Questions
References 1 bull NTDB 2013 pediatric Report bull Monkey bars httpsplaygroundchroniclesfileswordpresscom201307soccerjpg bull Screaming child httpblogsbabycentercomwp-contentuploads201409screaming-child-tantrum-fitjpg bull Pediatric airway image httpwwwcelebritydiagnosiscomwp-contentuploads201003pediatric-airwayjpg bull Child on backboard httpsencrypted-tbn2gstaticcomimagesq=tbnANd9GcQscrDVc8IH4MwkNGF6F1A9p7mSVzik5zrWyNvI-
qSwQT5S3GNyVg bull Elbow fracture httpwwwimageinterpretationcoukimageselbowSUPRACONDYLAR20LAT3jpg bull Bike riding httpsmile-per-daycomwp-contentuploads201412klr03jpg bull Dad and child pic httplaughingsquidcomwp-contentuploads471160jpg bull Weigth estimation inner city Am J Emerg Med 2015 Oct33(10)1364-7 doi 101016jajem201507040 Epub 2015 Jul 29 Weight
estimation in an inner-city pediatric ED the effect of obesity Chavez H1 Peterson RE2 Lo K3 Arel M4
bull Guess weight sign httpmedialiveauctiongroupneti963110572971_1jpgv=8CDDAAF8A5B9E20 bull Broselow tape httpsuploadwikimediaorgwikipediacommons994BTape1jpg bull Parent screaming httpmommyofamonstercomwp-contentuploads201301yellingjpg bull Prehospital pain management Am J Emerg Med 2015 Mar33(3)451-4 doi 101016jajem201412012 Epub 2014 Dec 18
Prehospital pain management of injured children a systematic review of current evidence Samuel N1 Steiner IP2 Shavit I3 bull Prehospital pain ped pain assessment Prehosp Emerg Care 2008 Apr-Jun12(2)182-6 doi 10108010903120801907471 Prehospital
pain assessment in pediatric trauma Izsak E1 Moore JL Stringfellow K Oswanski MF Lindstrom DA Stombaugh HA bull Ped pain management Prehosp Emerg Care 2005 Jan-Mar9(1)40-3 Prehospital pain management in children suffering traumatic
injury Swor R1 McEachin CM Seguin D Grall KH bull Prehospital intervention Allen CJ Teisch LF et al Prehospital care and transportation of pediatric trauma patients J Surg Res 2015
Aug197(2)240-6 JAMA 2000 Feb 9283(6)783-90 bull Effect of out-of-hospital pediatric endotracheal intubation on survival and neurological outcome a controlled clinical trial
Gausche M1 Lewis RJ Stratton SJ Haynes BE Gunter CS Goodrich SM Poore PD McCollough MD Henderson DP Pratt FD Seidel JS
bull Pediatric pain management survey Pediatr Emerg Care 2015 Sep 23 [Epub ahead of print] An Assessment of Newly Identified Barriers to and Enablers for Prehospital Pediatric Pain Management Whitley DE1 Li T Jones CM Cushman JT Williams DM Shah MN
References 2 bull httpwwwuptodatecomcontentsprehospital-pediatrics-and-emergency-medical-services-emsabstract6 bull httpwwwuptodatecomcontentsprehospital-pediatrics-and-emergency-medical-services-emsabstract7 bull Pediatr Crit Care Med 2011 Jul12(4)e166-70 doi 101097PCC0b013e3181f36f6e First responder
performance in pediatric trauma a comparison with an adult cohortBankole S1 Asuncion A Ross S Aghai Z Nollah L Echols H Da-Silva S
bull Drayna pc Browne LR et al Prehospital pediatric care Oppportunities for training treatment and research Prehosp Emerg Care 2015 Jul-Sep 19(3) Epub 2015 Feb 6
bull Pediatr Emerg Care 2001 Feb17(1) 5-9Pediatric pre-hospital advanced life support care in an urban setting Babl FE1 Vinci RJ Bauchner H Mottley L
bull Pediatr Crit Care Med 2015 Oct16(8)e260-7 doi 101097PCC0000000000000505Pediatric Out-of-Hospital Critical Procedures in the United States Carlson JN1 Gannon E Mann NC Jacobson KE Dai M Colleran C Wang HE
bull Pediatr Emerg Care 2009 Aug25(8)508-12 doi 101097PEC0b013e3181b0a0da The efficacy of pediatric advanced life support training in emergency medical service providers Baker TW1 King W Soto W Asher C Stolfi A Rowin ME
bull Sutton RM Case E et al ROC investigators A quantitative analysis of out-of-hospital pediatric and adolescent resuscitation quality A report from the ROC Epistry- Cardiac Arrest Resusciation 201593150-157
bull Resuscitation 2014 Aug85(8)1059-64 doi 101016jresuscitation201403307 Epub 2014 Apr 4 Neurocognitive long term follow-up study on drowned children Suominen PK1 Sutinen N2 Valle S3 Olkkola KT4 Loumlnnqvist T3
bull J Pediatr Surg 2010 Jul45(7)1413-9 doi 101016jjpedsurg200912020 Prehospital cardiopulmonary resuscitation in the pediatric trauma patient Murphy JT1 Jaiswal K Sabella J Vinson L Megison S Maxson RT
References 3 bull Pre atv accident
httpwwwctvnewscapolopoly_fs119871591409741949httpImageimagejpg_genderivativeslandscape_960imagejpg bull atv pic httpswwwutahadvocatescomwp-contentuploads201402atvAccidentLawyerjpg bull Blunt abdominal solid organ injury adult vs pediatric trauma center J Pediatr Surg 2015 Aug 28 pii S0022-3468(15)00526-6 doi
101016jjpedsurg201508012 [Epub ahead of print] Trauma center variation in the management of pediatric patients with blunt abdominal solid organ injury a national trauma data bank analysis Safavi A1 Skarsgard ED2 Rhee P1 Zangbar B1 Kulvatunyou N1 Tang A1 OKeeffe T1 Friese RS1 Joseph B3
bull Pediatric blunt abdominal injury Curr Opin Crit Care 2015 Sep 28 [Epub ahead of print] Pediatric blunt abdominal trauma current management Notrica DM1
bull Pediatric splenic injury management Am J Surg 2015 Jul 31 pii S0002-9610(15)00417-1 doi 101016jamjsurg201506009 [Epub ahead of print] Comparative effectiveness of treatment strategies for severe splenic trauma in the pediatric population Rialon KL1 Englum BR1 Gulack BC1 Guevara CJ2 Bhattacharya SD3 Shapiro ML4 Rice HE5 Scarborough JE4 Adibe OO6
bull Liver pic httpss-media-cache-ak0pinimgcom736x7da50e7da50eb2bb603c99ef6649ff897e26b5jpg bull Solid organ injury non op in peds J Trauma Acute Care Surg 2015 Oct79(4)683-93 doi 101097TA0000000000000808
Nonoperative management of blunt liver and spleen injury in children Evaluation of the ATOMAC guideline using GRADE Notrica DM1 Eubanks JW 3rd Tuggle DW Maxson RT Letton RW Garcia NM Alder AC Lawson KA St Peter SD Megison S Garcia Filion P
bull Pediaric vs nonped trauma ct use J Pediatr 2015 Oct167(4)897-904e3 doi 101016jjpeds201506052 Epub 2015 Jul 29 Variation in Computed Tomography Imaging for Pediatric Injury-Related Emergency Visits Marin JR1 Wang L2 Winger DG2 Mannix RC3
bull Solid organ management in ped population J Trauma Acute Care Surg 2015 Aug79(2)206-14quiz 332 doi 101097TA0000000000000731 Management of children with solid organ injuries after blunt torso trauma Wisner DH1 Kuppermann N Cooper A Menaker J Ehrlich P Kooistra J Mahajan P Lee L Cook LJ Yen K Lillis K Holmes JF
bull Triad of death image httpimageslidesharecdncomdamage-control-resuscitation-1304253390-phpapp0195damage-control-resuscitation-14-728jpgcb=1304235553
bull Tranexamic acid study Eckert MJ Wertin TM Tyner SD et al 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 77852
bull Image care accident httpsuploadwikimediaorgwikipediacommonsthumbee1Car_crash_1jpg1280px-Car_crash_1jpg
References 4 bull httpwwwsurgeryvcuedudivisionsacutesurghtml bull Trauma management Approach to the unstable child
httpwwwuptodatecomcontentstrauma-management-approach-to-the-unstable-childsource=search_resultampsearch=pediatric+trauma+childrenampselectedTitle=17E150
bull Trauma management Unique pediatric considerations httpwwwuptodatecomcontentstrauma-management-unique-pediatric-considerationssource=search_resultampsearch=pediatric+trauma+childrenampselectedTitle=37E150
References 5 bull httpwwwetiquettehellcomsmfindexphptopic=8666360 bull httpwwwstlouischildrensorghealth-care-professionalsems-providers bull httpwwwuchicagokidshospitalorgspecialtiesemergency-medicinespecialhtml bull httpwwwsimsacademyinfoFXpatienthtm bull httptheemtspotcomwp-contentuploads200902another-burn-patient-by-annette-larsonjpg bull httplastangryfancomwp-contentuploads200910Clint-Malarchukjpg bull httpwwwtraumaorgarchiveresusmassivehtml bull httpwwwuptodatecomcontentsimageimageKey=PEDS68694amptopicKey=EM2F6389ampsourc
e=previewampsearch=pediatric+hemorrhagic+shockampselectedTitle=17E150amprank=undefined bull httptheemtspotcomwp-contentuploads200902gcsgif bull httpwwwuptodatecomcontentsimageimageKey=EM2F60409amptopicKey=EM2F6571amprank
=17E150ampsource=see_linkampsearch=traumaamputdPopup=true bull httpwwwuptodatecomcontentsimageimageKey=EM2F80874amptopicKey=EM2F6571amprank
=17E150ampsource=see_linkampsearch=traumaamputdPopup=true bull httpempracticenewswordpresscomcategorynexus-criteria bull httpswwwgooglecomsearchq=pediatric+glasgow+coma+scaleamptbm=ischamptbo=uampsource=uni
vampsa=Xampei=8TiOU7TNC5WuyATp5YG4BQampsqi=2ampved=0CDYQsAQampbiw=1426ampbih=883q=canadian+c-spine+rulesamptbm=ischampfacrc=_ampimgdii=_ampimgrc=WI94QMHgMLTQmM253A3BP5nbsFhNCXK0FM3Bhttp253A252F252Fwwwbmjcom252Fhighwire252Ffilestream252F436003252Ffield_highwire_fragment_image_l252F0jpg3Bhttp253A252F252Fwwwbmjcom252Fcontent252F339252Fbmjb41463B12803B1253
References 5 bull httpwwwuptodatecomcontentsimageimageKey=EM2F76777amptopicKey=EM2F6571amprank
=17E150ampsource=see_linkampsearch=traumaamputdPopup=true bull httpwwwdocumentingrealitycomforumattachmentsf14964898d1246625322-firework-injury-
m80injury1jpg bull httpwwwpediatriceducationorg20050620 bull httpwwwarmstrongmedicalcomindexcfmgoproductdetailsec3ssec19cat61fam515 bull httpwwwuptodatecomcontentsimageimageKey=PEDS61087amptopicKey=ID2F7661ampsource
=outline_linkampsearch=tetanus+prophylaxisamputdPopup=true bull httpwwwafsecafmilsharedmediaphotodbweb110609-F-MJ378-009jpg bull httpwwwuptodatecomcontentsimageimageKey=EM75765amptopicKey= bull EM2F6389ampsource=outline_linkampsearch=massive+transfusion+protocolamputdPopup=true bull httpwwwmotifakecomimagedemotivational-postersmall0910whats-the-question-ignorance-
calvin-and-hobbes-demotivational-poster-1255020127jpg
XXXXBoston study ems peds trauma procedures- limited pediatric procedural exposure (but more adult experience) bull Catchment area 590000
over 1 year bull 555 pediatric ALS
transport ndash 19 blunt trauma ndash 10 penetrating trauma
bull IV 33 bull BMV 5 bull Intubation 3 bull 50 ALS providers average
year ndash IV- 37 ndash Intubation- 03 ndash IO- 006
bull 7 ped ems ndash 13 trauma
bull Critical procedures ndash 101000 peds cases ndash Intubation 671000 ndash IO 51000 ndash 81 successful
Pediatr Emerg Care 2001 Feb17(1)5-9 Pediatric pre-hospital advanced life support care in an urban setting
Babl FE1 Vinci RJ Bauchner H Mottley L
Pediatr Crit Care Med 2015 Oct16(8)e260-7 doi 101097PCC0000000000000505 Pediatric Out-of-Hospital Critical Procedures in the United States
Carlson JN1 Gannon E Mann NC Jacobson KE Dai M Colleran C Wang HE
C-spine bull C-spine injuries rare bull Take pt to closest hospital if over injuries
call for it (ie resuscitation altered mental status) primary guide
bull Mechanism ndash Altered mental status focal neuro change
torticollis substantial torso injury diving high speed auto neck pain underlying predisposing condition Acad Emerg Med 2014 Jan21(1)55-64 doi 101111acem12288
Comparison of outcomes for children with cervical spine injury based on destination hospital from scene of injury Anders JF1 Adelgais K Hoyle JD Jr Olsen C Jaffe DM Leonard JC Pediatric Emergency Care Applied Research Network
(PECARN)
Ann Emerg Med 2011 Aug58(2)145-55 doi 101016jannemergmed201008038 Epub 2010 Oct 29 Factors associated with cervical spine injury in children after blunt trauma
Leonard JC Kuppermann N Olsen C Babcock-Cimpello L Brown K Mahajan P Adelgais KM Anders J Borgialli D Donoghue A Hoyle JD Jr Kim E Leonard JR Lillis KA Nigrovic LE Powell EC Rebella
G Reeves SD Rogers AJ Stankovic C Teshome G Jaffe DM Pediatric Emergency Care Applied Research Network
- Itrsquos Hard to Put a Band-Aid on a Broken Spleen Pediatric Trauma
- Disclosures
- Objectives
- Pediatric Prehospital Care
- Mechanism
- Traumatic Pain Management
- Pediatric Trauma
- Deaths by Mechanism of Injury
- Pediatric Trauma
- Pediatric Trauma
- Airway Differences
- Pediatric-Adult Differences
- Pediatric Challenges
- Prehospital Pediatric Challenges
- Pediatric and Adult Trauma
- Scene Response
- Prehospital Intervention
- Where do you take the patient
- Patient arrives at the EDhellip
- Primary Survey
- Order is critical
- Slide Number 22
- Slide Number 23
- Airway
- Indications for Intubation
- Breathing
- ETT Intubation Basics
- Circulation
- Slide Number 29
- CirculationHemodynamic Changes
- Circulation
- Fluid Resuscitation Algorithm
- Reconsidering Crystalloid Resuscitation
- When to start MTP
- Disability
- Finishing Up the Evaluation
- Bad Scene Responses
- OHCA from Trauma
- Blunt Trauma- No Signs of Life
- OHCA with CPR on Arrival
- Pediatric Trauma
- Questions
- References 1
- References 2
- References 3
- References 4
- References 5
- References 5
- XXXXBoston study ems peds trauma procedures- limited pediatric procedural exposure (but more adult experience)
- C-spine
Bad Scene Responses
bull What are the outcomes of out-of-hospital cardiac arrest from blunt trauma
bull What are the outcomes of pediatric drowning patients
OHCA from Trauma
bull 2000-2003 bull 123 pts bull Mean age 73 yrs bull Most common
rhythms ndash Asystole 59 ndash PEA 29 ndash V-fib 35
bull 195 rosc in field ndash 98 survived for 24
hrs ndash 57 survived to
discharge ndash Drowning- 19
survival to discharge ndash Bystander CPR tripled
the survivor rate
Blunt Trauma- No Signs of Life
bull Review from 2002-2010 bull No signs of life- 025 of blunt trauma
ndash 25 resuscitated prior to hospital arrival bull 138 of these patients survived to discharge
bull 44 overall survived to hospital discharge
OHCA with CPR on Arrival
bull 169 children bull 141 deaths bull 69 required cpr on arrival- none survived bull 87 of patients requiring CPR on arrival
expired in the ED bull Of the 28 survivors
ndash 55 of survivors had full neurologic recovery
Pediatric Trauma
bull Fortunately these cases represent only a small fraction of EMS transports
bull Despite a few key differences pediatric trauma care overall is very similar to adult trauma care
Questions
References 1 bull NTDB 2013 pediatric Report bull Monkey bars httpsplaygroundchroniclesfileswordpresscom201307soccerjpg bull Screaming child httpblogsbabycentercomwp-contentuploads201409screaming-child-tantrum-fitjpg bull Pediatric airway image httpwwwcelebritydiagnosiscomwp-contentuploads201003pediatric-airwayjpg bull Child on backboard httpsencrypted-tbn2gstaticcomimagesq=tbnANd9GcQscrDVc8IH4MwkNGF6F1A9p7mSVzik5zrWyNvI-
qSwQT5S3GNyVg bull Elbow fracture httpwwwimageinterpretationcoukimageselbowSUPRACONDYLAR20LAT3jpg bull Bike riding httpsmile-per-daycomwp-contentuploads201412klr03jpg bull Dad and child pic httplaughingsquidcomwp-contentuploads471160jpg bull Weigth estimation inner city Am J Emerg Med 2015 Oct33(10)1364-7 doi 101016jajem201507040 Epub 2015 Jul 29 Weight
estimation in an inner-city pediatric ED the effect of obesity Chavez H1 Peterson RE2 Lo K3 Arel M4
bull Guess weight sign httpmedialiveauctiongroupneti963110572971_1jpgv=8CDDAAF8A5B9E20 bull Broselow tape httpsuploadwikimediaorgwikipediacommons994BTape1jpg bull Parent screaming httpmommyofamonstercomwp-contentuploads201301yellingjpg bull Prehospital pain management Am J Emerg Med 2015 Mar33(3)451-4 doi 101016jajem201412012 Epub 2014 Dec 18
Prehospital pain management of injured children a systematic review of current evidence Samuel N1 Steiner IP2 Shavit I3 bull Prehospital pain ped pain assessment Prehosp Emerg Care 2008 Apr-Jun12(2)182-6 doi 10108010903120801907471 Prehospital
pain assessment in pediatric trauma Izsak E1 Moore JL Stringfellow K Oswanski MF Lindstrom DA Stombaugh HA bull Ped pain management Prehosp Emerg Care 2005 Jan-Mar9(1)40-3 Prehospital pain management in children suffering traumatic
injury Swor R1 McEachin CM Seguin D Grall KH bull Prehospital intervention Allen CJ Teisch LF et al Prehospital care and transportation of pediatric trauma patients J Surg Res 2015
Aug197(2)240-6 JAMA 2000 Feb 9283(6)783-90 bull Effect of out-of-hospital pediatric endotracheal intubation on survival and neurological outcome a controlled clinical trial
Gausche M1 Lewis RJ Stratton SJ Haynes BE Gunter CS Goodrich SM Poore PD McCollough MD Henderson DP Pratt FD Seidel JS
bull Pediatric pain management survey Pediatr Emerg Care 2015 Sep 23 [Epub ahead of print] An Assessment of Newly Identified Barriers to and Enablers for Prehospital Pediatric Pain Management Whitley DE1 Li T Jones CM Cushman JT Williams DM Shah MN
References 2 bull httpwwwuptodatecomcontentsprehospital-pediatrics-and-emergency-medical-services-emsabstract6 bull httpwwwuptodatecomcontentsprehospital-pediatrics-and-emergency-medical-services-emsabstract7 bull Pediatr Crit Care Med 2011 Jul12(4)e166-70 doi 101097PCC0b013e3181f36f6e First responder
performance in pediatric trauma a comparison with an adult cohortBankole S1 Asuncion A Ross S Aghai Z Nollah L Echols H Da-Silva S
bull Drayna pc Browne LR et al Prehospital pediatric care Oppportunities for training treatment and research Prehosp Emerg Care 2015 Jul-Sep 19(3) Epub 2015 Feb 6
bull Pediatr Emerg Care 2001 Feb17(1) 5-9Pediatric pre-hospital advanced life support care in an urban setting Babl FE1 Vinci RJ Bauchner H Mottley L
bull Pediatr Crit Care Med 2015 Oct16(8)e260-7 doi 101097PCC0000000000000505Pediatric Out-of-Hospital Critical Procedures in the United States Carlson JN1 Gannon E Mann NC Jacobson KE Dai M Colleran C Wang HE
bull Pediatr Emerg Care 2009 Aug25(8)508-12 doi 101097PEC0b013e3181b0a0da The efficacy of pediatric advanced life support training in emergency medical service providers Baker TW1 King W Soto W Asher C Stolfi A Rowin ME
bull Sutton RM Case E et al ROC investigators A quantitative analysis of out-of-hospital pediatric and adolescent resuscitation quality A report from the ROC Epistry- Cardiac Arrest Resusciation 201593150-157
bull Resuscitation 2014 Aug85(8)1059-64 doi 101016jresuscitation201403307 Epub 2014 Apr 4 Neurocognitive long term follow-up study on drowned children Suominen PK1 Sutinen N2 Valle S3 Olkkola KT4 Loumlnnqvist T3
bull J Pediatr Surg 2010 Jul45(7)1413-9 doi 101016jjpedsurg200912020 Prehospital cardiopulmonary resuscitation in the pediatric trauma patient Murphy JT1 Jaiswal K Sabella J Vinson L Megison S Maxson RT
References 3 bull Pre atv accident
httpwwwctvnewscapolopoly_fs119871591409741949httpImageimagejpg_genderivativeslandscape_960imagejpg bull atv pic httpswwwutahadvocatescomwp-contentuploads201402atvAccidentLawyerjpg bull Blunt abdominal solid organ injury adult vs pediatric trauma center J Pediatr Surg 2015 Aug 28 pii S0022-3468(15)00526-6 doi
101016jjpedsurg201508012 [Epub ahead of print] Trauma center variation in the management of pediatric patients with blunt abdominal solid organ injury a national trauma data bank analysis Safavi A1 Skarsgard ED2 Rhee P1 Zangbar B1 Kulvatunyou N1 Tang A1 OKeeffe T1 Friese RS1 Joseph B3
bull Pediatric blunt abdominal injury Curr Opin Crit Care 2015 Sep 28 [Epub ahead of print] Pediatric blunt abdominal trauma current management Notrica DM1
bull Pediatric splenic injury management Am J Surg 2015 Jul 31 pii S0002-9610(15)00417-1 doi 101016jamjsurg201506009 [Epub ahead of print] Comparative effectiveness of treatment strategies for severe splenic trauma in the pediatric population Rialon KL1 Englum BR1 Gulack BC1 Guevara CJ2 Bhattacharya SD3 Shapiro ML4 Rice HE5 Scarborough JE4 Adibe OO6
bull Liver pic httpss-media-cache-ak0pinimgcom736x7da50e7da50eb2bb603c99ef6649ff897e26b5jpg bull Solid organ injury non op in peds J Trauma Acute Care Surg 2015 Oct79(4)683-93 doi 101097TA0000000000000808
Nonoperative management of blunt liver and spleen injury in children Evaluation of the ATOMAC guideline using GRADE Notrica DM1 Eubanks JW 3rd Tuggle DW Maxson RT Letton RW Garcia NM Alder AC Lawson KA St Peter SD Megison S Garcia Filion P
bull Pediaric vs nonped trauma ct use J Pediatr 2015 Oct167(4)897-904e3 doi 101016jjpeds201506052 Epub 2015 Jul 29 Variation in Computed Tomography Imaging for Pediatric Injury-Related Emergency Visits Marin JR1 Wang L2 Winger DG2 Mannix RC3
bull Solid organ management in ped population J Trauma Acute Care Surg 2015 Aug79(2)206-14quiz 332 doi 101097TA0000000000000731 Management of children with solid organ injuries after blunt torso trauma Wisner DH1 Kuppermann N Cooper A Menaker J Ehrlich P Kooistra J Mahajan P Lee L Cook LJ Yen K Lillis K Holmes JF
bull Triad of death image httpimageslidesharecdncomdamage-control-resuscitation-1304253390-phpapp0195damage-control-resuscitation-14-728jpgcb=1304235553
bull Tranexamic acid study Eckert MJ Wertin TM Tyner SD et al 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 77852
bull Image care accident httpsuploadwikimediaorgwikipediacommonsthumbee1Car_crash_1jpg1280px-Car_crash_1jpg
References 4 bull httpwwwsurgeryvcuedudivisionsacutesurghtml bull Trauma management Approach to the unstable child
httpwwwuptodatecomcontentstrauma-management-approach-to-the-unstable-childsource=search_resultampsearch=pediatric+trauma+childrenampselectedTitle=17E150
bull Trauma management Unique pediatric considerations httpwwwuptodatecomcontentstrauma-management-unique-pediatric-considerationssource=search_resultampsearch=pediatric+trauma+childrenampselectedTitle=37E150
References 5 bull httpwwwetiquettehellcomsmfindexphptopic=8666360 bull httpwwwstlouischildrensorghealth-care-professionalsems-providers bull httpwwwuchicagokidshospitalorgspecialtiesemergency-medicinespecialhtml bull httpwwwsimsacademyinfoFXpatienthtm bull httptheemtspotcomwp-contentuploads200902another-burn-patient-by-annette-larsonjpg bull httplastangryfancomwp-contentuploads200910Clint-Malarchukjpg bull httpwwwtraumaorgarchiveresusmassivehtml bull httpwwwuptodatecomcontentsimageimageKey=PEDS68694amptopicKey=EM2F6389ampsourc
e=previewampsearch=pediatric+hemorrhagic+shockampselectedTitle=17E150amprank=undefined bull httptheemtspotcomwp-contentuploads200902gcsgif bull httpwwwuptodatecomcontentsimageimageKey=EM2F60409amptopicKey=EM2F6571amprank
=17E150ampsource=see_linkampsearch=traumaamputdPopup=true bull httpwwwuptodatecomcontentsimageimageKey=EM2F80874amptopicKey=EM2F6571amprank
=17E150ampsource=see_linkampsearch=traumaamputdPopup=true bull httpempracticenewswordpresscomcategorynexus-criteria bull httpswwwgooglecomsearchq=pediatric+glasgow+coma+scaleamptbm=ischamptbo=uampsource=uni
vampsa=Xampei=8TiOU7TNC5WuyATp5YG4BQampsqi=2ampved=0CDYQsAQampbiw=1426ampbih=883q=canadian+c-spine+rulesamptbm=ischampfacrc=_ampimgdii=_ampimgrc=WI94QMHgMLTQmM253A3BP5nbsFhNCXK0FM3Bhttp253A252F252Fwwwbmjcom252Fhighwire252Ffilestream252F436003252Ffield_highwire_fragment_image_l252F0jpg3Bhttp253A252F252Fwwwbmjcom252Fcontent252F339252Fbmjb41463B12803B1253
References 5 bull httpwwwuptodatecomcontentsimageimageKey=EM2F76777amptopicKey=EM2F6571amprank
=17E150ampsource=see_linkampsearch=traumaamputdPopup=true bull httpwwwdocumentingrealitycomforumattachmentsf14964898d1246625322-firework-injury-
m80injury1jpg bull httpwwwpediatriceducationorg20050620 bull httpwwwarmstrongmedicalcomindexcfmgoproductdetailsec3ssec19cat61fam515 bull httpwwwuptodatecomcontentsimageimageKey=PEDS61087amptopicKey=ID2F7661ampsource
=outline_linkampsearch=tetanus+prophylaxisamputdPopup=true bull httpwwwafsecafmilsharedmediaphotodbweb110609-F-MJ378-009jpg bull httpwwwuptodatecomcontentsimageimageKey=EM75765amptopicKey= bull EM2F6389ampsource=outline_linkampsearch=massive+transfusion+protocolamputdPopup=true bull httpwwwmotifakecomimagedemotivational-postersmall0910whats-the-question-ignorance-
calvin-and-hobbes-demotivational-poster-1255020127jpg
XXXXBoston study ems peds trauma procedures- limited pediatric procedural exposure (but more adult experience) bull Catchment area 590000
over 1 year bull 555 pediatric ALS
transport ndash 19 blunt trauma ndash 10 penetrating trauma
bull IV 33 bull BMV 5 bull Intubation 3 bull 50 ALS providers average
year ndash IV- 37 ndash Intubation- 03 ndash IO- 006
bull 7 ped ems ndash 13 trauma
bull Critical procedures ndash 101000 peds cases ndash Intubation 671000 ndash IO 51000 ndash 81 successful
Pediatr Emerg Care 2001 Feb17(1)5-9 Pediatric pre-hospital advanced life support care in an urban setting
Babl FE1 Vinci RJ Bauchner H Mottley L
Pediatr Crit Care Med 2015 Oct16(8)e260-7 doi 101097PCC0000000000000505 Pediatric Out-of-Hospital Critical Procedures in the United States
Carlson JN1 Gannon E Mann NC Jacobson KE Dai M Colleran C Wang HE
C-spine bull C-spine injuries rare bull Take pt to closest hospital if over injuries
call for it (ie resuscitation altered mental status) primary guide
bull Mechanism ndash Altered mental status focal neuro change
torticollis substantial torso injury diving high speed auto neck pain underlying predisposing condition Acad Emerg Med 2014 Jan21(1)55-64 doi 101111acem12288
Comparison of outcomes for children with cervical spine injury based on destination hospital from scene of injury Anders JF1 Adelgais K Hoyle JD Jr Olsen C Jaffe DM Leonard JC Pediatric Emergency Care Applied Research Network
(PECARN)
Ann Emerg Med 2011 Aug58(2)145-55 doi 101016jannemergmed201008038 Epub 2010 Oct 29 Factors associated with cervical spine injury in children after blunt trauma
Leonard JC Kuppermann N Olsen C Babcock-Cimpello L Brown K Mahajan P Adelgais KM Anders J Borgialli D Donoghue A Hoyle JD Jr Kim E Leonard JR Lillis KA Nigrovic LE Powell EC Rebella
G Reeves SD Rogers AJ Stankovic C Teshome G Jaffe DM Pediatric Emergency Care Applied Research Network
- Itrsquos Hard to Put a Band-Aid on a Broken Spleen Pediatric Trauma
- Disclosures
- Objectives
- Pediatric Prehospital Care
- Mechanism
- Traumatic Pain Management
- Pediatric Trauma
- Deaths by Mechanism of Injury
- Pediatric Trauma
- Pediatric Trauma
- Airway Differences
- Pediatric-Adult Differences
- Pediatric Challenges
- Prehospital Pediatric Challenges
- Pediatric and Adult Trauma
- Scene Response
- Prehospital Intervention
- Where do you take the patient
- Patient arrives at the EDhellip
- Primary Survey
- Order is critical
- Slide Number 22
- Slide Number 23
- Airway
- Indications for Intubation
- Breathing
- ETT Intubation Basics
- Circulation
- Slide Number 29
- CirculationHemodynamic Changes
- Circulation
- Fluid Resuscitation Algorithm
- Reconsidering Crystalloid Resuscitation
- When to start MTP
- Disability
- Finishing Up the Evaluation
- Bad Scene Responses
- OHCA from Trauma
- Blunt Trauma- No Signs of Life
- OHCA with CPR on Arrival
- Pediatric Trauma
- Questions
- References 1
- References 2
- References 3
- References 4
- References 5
- References 5
- XXXXBoston study ems peds trauma procedures- limited pediatric procedural exposure (but more adult experience)
- C-spine
OHCA from Trauma
bull 2000-2003 bull 123 pts bull Mean age 73 yrs bull Most common
rhythms ndash Asystole 59 ndash PEA 29 ndash V-fib 35
bull 195 rosc in field ndash 98 survived for 24
hrs ndash 57 survived to
discharge ndash Drowning- 19
survival to discharge ndash Bystander CPR tripled
the survivor rate
Blunt Trauma- No Signs of Life
bull Review from 2002-2010 bull No signs of life- 025 of blunt trauma
ndash 25 resuscitated prior to hospital arrival bull 138 of these patients survived to discharge
bull 44 overall survived to hospital discharge
OHCA with CPR on Arrival
bull 169 children bull 141 deaths bull 69 required cpr on arrival- none survived bull 87 of patients requiring CPR on arrival
expired in the ED bull Of the 28 survivors
ndash 55 of survivors had full neurologic recovery
Pediatric Trauma
bull Fortunately these cases represent only a small fraction of EMS transports
bull Despite a few key differences pediatric trauma care overall is very similar to adult trauma care
Questions
References 1 bull NTDB 2013 pediatric Report bull Monkey bars httpsplaygroundchroniclesfileswordpresscom201307soccerjpg bull Screaming child httpblogsbabycentercomwp-contentuploads201409screaming-child-tantrum-fitjpg bull Pediatric airway image httpwwwcelebritydiagnosiscomwp-contentuploads201003pediatric-airwayjpg bull Child on backboard httpsencrypted-tbn2gstaticcomimagesq=tbnANd9GcQscrDVc8IH4MwkNGF6F1A9p7mSVzik5zrWyNvI-
qSwQT5S3GNyVg bull Elbow fracture httpwwwimageinterpretationcoukimageselbowSUPRACONDYLAR20LAT3jpg bull Bike riding httpsmile-per-daycomwp-contentuploads201412klr03jpg bull Dad and child pic httplaughingsquidcomwp-contentuploads471160jpg bull Weigth estimation inner city Am J Emerg Med 2015 Oct33(10)1364-7 doi 101016jajem201507040 Epub 2015 Jul 29 Weight
estimation in an inner-city pediatric ED the effect of obesity Chavez H1 Peterson RE2 Lo K3 Arel M4
bull Guess weight sign httpmedialiveauctiongroupneti963110572971_1jpgv=8CDDAAF8A5B9E20 bull Broselow tape httpsuploadwikimediaorgwikipediacommons994BTape1jpg bull Parent screaming httpmommyofamonstercomwp-contentuploads201301yellingjpg bull Prehospital pain management Am J Emerg Med 2015 Mar33(3)451-4 doi 101016jajem201412012 Epub 2014 Dec 18
Prehospital pain management of injured children a systematic review of current evidence Samuel N1 Steiner IP2 Shavit I3 bull Prehospital pain ped pain assessment Prehosp Emerg Care 2008 Apr-Jun12(2)182-6 doi 10108010903120801907471 Prehospital
pain assessment in pediatric trauma Izsak E1 Moore JL Stringfellow K Oswanski MF Lindstrom DA Stombaugh HA bull Ped pain management Prehosp Emerg Care 2005 Jan-Mar9(1)40-3 Prehospital pain management in children suffering traumatic
injury Swor R1 McEachin CM Seguin D Grall KH bull Prehospital intervention Allen CJ Teisch LF et al Prehospital care and transportation of pediatric trauma patients J Surg Res 2015
Aug197(2)240-6 JAMA 2000 Feb 9283(6)783-90 bull Effect of out-of-hospital pediatric endotracheal intubation on survival and neurological outcome a controlled clinical trial
Gausche M1 Lewis RJ Stratton SJ Haynes BE Gunter CS Goodrich SM Poore PD McCollough MD Henderson DP Pratt FD Seidel JS
bull Pediatric pain management survey Pediatr Emerg Care 2015 Sep 23 [Epub ahead of print] An Assessment of Newly Identified Barriers to and Enablers for Prehospital Pediatric Pain Management Whitley DE1 Li T Jones CM Cushman JT Williams DM Shah MN
References 2 bull httpwwwuptodatecomcontentsprehospital-pediatrics-and-emergency-medical-services-emsabstract6 bull httpwwwuptodatecomcontentsprehospital-pediatrics-and-emergency-medical-services-emsabstract7 bull Pediatr Crit Care Med 2011 Jul12(4)e166-70 doi 101097PCC0b013e3181f36f6e First responder
performance in pediatric trauma a comparison with an adult cohortBankole S1 Asuncion A Ross S Aghai Z Nollah L Echols H Da-Silva S
bull Drayna pc Browne LR et al Prehospital pediatric care Oppportunities for training treatment and research Prehosp Emerg Care 2015 Jul-Sep 19(3) Epub 2015 Feb 6
bull Pediatr Emerg Care 2001 Feb17(1) 5-9Pediatric pre-hospital advanced life support care in an urban setting Babl FE1 Vinci RJ Bauchner H Mottley L
bull Pediatr Crit Care Med 2015 Oct16(8)e260-7 doi 101097PCC0000000000000505Pediatric Out-of-Hospital Critical Procedures in the United States Carlson JN1 Gannon E Mann NC Jacobson KE Dai M Colleran C Wang HE
bull Pediatr Emerg Care 2009 Aug25(8)508-12 doi 101097PEC0b013e3181b0a0da The efficacy of pediatric advanced life support training in emergency medical service providers Baker TW1 King W Soto W Asher C Stolfi A Rowin ME
bull Sutton RM Case E et al ROC investigators A quantitative analysis of out-of-hospital pediatric and adolescent resuscitation quality A report from the ROC Epistry- Cardiac Arrest Resusciation 201593150-157
bull Resuscitation 2014 Aug85(8)1059-64 doi 101016jresuscitation201403307 Epub 2014 Apr 4 Neurocognitive long term follow-up study on drowned children Suominen PK1 Sutinen N2 Valle S3 Olkkola KT4 Loumlnnqvist T3
bull J Pediatr Surg 2010 Jul45(7)1413-9 doi 101016jjpedsurg200912020 Prehospital cardiopulmonary resuscitation in the pediatric trauma patient Murphy JT1 Jaiswal K Sabella J Vinson L Megison S Maxson RT
References 3 bull Pre atv accident
httpwwwctvnewscapolopoly_fs119871591409741949httpImageimagejpg_genderivativeslandscape_960imagejpg bull atv pic httpswwwutahadvocatescomwp-contentuploads201402atvAccidentLawyerjpg bull Blunt abdominal solid organ injury adult vs pediatric trauma center J Pediatr Surg 2015 Aug 28 pii S0022-3468(15)00526-6 doi
101016jjpedsurg201508012 [Epub ahead of print] Trauma center variation in the management of pediatric patients with blunt abdominal solid organ injury a national trauma data bank analysis Safavi A1 Skarsgard ED2 Rhee P1 Zangbar B1 Kulvatunyou N1 Tang A1 OKeeffe T1 Friese RS1 Joseph B3
bull Pediatric blunt abdominal injury Curr Opin Crit Care 2015 Sep 28 [Epub ahead of print] Pediatric blunt abdominal trauma current management Notrica DM1
bull Pediatric splenic injury management Am J Surg 2015 Jul 31 pii S0002-9610(15)00417-1 doi 101016jamjsurg201506009 [Epub ahead of print] Comparative effectiveness of treatment strategies for severe splenic trauma in the pediatric population Rialon KL1 Englum BR1 Gulack BC1 Guevara CJ2 Bhattacharya SD3 Shapiro ML4 Rice HE5 Scarborough JE4 Adibe OO6
bull Liver pic httpss-media-cache-ak0pinimgcom736x7da50e7da50eb2bb603c99ef6649ff897e26b5jpg bull Solid organ injury non op in peds J Trauma Acute Care Surg 2015 Oct79(4)683-93 doi 101097TA0000000000000808
Nonoperative management of blunt liver and spleen injury in children Evaluation of the ATOMAC guideline using GRADE Notrica DM1 Eubanks JW 3rd Tuggle DW Maxson RT Letton RW Garcia NM Alder AC Lawson KA St Peter SD Megison S Garcia Filion P
bull Pediaric vs nonped trauma ct use J Pediatr 2015 Oct167(4)897-904e3 doi 101016jjpeds201506052 Epub 2015 Jul 29 Variation in Computed Tomography Imaging for Pediatric Injury-Related Emergency Visits Marin JR1 Wang L2 Winger DG2 Mannix RC3
bull Solid organ management in ped population J Trauma Acute Care Surg 2015 Aug79(2)206-14quiz 332 doi 101097TA0000000000000731 Management of children with solid organ injuries after blunt torso trauma Wisner DH1 Kuppermann N Cooper A Menaker J Ehrlich P Kooistra J Mahajan P Lee L Cook LJ Yen K Lillis K Holmes JF
bull Triad of death image httpimageslidesharecdncomdamage-control-resuscitation-1304253390-phpapp0195damage-control-resuscitation-14-728jpgcb=1304235553
bull Tranexamic acid study Eckert MJ Wertin TM Tyner SD et al 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 77852
bull Image care accident httpsuploadwikimediaorgwikipediacommonsthumbee1Car_crash_1jpg1280px-Car_crash_1jpg
References 4 bull httpwwwsurgeryvcuedudivisionsacutesurghtml bull Trauma management Approach to the unstable child
httpwwwuptodatecomcontentstrauma-management-approach-to-the-unstable-childsource=search_resultampsearch=pediatric+trauma+childrenampselectedTitle=17E150
bull Trauma management Unique pediatric considerations httpwwwuptodatecomcontentstrauma-management-unique-pediatric-considerationssource=search_resultampsearch=pediatric+trauma+childrenampselectedTitle=37E150
References 5 bull httpwwwetiquettehellcomsmfindexphptopic=8666360 bull httpwwwstlouischildrensorghealth-care-professionalsems-providers bull httpwwwuchicagokidshospitalorgspecialtiesemergency-medicinespecialhtml bull httpwwwsimsacademyinfoFXpatienthtm bull httptheemtspotcomwp-contentuploads200902another-burn-patient-by-annette-larsonjpg bull httplastangryfancomwp-contentuploads200910Clint-Malarchukjpg bull httpwwwtraumaorgarchiveresusmassivehtml bull httpwwwuptodatecomcontentsimageimageKey=PEDS68694amptopicKey=EM2F6389ampsourc
e=previewampsearch=pediatric+hemorrhagic+shockampselectedTitle=17E150amprank=undefined bull httptheemtspotcomwp-contentuploads200902gcsgif bull httpwwwuptodatecomcontentsimageimageKey=EM2F60409amptopicKey=EM2F6571amprank
=17E150ampsource=see_linkampsearch=traumaamputdPopup=true bull httpwwwuptodatecomcontentsimageimageKey=EM2F80874amptopicKey=EM2F6571amprank
=17E150ampsource=see_linkampsearch=traumaamputdPopup=true bull httpempracticenewswordpresscomcategorynexus-criteria bull httpswwwgooglecomsearchq=pediatric+glasgow+coma+scaleamptbm=ischamptbo=uampsource=uni
vampsa=Xampei=8TiOU7TNC5WuyATp5YG4BQampsqi=2ampved=0CDYQsAQampbiw=1426ampbih=883q=canadian+c-spine+rulesamptbm=ischampfacrc=_ampimgdii=_ampimgrc=WI94QMHgMLTQmM253A3BP5nbsFhNCXK0FM3Bhttp253A252F252Fwwwbmjcom252Fhighwire252Ffilestream252F436003252Ffield_highwire_fragment_image_l252F0jpg3Bhttp253A252F252Fwwwbmjcom252Fcontent252F339252Fbmjb41463B12803B1253
References 5 bull httpwwwuptodatecomcontentsimageimageKey=EM2F76777amptopicKey=EM2F6571amprank
=17E150ampsource=see_linkampsearch=traumaamputdPopup=true bull httpwwwdocumentingrealitycomforumattachmentsf14964898d1246625322-firework-injury-
m80injury1jpg bull httpwwwpediatriceducationorg20050620 bull httpwwwarmstrongmedicalcomindexcfmgoproductdetailsec3ssec19cat61fam515 bull httpwwwuptodatecomcontentsimageimageKey=PEDS61087amptopicKey=ID2F7661ampsource
=outline_linkampsearch=tetanus+prophylaxisamputdPopup=true bull httpwwwafsecafmilsharedmediaphotodbweb110609-F-MJ378-009jpg bull httpwwwuptodatecomcontentsimageimageKey=EM75765amptopicKey= bull EM2F6389ampsource=outline_linkampsearch=massive+transfusion+protocolamputdPopup=true bull httpwwwmotifakecomimagedemotivational-postersmall0910whats-the-question-ignorance-
calvin-and-hobbes-demotivational-poster-1255020127jpg
XXXXBoston study ems peds trauma procedures- limited pediatric procedural exposure (but more adult experience) bull Catchment area 590000
over 1 year bull 555 pediatric ALS
transport ndash 19 blunt trauma ndash 10 penetrating trauma
bull IV 33 bull BMV 5 bull Intubation 3 bull 50 ALS providers average
year ndash IV- 37 ndash Intubation- 03 ndash IO- 006
bull 7 ped ems ndash 13 trauma
bull Critical procedures ndash 101000 peds cases ndash Intubation 671000 ndash IO 51000 ndash 81 successful
Pediatr Emerg Care 2001 Feb17(1)5-9 Pediatric pre-hospital advanced life support care in an urban setting
Babl FE1 Vinci RJ Bauchner H Mottley L
Pediatr Crit Care Med 2015 Oct16(8)e260-7 doi 101097PCC0000000000000505 Pediatric Out-of-Hospital Critical Procedures in the United States
Carlson JN1 Gannon E Mann NC Jacobson KE Dai M Colleran C Wang HE
C-spine bull C-spine injuries rare bull Take pt to closest hospital if over injuries
call for it (ie resuscitation altered mental status) primary guide
bull Mechanism ndash Altered mental status focal neuro change
torticollis substantial torso injury diving high speed auto neck pain underlying predisposing condition Acad Emerg Med 2014 Jan21(1)55-64 doi 101111acem12288
Comparison of outcomes for children with cervical spine injury based on destination hospital from scene of injury Anders JF1 Adelgais K Hoyle JD Jr Olsen C Jaffe DM Leonard JC Pediatric Emergency Care Applied Research Network
(PECARN)
Ann Emerg Med 2011 Aug58(2)145-55 doi 101016jannemergmed201008038 Epub 2010 Oct 29 Factors associated with cervical spine injury in children after blunt trauma
Leonard JC Kuppermann N Olsen C Babcock-Cimpello L Brown K Mahajan P Adelgais KM Anders J Borgialli D Donoghue A Hoyle JD Jr Kim E Leonard JR Lillis KA Nigrovic LE Powell EC Rebella
G Reeves SD Rogers AJ Stankovic C Teshome G Jaffe DM Pediatric Emergency Care Applied Research Network
- Itrsquos Hard to Put a Band-Aid on a Broken Spleen Pediatric Trauma
- Disclosures
- Objectives
- Pediatric Prehospital Care
- Mechanism
- Traumatic Pain Management
- Pediatric Trauma
- Deaths by Mechanism of Injury
- Pediatric Trauma
- Pediatric Trauma
- Airway Differences
- Pediatric-Adult Differences
- Pediatric Challenges
- Prehospital Pediatric Challenges
- Pediatric and Adult Trauma
- Scene Response
- Prehospital Intervention
- Where do you take the patient
- Patient arrives at the EDhellip
- Primary Survey
- Order is critical
- Slide Number 22
- Slide Number 23
- Airway
- Indications for Intubation
- Breathing
- ETT Intubation Basics
- Circulation
- Slide Number 29
- CirculationHemodynamic Changes
- Circulation
- Fluid Resuscitation Algorithm
- Reconsidering Crystalloid Resuscitation
- When to start MTP
- Disability
- Finishing Up the Evaluation
- Bad Scene Responses
- OHCA from Trauma
- Blunt Trauma- No Signs of Life
- OHCA with CPR on Arrival
- Pediatric Trauma
- Questions
- References 1
- References 2
- References 3
- References 4
- References 5
- References 5
- XXXXBoston study ems peds trauma procedures- limited pediatric procedural exposure (but more adult experience)
- C-spine
Blunt Trauma- No Signs of Life
bull Review from 2002-2010 bull No signs of life- 025 of blunt trauma
ndash 25 resuscitated prior to hospital arrival bull 138 of these patients survived to discharge
bull 44 overall survived to hospital discharge
OHCA with CPR on Arrival
bull 169 children bull 141 deaths bull 69 required cpr on arrival- none survived bull 87 of patients requiring CPR on arrival
expired in the ED bull Of the 28 survivors
ndash 55 of survivors had full neurologic recovery
Pediatric Trauma
bull Fortunately these cases represent only a small fraction of EMS transports
bull Despite a few key differences pediatric trauma care overall is very similar to adult trauma care
Questions
References 1 bull NTDB 2013 pediatric Report bull Monkey bars httpsplaygroundchroniclesfileswordpresscom201307soccerjpg bull Screaming child httpblogsbabycentercomwp-contentuploads201409screaming-child-tantrum-fitjpg bull Pediatric airway image httpwwwcelebritydiagnosiscomwp-contentuploads201003pediatric-airwayjpg bull Child on backboard httpsencrypted-tbn2gstaticcomimagesq=tbnANd9GcQscrDVc8IH4MwkNGF6F1A9p7mSVzik5zrWyNvI-
qSwQT5S3GNyVg bull Elbow fracture httpwwwimageinterpretationcoukimageselbowSUPRACONDYLAR20LAT3jpg bull Bike riding httpsmile-per-daycomwp-contentuploads201412klr03jpg bull Dad and child pic httplaughingsquidcomwp-contentuploads471160jpg bull Weigth estimation inner city Am J Emerg Med 2015 Oct33(10)1364-7 doi 101016jajem201507040 Epub 2015 Jul 29 Weight
estimation in an inner-city pediatric ED the effect of obesity Chavez H1 Peterson RE2 Lo K3 Arel M4
bull Guess weight sign httpmedialiveauctiongroupneti963110572971_1jpgv=8CDDAAF8A5B9E20 bull Broselow tape httpsuploadwikimediaorgwikipediacommons994BTape1jpg bull Parent screaming httpmommyofamonstercomwp-contentuploads201301yellingjpg bull Prehospital pain management Am J Emerg Med 2015 Mar33(3)451-4 doi 101016jajem201412012 Epub 2014 Dec 18
Prehospital pain management of injured children a systematic review of current evidence Samuel N1 Steiner IP2 Shavit I3 bull Prehospital pain ped pain assessment Prehosp Emerg Care 2008 Apr-Jun12(2)182-6 doi 10108010903120801907471 Prehospital
pain assessment in pediatric trauma Izsak E1 Moore JL Stringfellow K Oswanski MF Lindstrom DA Stombaugh HA bull Ped pain management Prehosp Emerg Care 2005 Jan-Mar9(1)40-3 Prehospital pain management in children suffering traumatic
injury Swor R1 McEachin CM Seguin D Grall KH bull Prehospital intervention Allen CJ Teisch LF et al Prehospital care and transportation of pediatric trauma patients J Surg Res 2015
Aug197(2)240-6 JAMA 2000 Feb 9283(6)783-90 bull Effect of out-of-hospital pediatric endotracheal intubation on survival and neurological outcome a controlled clinical trial
Gausche M1 Lewis RJ Stratton SJ Haynes BE Gunter CS Goodrich SM Poore PD McCollough MD Henderson DP Pratt FD Seidel JS
bull Pediatric pain management survey Pediatr Emerg Care 2015 Sep 23 [Epub ahead of print] An Assessment of Newly Identified Barriers to and Enablers for Prehospital Pediatric Pain Management Whitley DE1 Li T Jones CM Cushman JT Williams DM Shah MN
References 2 bull httpwwwuptodatecomcontentsprehospital-pediatrics-and-emergency-medical-services-emsabstract6 bull httpwwwuptodatecomcontentsprehospital-pediatrics-and-emergency-medical-services-emsabstract7 bull Pediatr Crit Care Med 2011 Jul12(4)e166-70 doi 101097PCC0b013e3181f36f6e First responder
performance in pediatric trauma a comparison with an adult cohortBankole S1 Asuncion A Ross S Aghai Z Nollah L Echols H Da-Silva S
bull Drayna pc Browne LR et al Prehospital pediatric care Oppportunities for training treatment and research Prehosp Emerg Care 2015 Jul-Sep 19(3) Epub 2015 Feb 6
bull Pediatr Emerg Care 2001 Feb17(1) 5-9Pediatric pre-hospital advanced life support care in an urban setting Babl FE1 Vinci RJ Bauchner H Mottley L
bull Pediatr Crit Care Med 2015 Oct16(8)e260-7 doi 101097PCC0000000000000505Pediatric Out-of-Hospital Critical Procedures in the United States Carlson JN1 Gannon E Mann NC Jacobson KE Dai M Colleran C Wang HE
bull Pediatr Emerg Care 2009 Aug25(8)508-12 doi 101097PEC0b013e3181b0a0da The efficacy of pediatric advanced life support training in emergency medical service providers Baker TW1 King W Soto W Asher C Stolfi A Rowin ME
bull Sutton RM Case E et al ROC investigators A quantitative analysis of out-of-hospital pediatric and adolescent resuscitation quality A report from the ROC Epistry- Cardiac Arrest Resusciation 201593150-157
bull Resuscitation 2014 Aug85(8)1059-64 doi 101016jresuscitation201403307 Epub 2014 Apr 4 Neurocognitive long term follow-up study on drowned children Suominen PK1 Sutinen N2 Valle S3 Olkkola KT4 Loumlnnqvist T3
bull J Pediatr Surg 2010 Jul45(7)1413-9 doi 101016jjpedsurg200912020 Prehospital cardiopulmonary resuscitation in the pediatric trauma patient Murphy JT1 Jaiswal K Sabella J Vinson L Megison S Maxson RT
References 3 bull Pre atv accident
httpwwwctvnewscapolopoly_fs119871591409741949httpImageimagejpg_genderivativeslandscape_960imagejpg bull atv pic httpswwwutahadvocatescomwp-contentuploads201402atvAccidentLawyerjpg bull Blunt abdominal solid organ injury adult vs pediatric trauma center J Pediatr Surg 2015 Aug 28 pii S0022-3468(15)00526-6 doi
101016jjpedsurg201508012 [Epub ahead of print] Trauma center variation in the management of pediatric patients with blunt abdominal solid organ injury a national trauma data bank analysis Safavi A1 Skarsgard ED2 Rhee P1 Zangbar B1 Kulvatunyou N1 Tang A1 OKeeffe T1 Friese RS1 Joseph B3
bull Pediatric blunt abdominal injury Curr Opin Crit Care 2015 Sep 28 [Epub ahead of print] Pediatric blunt abdominal trauma current management Notrica DM1
bull Pediatric splenic injury management Am J Surg 2015 Jul 31 pii S0002-9610(15)00417-1 doi 101016jamjsurg201506009 [Epub ahead of print] Comparative effectiveness of treatment strategies for severe splenic trauma in the pediatric population Rialon KL1 Englum BR1 Gulack BC1 Guevara CJ2 Bhattacharya SD3 Shapiro ML4 Rice HE5 Scarborough JE4 Adibe OO6
bull Liver pic httpss-media-cache-ak0pinimgcom736x7da50e7da50eb2bb603c99ef6649ff897e26b5jpg bull Solid organ injury non op in peds J Trauma Acute Care Surg 2015 Oct79(4)683-93 doi 101097TA0000000000000808
Nonoperative management of blunt liver and spleen injury in children Evaluation of the ATOMAC guideline using GRADE Notrica DM1 Eubanks JW 3rd Tuggle DW Maxson RT Letton RW Garcia NM Alder AC Lawson KA St Peter SD Megison S Garcia Filion P
bull Pediaric vs nonped trauma ct use J Pediatr 2015 Oct167(4)897-904e3 doi 101016jjpeds201506052 Epub 2015 Jul 29 Variation in Computed Tomography Imaging for Pediatric Injury-Related Emergency Visits Marin JR1 Wang L2 Winger DG2 Mannix RC3
bull Solid organ management in ped population J Trauma Acute Care Surg 2015 Aug79(2)206-14quiz 332 doi 101097TA0000000000000731 Management of children with solid organ injuries after blunt torso trauma Wisner DH1 Kuppermann N Cooper A Menaker J Ehrlich P Kooistra J Mahajan P Lee L Cook LJ Yen K Lillis K Holmes JF
bull Triad of death image httpimageslidesharecdncomdamage-control-resuscitation-1304253390-phpapp0195damage-control-resuscitation-14-728jpgcb=1304235553
bull Tranexamic acid study Eckert MJ Wertin TM Tyner SD et al 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 77852
bull Image care accident httpsuploadwikimediaorgwikipediacommonsthumbee1Car_crash_1jpg1280px-Car_crash_1jpg
References 4 bull httpwwwsurgeryvcuedudivisionsacutesurghtml bull Trauma management Approach to the unstable child
httpwwwuptodatecomcontentstrauma-management-approach-to-the-unstable-childsource=search_resultampsearch=pediatric+trauma+childrenampselectedTitle=17E150
bull Trauma management Unique pediatric considerations httpwwwuptodatecomcontentstrauma-management-unique-pediatric-considerationssource=search_resultampsearch=pediatric+trauma+childrenampselectedTitle=37E150
References 5 bull httpwwwetiquettehellcomsmfindexphptopic=8666360 bull httpwwwstlouischildrensorghealth-care-professionalsems-providers bull httpwwwuchicagokidshospitalorgspecialtiesemergency-medicinespecialhtml bull httpwwwsimsacademyinfoFXpatienthtm bull httptheemtspotcomwp-contentuploads200902another-burn-patient-by-annette-larsonjpg bull httplastangryfancomwp-contentuploads200910Clint-Malarchukjpg bull httpwwwtraumaorgarchiveresusmassivehtml bull httpwwwuptodatecomcontentsimageimageKey=PEDS68694amptopicKey=EM2F6389ampsourc
e=previewampsearch=pediatric+hemorrhagic+shockampselectedTitle=17E150amprank=undefined bull httptheemtspotcomwp-contentuploads200902gcsgif bull httpwwwuptodatecomcontentsimageimageKey=EM2F60409amptopicKey=EM2F6571amprank
=17E150ampsource=see_linkampsearch=traumaamputdPopup=true bull httpwwwuptodatecomcontentsimageimageKey=EM2F80874amptopicKey=EM2F6571amprank
=17E150ampsource=see_linkampsearch=traumaamputdPopup=true bull httpempracticenewswordpresscomcategorynexus-criteria bull httpswwwgooglecomsearchq=pediatric+glasgow+coma+scaleamptbm=ischamptbo=uampsource=uni
vampsa=Xampei=8TiOU7TNC5WuyATp5YG4BQampsqi=2ampved=0CDYQsAQampbiw=1426ampbih=883q=canadian+c-spine+rulesamptbm=ischampfacrc=_ampimgdii=_ampimgrc=WI94QMHgMLTQmM253A3BP5nbsFhNCXK0FM3Bhttp253A252F252Fwwwbmjcom252Fhighwire252Ffilestream252F436003252Ffield_highwire_fragment_image_l252F0jpg3Bhttp253A252F252Fwwwbmjcom252Fcontent252F339252Fbmjb41463B12803B1253
References 5 bull httpwwwuptodatecomcontentsimageimageKey=EM2F76777amptopicKey=EM2F6571amprank
=17E150ampsource=see_linkampsearch=traumaamputdPopup=true bull httpwwwdocumentingrealitycomforumattachmentsf14964898d1246625322-firework-injury-
m80injury1jpg bull httpwwwpediatriceducationorg20050620 bull httpwwwarmstrongmedicalcomindexcfmgoproductdetailsec3ssec19cat61fam515 bull httpwwwuptodatecomcontentsimageimageKey=PEDS61087amptopicKey=ID2F7661ampsource
=outline_linkampsearch=tetanus+prophylaxisamputdPopup=true bull httpwwwafsecafmilsharedmediaphotodbweb110609-F-MJ378-009jpg bull httpwwwuptodatecomcontentsimageimageKey=EM75765amptopicKey= bull EM2F6389ampsource=outline_linkampsearch=massive+transfusion+protocolamputdPopup=true bull httpwwwmotifakecomimagedemotivational-postersmall0910whats-the-question-ignorance-
calvin-and-hobbes-demotivational-poster-1255020127jpg
XXXXBoston study ems peds trauma procedures- limited pediatric procedural exposure (but more adult experience) bull Catchment area 590000
over 1 year bull 555 pediatric ALS
transport ndash 19 blunt trauma ndash 10 penetrating trauma
bull IV 33 bull BMV 5 bull Intubation 3 bull 50 ALS providers average
year ndash IV- 37 ndash Intubation- 03 ndash IO- 006
bull 7 ped ems ndash 13 trauma
bull Critical procedures ndash 101000 peds cases ndash Intubation 671000 ndash IO 51000 ndash 81 successful
Pediatr Emerg Care 2001 Feb17(1)5-9 Pediatric pre-hospital advanced life support care in an urban setting
Babl FE1 Vinci RJ Bauchner H Mottley L
Pediatr Crit Care Med 2015 Oct16(8)e260-7 doi 101097PCC0000000000000505 Pediatric Out-of-Hospital Critical Procedures in the United States
Carlson JN1 Gannon E Mann NC Jacobson KE Dai M Colleran C Wang HE
C-spine bull C-spine injuries rare bull Take pt to closest hospital if over injuries
call for it (ie resuscitation altered mental status) primary guide
bull Mechanism ndash Altered mental status focal neuro change
torticollis substantial torso injury diving high speed auto neck pain underlying predisposing condition Acad Emerg Med 2014 Jan21(1)55-64 doi 101111acem12288
Comparison of outcomes for children with cervical spine injury based on destination hospital from scene of injury Anders JF1 Adelgais K Hoyle JD Jr Olsen C Jaffe DM Leonard JC Pediatric Emergency Care Applied Research Network
(PECARN)
Ann Emerg Med 2011 Aug58(2)145-55 doi 101016jannemergmed201008038 Epub 2010 Oct 29 Factors associated with cervical spine injury in children after blunt trauma
Leonard JC Kuppermann N Olsen C Babcock-Cimpello L Brown K Mahajan P Adelgais KM Anders J Borgialli D Donoghue A Hoyle JD Jr Kim E Leonard JR Lillis KA Nigrovic LE Powell EC Rebella
G Reeves SD Rogers AJ Stankovic C Teshome G Jaffe DM Pediatric Emergency Care Applied Research Network
- Itrsquos Hard to Put a Band-Aid on a Broken Spleen Pediatric Trauma
- Disclosures
- Objectives
- Pediatric Prehospital Care
- Mechanism
- Traumatic Pain Management
- Pediatric Trauma
- Deaths by Mechanism of Injury
- Pediatric Trauma
- Pediatric Trauma
- Airway Differences
- Pediatric-Adult Differences
- Pediatric Challenges
- Prehospital Pediatric Challenges
- Pediatric and Adult Trauma
- Scene Response
- Prehospital Intervention
- Where do you take the patient
- Patient arrives at the EDhellip
- Primary Survey
- Order is critical
- Slide Number 22
- Slide Number 23
- Airway
- Indications for Intubation
- Breathing
- ETT Intubation Basics
- Circulation
- Slide Number 29
- CirculationHemodynamic Changes
- Circulation
- Fluid Resuscitation Algorithm
- Reconsidering Crystalloid Resuscitation
- When to start MTP
- Disability
- Finishing Up the Evaluation
- Bad Scene Responses
- OHCA from Trauma
- Blunt Trauma- No Signs of Life
- OHCA with CPR on Arrival
- Pediatric Trauma
- Questions
- References 1
- References 2
- References 3
- References 4
- References 5
- References 5
- XXXXBoston study ems peds trauma procedures- limited pediatric procedural exposure (but more adult experience)
- C-spine
OHCA with CPR on Arrival
bull 169 children bull 141 deaths bull 69 required cpr on arrival- none survived bull 87 of patients requiring CPR on arrival
expired in the ED bull Of the 28 survivors
ndash 55 of survivors had full neurologic recovery
Pediatric Trauma
bull Fortunately these cases represent only a small fraction of EMS transports
bull Despite a few key differences pediatric trauma care overall is very similar to adult trauma care
Questions
References 1 bull NTDB 2013 pediatric Report bull Monkey bars httpsplaygroundchroniclesfileswordpresscom201307soccerjpg bull Screaming child httpblogsbabycentercomwp-contentuploads201409screaming-child-tantrum-fitjpg bull Pediatric airway image httpwwwcelebritydiagnosiscomwp-contentuploads201003pediatric-airwayjpg bull Child on backboard httpsencrypted-tbn2gstaticcomimagesq=tbnANd9GcQscrDVc8IH4MwkNGF6F1A9p7mSVzik5zrWyNvI-
qSwQT5S3GNyVg bull Elbow fracture httpwwwimageinterpretationcoukimageselbowSUPRACONDYLAR20LAT3jpg bull Bike riding httpsmile-per-daycomwp-contentuploads201412klr03jpg bull Dad and child pic httplaughingsquidcomwp-contentuploads471160jpg bull Weigth estimation inner city Am J Emerg Med 2015 Oct33(10)1364-7 doi 101016jajem201507040 Epub 2015 Jul 29 Weight
estimation in an inner-city pediatric ED the effect of obesity Chavez H1 Peterson RE2 Lo K3 Arel M4
bull Guess weight sign httpmedialiveauctiongroupneti963110572971_1jpgv=8CDDAAF8A5B9E20 bull Broselow tape httpsuploadwikimediaorgwikipediacommons994BTape1jpg bull Parent screaming httpmommyofamonstercomwp-contentuploads201301yellingjpg bull Prehospital pain management Am J Emerg Med 2015 Mar33(3)451-4 doi 101016jajem201412012 Epub 2014 Dec 18
Prehospital pain management of injured children a systematic review of current evidence Samuel N1 Steiner IP2 Shavit I3 bull Prehospital pain ped pain assessment Prehosp Emerg Care 2008 Apr-Jun12(2)182-6 doi 10108010903120801907471 Prehospital
pain assessment in pediatric trauma Izsak E1 Moore JL Stringfellow K Oswanski MF Lindstrom DA Stombaugh HA bull Ped pain management Prehosp Emerg Care 2005 Jan-Mar9(1)40-3 Prehospital pain management in children suffering traumatic
injury Swor R1 McEachin CM Seguin D Grall KH bull Prehospital intervention Allen CJ Teisch LF et al Prehospital care and transportation of pediatric trauma patients J Surg Res 2015
Aug197(2)240-6 JAMA 2000 Feb 9283(6)783-90 bull Effect of out-of-hospital pediatric endotracheal intubation on survival and neurological outcome a controlled clinical trial
Gausche M1 Lewis RJ Stratton SJ Haynes BE Gunter CS Goodrich SM Poore PD McCollough MD Henderson DP Pratt FD Seidel JS
bull Pediatric pain management survey Pediatr Emerg Care 2015 Sep 23 [Epub ahead of print] An Assessment of Newly Identified Barriers to and Enablers for Prehospital Pediatric Pain Management Whitley DE1 Li T Jones CM Cushman JT Williams DM Shah MN
References 2 bull httpwwwuptodatecomcontentsprehospital-pediatrics-and-emergency-medical-services-emsabstract6 bull httpwwwuptodatecomcontentsprehospital-pediatrics-and-emergency-medical-services-emsabstract7 bull Pediatr Crit Care Med 2011 Jul12(4)e166-70 doi 101097PCC0b013e3181f36f6e First responder
performance in pediatric trauma a comparison with an adult cohortBankole S1 Asuncion A Ross S Aghai Z Nollah L Echols H Da-Silva S
bull Drayna pc Browne LR et al Prehospital pediatric care Oppportunities for training treatment and research Prehosp Emerg Care 2015 Jul-Sep 19(3) Epub 2015 Feb 6
bull Pediatr Emerg Care 2001 Feb17(1) 5-9Pediatric pre-hospital advanced life support care in an urban setting Babl FE1 Vinci RJ Bauchner H Mottley L
bull Pediatr Crit Care Med 2015 Oct16(8)e260-7 doi 101097PCC0000000000000505Pediatric Out-of-Hospital Critical Procedures in the United States Carlson JN1 Gannon E Mann NC Jacobson KE Dai M Colleran C Wang HE
bull Pediatr Emerg Care 2009 Aug25(8)508-12 doi 101097PEC0b013e3181b0a0da The efficacy of pediatric advanced life support training in emergency medical service providers Baker TW1 King W Soto W Asher C Stolfi A Rowin ME
bull Sutton RM Case E et al ROC investigators A quantitative analysis of out-of-hospital pediatric and adolescent resuscitation quality A report from the ROC Epistry- Cardiac Arrest Resusciation 201593150-157
bull Resuscitation 2014 Aug85(8)1059-64 doi 101016jresuscitation201403307 Epub 2014 Apr 4 Neurocognitive long term follow-up study on drowned children Suominen PK1 Sutinen N2 Valle S3 Olkkola KT4 Loumlnnqvist T3
bull J Pediatr Surg 2010 Jul45(7)1413-9 doi 101016jjpedsurg200912020 Prehospital cardiopulmonary resuscitation in the pediatric trauma patient Murphy JT1 Jaiswal K Sabella J Vinson L Megison S Maxson RT
References 3 bull Pre atv accident
httpwwwctvnewscapolopoly_fs119871591409741949httpImageimagejpg_genderivativeslandscape_960imagejpg bull atv pic httpswwwutahadvocatescomwp-contentuploads201402atvAccidentLawyerjpg bull Blunt abdominal solid organ injury adult vs pediatric trauma center J Pediatr Surg 2015 Aug 28 pii S0022-3468(15)00526-6 doi
101016jjpedsurg201508012 [Epub ahead of print] Trauma center variation in the management of pediatric patients with blunt abdominal solid organ injury a national trauma data bank analysis Safavi A1 Skarsgard ED2 Rhee P1 Zangbar B1 Kulvatunyou N1 Tang A1 OKeeffe T1 Friese RS1 Joseph B3
bull Pediatric blunt abdominal injury Curr Opin Crit Care 2015 Sep 28 [Epub ahead of print] Pediatric blunt abdominal trauma current management Notrica DM1
bull Pediatric splenic injury management Am J Surg 2015 Jul 31 pii S0002-9610(15)00417-1 doi 101016jamjsurg201506009 [Epub ahead of print] Comparative effectiveness of treatment strategies for severe splenic trauma in the pediatric population Rialon KL1 Englum BR1 Gulack BC1 Guevara CJ2 Bhattacharya SD3 Shapiro ML4 Rice HE5 Scarborough JE4 Adibe OO6
bull Liver pic httpss-media-cache-ak0pinimgcom736x7da50e7da50eb2bb603c99ef6649ff897e26b5jpg bull Solid organ injury non op in peds J Trauma Acute Care Surg 2015 Oct79(4)683-93 doi 101097TA0000000000000808
Nonoperative management of blunt liver and spleen injury in children Evaluation of the ATOMAC guideline using GRADE Notrica DM1 Eubanks JW 3rd Tuggle DW Maxson RT Letton RW Garcia NM Alder AC Lawson KA St Peter SD Megison S Garcia Filion P
bull Pediaric vs nonped trauma ct use J Pediatr 2015 Oct167(4)897-904e3 doi 101016jjpeds201506052 Epub 2015 Jul 29 Variation in Computed Tomography Imaging for Pediatric Injury-Related Emergency Visits Marin JR1 Wang L2 Winger DG2 Mannix RC3
bull Solid organ management in ped population J Trauma Acute Care Surg 2015 Aug79(2)206-14quiz 332 doi 101097TA0000000000000731 Management of children with solid organ injuries after blunt torso trauma Wisner DH1 Kuppermann N Cooper A Menaker J Ehrlich P Kooistra J Mahajan P Lee L Cook LJ Yen K Lillis K Holmes JF
bull Triad of death image httpimageslidesharecdncomdamage-control-resuscitation-1304253390-phpapp0195damage-control-resuscitation-14-728jpgcb=1304235553
bull Tranexamic acid study Eckert MJ Wertin TM Tyner SD et al 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 77852
bull Image care accident httpsuploadwikimediaorgwikipediacommonsthumbee1Car_crash_1jpg1280px-Car_crash_1jpg
References 4 bull httpwwwsurgeryvcuedudivisionsacutesurghtml bull Trauma management Approach to the unstable child
httpwwwuptodatecomcontentstrauma-management-approach-to-the-unstable-childsource=search_resultampsearch=pediatric+trauma+childrenampselectedTitle=17E150
bull Trauma management Unique pediatric considerations httpwwwuptodatecomcontentstrauma-management-unique-pediatric-considerationssource=search_resultampsearch=pediatric+trauma+childrenampselectedTitle=37E150
References 5 bull httpwwwetiquettehellcomsmfindexphptopic=8666360 bull httpwwwstlouischildrensorghealth-care-professionalsems-providers bull httpwwwuchicagokidshospitalorgspecialtiesemergency-medicinespecialhtml bull httpwwwsimsacademyinfoFXpatienthtm bull httptheemtspotcomwp-contentuploads200902another-burn-patient-by-annette-larsonjpg bull httplastangryfancomwp-contentuploads200910Clint-Malarchukjpg bull httpwwwtraumaorgarchiveresusmassivehtml bull httpwwwuptodatecomcontentsimageimageKey=PEDS68694amptopicKey=EM2F6389ampsourc
e=previewampsearch=pediatric+hemorrhagic+shockampselectedTitle=17E150amprank=undefined bull httptheemtspotcomwp-contentuploads200902gcsgif bull httpwwwuptodatecomcontentsimageimageKey=EM2F60409amptopicKey=EM2F6571amprank
=17E150ampsource=see_linkampsearch=traumaamputdPopup=true bull httpwwwuptodatecomcontentsimageimageKey=EM2F80874amptopicKey=EM2F6571amprank
=17E150ampsource=see_linkampsearch=traumaamputdPopup=true bull httpempracticenewswordpresscomcategorynexus-criteria bull httpswwwgooglecomsearchq=pediatric+glasgow+coma+scaleamptbm=ischamptbo=uampsource=uni
vampsa=Xampei=8TiOU7TNC5WuyATp5YG4BQampsqi=2ampved=0CDYQsAQampbiw=1426ampbih=883q=canadian+c-spine+rulesamptbm=ischampfacrc=_ampimgdii=_ampimgrc=WI94QMHgMLTQmM253A3BP5nbsFhNCXK0FM3Bhttp253A252F252Fwwwbmjcom252Fhighwire252Ffilestream252F436003252Ffield_highwire_fragment_image_l252F0jpg3Bhttp253A252F252Fwwwbmjcom252Fcontent252F339252Fbmjb41463B12803B1253
References 5 bull httpwwwuptodatecomcontentsimageimageKey=EM2F76777amptopicKey=EM2F6571amprank
=17E150ampsource=see_linkampsearch=traumaamputdPopup=true bull httpwwwdocumentingrealitycomforumattachmentsf14964898d1246625322-firework-injury-
m80injury1jpg bull httpwwwpediatriceducationorg20050620 bull httpwwwarmstrongmedicalcomindexcfmgoproductdetailsec3ssec19cat61fam515 bull httpwwwuptodatecomcontentsimageimageKey=PEDS61087amptopicKey=ID2F7661ampsource
=outline_linkampsearch=tetanus+prophylaxisamputdPopup=true bull httpwwwafsecafmilsharedmediaphotodbweb110609-F-MJ378-009jpg bull httpwwwuptodatecomcontentsimageimageKey=EM75765amptopicKey= bull EM2F6389ampsource=outline_linkampsearch=massive+transfusion+protocolamputdPopup=true bull httpwwwmotifakecomimagedemotivational-postersmall0910whats-the-question-ignorance-
calvin-and-hobbes-demotivational-poster-1255020127jpg
XXXXBoston study ems peds trauma procedures- limited pediatric procedural exposure (but more adult experience) bull Catchment area 590000
over 1 year bull 555 pediatric ALS
transport ndash 19 blunt trauma ndash 10 penetrating trauma
bull IV 33 bull BMV 5 bull Intubation 3 bull 50 ALS providers average
year ndash IV- 37 ndash Intubation- 03 ndash IO- 006
bull 7 ped ems ndash 13 trauma
bull Critical procedures ndash 101000 peds cases ndash Intubation 671000 ndash IO 51000 ndash 81 successful
Pediatr Emerg Care 2001 Feb17(1)5-9 Pediatric pre-hospital advanced life support care in an urban setting
Babl FE1 Vinci RJ Bauchner H Mottley L
Pediatr Crit Care Med 2015 Oct16(8)e260-7 doi 101097PCC0000000000000505 Pediatric Out-of-Hospital Critical Procedures in the United States
Carlson JN1 Gannon E Mann NC Jacobson KE Dai M Colleran C Wang HE
C-spine bull C-spine injuries rare bull Take pt to closest hospital if over injuries
call for it (ie resuscitation altered mental status) primary guide
bull Mechanism ndash Altered mental status focal neuro change
torticollis substantial torso injury diving high speed auto neck pain underlying predisposing condition Acad Emerg Med 2014 Jan21(1)55-64 doi 101111acem12288
Comparison of outcomes for children with cervical spine injury based on destination hospital from scene of injury Anders JF1 Adelgais K Hoyle JD Jr Olsen C Jaffe DM Leonard JC Pediatric Emergency Care Applied Research Network
(PECARN)
Ann Emerg Med 2011 Aug58(2)145-55 doi 101016jannemergmed201008038 Epub 2010 Oct 29 Factors associated with cervical spine injury in children after blunt trauma
Leonard JC Kuppermann N Olsen C Babcock-Cimpello L Brown K Mahajan P Adelgais KM Anders J Borgialli D Donoghue A Hoyle JD Jr Kim E Leonard JR Lillis KA Nigrovic LE Powell EC Rebella
G Reeves SD Rogers AJ Stankovic C Teshome G Jaffe DM Pediatric Emergency Care Applied Research Network
- Itrsquos Hard to Put a Band-Aid on a Broken Spleen Pediatric Trauma
- Disclosures
- Objectives
- Pediatric Prehospital Care
- Mechanism
- Traumatic Pain Management
- Pediatric Trauma
- Deaths by Mechanism of Injury
- Pediatric Trauma
- Pediatric Trauma
- Airway Differences
- Pediatric-Adult Differences
- Pediatric Challenges
- Prehospital Pediatric Challenges
- Pediatric and Adult Trauma
- Scene Response
- Prehospital Intervention
- Where do you take the patient
- Patient arrives at the EDhellip
- Primary Survey
- Order is critical
- Slide Number 22
- Slide Number 23
- Airway
- Indications for Intubation
- Breathing
- ETT Intubation Basics
- Circulation
- Slide Number 29
- CirculationHemodynamic Changes
- Circulation
- Fluid Resuscitation Algorithm
- Reconsidering Crystalloid Resuscitation
- When to start MTP
- Disability
- Finishing Up the Evaluation
- Bad Scene Responses
- OHCA from Trauma
- Blunt Trauma- No Signs of Life
- OHCA with CPR on Arrival
- Pediatric Trauma
- Questions
- References 1
- References 2
- References 3
- References 4
- References 5
- References 5
- XXXXBoston study ems peds trauma procedures- limited pediatric procedural exposure (but more adult experience)
- C-spine
Pediatric Trauma
bull Fortunately these cases represent only a small fraction of EMS transports
bull Despite a few key differences pediatric trauma care overall is very similar to adult trauma care
Questions
References 1 bull NTDB 2013 pediatric Report bull Monkey bars httpsplaygroundchroniclesfileswordpresscom201307soccerjpg bull Screaming child httpblogsbabycentercomwp-contentuploads201409screaming-child-tantrum-fitjpg bull Pediatric airway image httpwwwcelebritydiagnosiscomwp-contentuploads201003pediatric-airwayjpg bull Child on backboard httpsencrypted-tbn2gstaticcomimagesq=tbnANd9GcQscrDVc8IH4MwkNGF6F1A9p7mSVzik5zrWyNvI-
qSwQT5S3GNyVg bull Elbow fracture httpwwwimageinterpretationcoukimageselbowSUPRACONDYLAR20LAT3jpg bull Bike riding httpsmile-per-daycomwp-contentuploads201412klr03jpg bull Dad and child pic httplaughingsquidcomwp-contentuploads471160jpg bull Weigth estimation inner city Am J Emerg Med 2015 Oct33(10)1364-7 doi 101016jajem201507040 Epub 2015 Jul 29 Weight
estimation in an inner-city pediatric ED the effect of obesity Chavez H1 Peterson RE2 Lo K3 Arel M4
bull Guess weight sign httpmedialiveauctiongroupneti963110572971_1jpgv=8CDDAAF8A5B9E20 bull Broselow tape httpsuploadwikimediaorgwikipediacommons994BTape1jpg bull Parent screaming httpmommyofamonstercomwp-contentuploads201301yellingjpg bull Prehospital pain management Am J Emerg Med 2015 Mar33(3)451-4 doi 101016jajem201412012 Epub 2014 Dec 18
Prehospital pain management of injured children a systematic review of current evidence Samuel N1 Steiner IP2 Shavit I3 bull Prehospital pain ped pain assessment Prehosp Emerg Care 2008 Apr-Jun12(2)182-6 doi 10108010903120801907471 Prehospital
pain assessment in pediatric trauma Izsak E1 Moore JL Stringfellow K Oswanski MF Lindstrom DA Stombaugh HA bull Ped pain management Prehosp Emerg Care 2005 Jan-Mar9(1)40-3 Prehospital pain management in children suffering traumatic
injury Swor R1 McEachin CM Seguin D Grall KH bull Prehospital intervention Allen CJ Teisch LF et al Prehospital care and transportation of pediatric trauma patients J Surg Res 2015
Aug197(2)240-6 JAMA 2000 Feb 9283(6)783-90 bull Effect of out-of-hospital pediatric endotracheal intubation on survival and neurological outcome a controlled clinical trial
Gausche M1 Lewis RJ Stratton SJ Haynes BE Gunter CS Goodrich SM Poore PD McCollough MD Henderson DP Pratt FD Seidel JS
bull Pediatric pain management survey Pediatr Emerg Care 2015 Sep 23 [Epub ahead of print] An Assessment of Newly Identified Barriers to and Enablers for Prehospital Pediatric Pain Management Whitley DE1 Li T Jones CM Cushman JT Williams DM Shah MN
References 2 bull httpwwwuptodatecomcontentsprehospital-pediatrics-and-emergency-medical-services-emsabstract6 bull httpwwwuptodatecomcontentsprehospital-pediatrics-and-emergency-medical-services-emsabstract7 bull Pediatr Crit Care Med 2011 Jul12(4)e166-70 doi 101097PCC0b013e3181f36f6e First responder
performance in pediatric trauma a comparison with an adult cohortBankole S1 Asuncion A Ross S Aghai Z Nollah L Echols H Da-Silva S
bull Drayna pc Browne LR et al Prehospital pediatric care Oppportunities for training treatment and research Prehosp Emerg Care 2015 Jul-Sep 19(3) Epub 2015 Feb 6
bull Pediatr Emerg Care 2001 Feb17(1) 5-9Pediatric pre-hospital advanced life support care in an urban setting Babl FE1 Vinci RJ Bauchner H Mottley L
bull Pediatr Crit Care Med 2015 Oct16(8)e260-7 doi 101097PCC0000000000000505Pediatric Out-of-Hospital Critical Procedures in the United States Carlson JN1 Gannon E Mann NC Jacobson KE Dai M Colleran C Wang HE
bull Pediatr Emerg Care 2009 Aug25(8)508-12 doi 101097PEC0b013e3181b0a0da The efficacy of pediatric advanced life support training in emergency medical service providers Baker TW1 King W Soto W Asher C Stolfi A Rowin ME
bull Sutton RM Case E et al ROC investigators A quantitative analysis of out-of-hospital pediatric and adolescent resuscitation quality A report from the ROC Epistry- Cardiac Arrest Resusciation 201593150-157
bull Resuscitation 2014 Aug85(8)1059-64 doi 101016jresuscitation201403307 Epub 2014 Apr 4 Neurocognitive long term follow-up study on drowned children Suominen PK1 Sutinen N2 Valle S3 Olkkola KT4 Loumlnnqvist T3
bull J Pediatr Surg 2010 Jul45(7)1413-9 doi 101016jjpedsurg200912020 Prehospital cardiopulmonary resuscitation in the pediatric trauma patient Murphy JT1 Jaiswal K Sabella J Vinson L Megison S Maxson RT
References 3 bull Pre atv accident
httpwwwctvnewscapolopoly_fs119871591409741949httpImageimagejpg_genderivativeslandscape_960imagejpg bull atv pic httpswwwutahadvocatescomwp-contentuploads201402atvAccidentLawyerjpg bull Blunt abdominal solid organ injury adult vs pediatric trauma center J Pediatr Surg 2015 Aug 28 pii S0022-3468(15)00526-6 doi
101016jjpedsurg201508012 [Epub ahead of print] Trauma center variation in the management of pediatric patients with blunt abdominal solid organ injury a national trauma data bank analysis Safavi A1 Skarsgard ED2 Rhee P1 Zangbar B1 Kulvatunyou N1 Tang A1 OKeeffe T1 Friese RS1 Joseph B3
bull Pediatric blunt abdominal injury Curr Opin Crit Care 2015 Sep 28 [Epub ahead of print] Pediatric blunt abdominal trauma current management Notrica DM1
bull Pediatric splenic injury management Am J Surg 2015 Jul 31 pii S0002-9610(15)00417-1 doi 101016jamjsurg201506009 [Epub ahead of print] Comparative effectiveness of treatment strategies for severe splenic trauma in the pediatric population Rialon KL1 Englum BR1 Gulack BC1 Guevara CJ2 Bhattacharya SD3 Shapiro ML4 Rice HE5 Scarborough JE4 Adibe OO6
bull Liver pic httpss-media-cache-ak0pinimgcom736x7da50e7da50eb2bb603c99ef6649ff897e26b5jpg bull Solid organ injury non op in peds J Trauma Acute Care Surg 2015 Oct79(4)683-93 doi 101097TA0000000000000808
Nonoperative management of blunt liver and spleen injury in children Evaluation of the ATOMAC guideline using GRADE Notrica DM1 Eubanks JW 3rd Tuggle DW Maxson RT Letton RW Garcia NM Alder AC Lawson KA St Peter SD Megison S Garcia Filion P
bull Pediaric vs nonped trauma ct use J Pediatr 2015 Oct167(4)897-904e3 doi 101016jjpeds201506052 Epub 2015 Jul 29 Variation in Computed Tomography Imaging for Pediatric Injury-Related Emergency Visits Marin JR1 Wang L2 Winger DG2 Mannix RC3
bull Solid organ management in ped population J Trauma Acute Care Surg 2015 Aug79(2)206-14quiz 332 doi 101097TA0000000000000731 Management of children with solid organ injuries after blunt torso trauma Wisner DH1 Kuppermann N Cooper A Menaker J Ehrlich P Kooistra J Mahajan P Lee L Cook LJ Yen K Lillis K Holmes JF
bull Triad of death image httpimageslidesharecdncomdamage-control-resuscitation-1304253390-phpapp0195damage-control-resuscitation-14-728jpgcb=1304235553
bull Tranexamic acid study Eckert MJ Wertin TM Tyner SD et al 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 77852
bull Image care accident httpsuploadwikimediaorgwikipediacommonsthumbee1Car_crash_1jpg1280px-Car_crash_1jpg
References 4 bull httpwwwsurgeryvcuedudivisionsacutesurghtml bull Trauma management Approach to the unstable child
httpwwwuptodatecomcontentstrauma-management-approach-to-the-unstable-childsource=search_resultampsearch=pediatric+trauma+childrenampselectedTitle=17E150
bull Trauma management Unique pediatric considerations httpwwwuptodatecomcontentstrauma-management-unique-pediatric-considerationssource=search_resultampsearch=pediatric+trauma+childrenampselectedTitle=37E150
References 5 bull httpwwwetiquettehellcomsmfindexphptopic=8666360 bull httpwwwstlouischildrensorghealth-care-professionalsems-providers bull httpwwwuchicagokidshospitalorgspecialtiesemergency-medicinespecialhtml bull httpwwwsimsacademyinfoFXpatienthtm bull httptheemtspotcomwp-contentuploads200902another-burn-patient-by-annette-larsonjpg bull httplastangryfancomwp-contentuploads200910Clint-Malarchukjpg bull httpwwwtraumaorgarchiveresusmassivehtml bull httpwwwuptodatecomcontentsimageimageKey=PEDS68694amptopicKey=EM2F6389ampsourc
e=previewampsearch=pediatric+hemorrhagic+shockampselectedTitle=17E150amprank=undefined bull httptheemtspotcomwp-contentuploads200902gcsgif bull httpwwwuptodatecomcontentsimageimageKey=EM2F60409amptopicKey=EM2F6571amprank
=17E150ampsource=see_linkampsearch=traumaamputdPopup=true bull httpwwwuptodatecomcontentsimageimageKey=EM2F80874amptopicKey=EM2F6571amprank
=17E150ampsource=see_linkampsearch=traumaamputdPopup=true bull httpempracticenewswordpresscomcategorynexus-criteria bull httpswwwgooglecomsearchq=pediatric+glasgow+coma+scaleamptbm=ischamptbo=uampsource=uni
vampsa=Xampei=8TiOU7TNC5WuyATp5YG4BQampsqi=2ampved=0CDYQsAQampbiw=1426ampbih=883q=canadian+c-spine+rulesamptbm=ischampfacrc=_ampimgdii=_ampimgrc=WI94QMHgMLTQmM253A3BP5nbsFhNCXK0FM3Bhttp253A252F252Fwwwbmjcom252Fhighwire252Ffilestream252F436003252Ffield_highwire_fragment_image_l252F0jpg3Bhttp253A252F252Fwwwbmjcom252Fcontent252F339252Fbmjb41463B12803B1253
References 5 bull httpwwwuptodatecomcontentsimageimageKey=EM2F76777amptopicKey=EM2F6571amprank
=17E150ampsource=see_linkampsearch=traumaamputdPopup=true bull httpwwwdocumentingrealitycomforumattachmentsf14964898d1246625322-firework-injury-
m80injury1jpg bull httpwwwpediatriceducationorg20050620 bull httpwwwarmstrongmedicalcomindexcfmgoproductdetailsec3ssec19cat61fam515 bull httpwwwuptodatecomcontentsimageimageKey=PEDS61087amptopicKey=ID2F7661ampsource
=outline_linkampsearch=tetanus+prophylaxisamputdPopup=true bull httpwwwafsecafmilsharedmediaphotodbweb110609-F-MJ378-009jpg bull httpwwwuptodatecomcontentsimageimageKey=EM75765amptopicKey= bull EM2F6389ampsource=outline_linkampsearch=massive+transfusion+protocolamputdPopup=true bull httpwwwmotifakecomimagedemotivational-postersmall0910whats-the-question-ignorance-
calvin-and-hobbes-demotivational-poster-1255020127jpg
XXXXBoston study ems peds trauma procedures- limited pediatric procedural exposure (but more adult experience) bull Catchment area 590000
over 1 year bull 555 pediatric ALS
transport ndash 19 blunt trauma ndash 10 penetrating trauma
bull IV 33 bull BMV 5 bull Intubation 3 bull 50 ALS providers average
year ndash IV- 37 ndash Intubation- 03 ndash IO- 006
bull 7 ped ems ndash 13 trauma
bull Critical procedures ndash 101000 peds cases ndash Intubation 671000 ndash IO 51000 ndash 81 successful
Pediatr Emerg Care 2001 Feb17(1)5-9 Pediatric pre-hospital advanced life support care in an urban setting
Babl FE1 Vinci RJ Bauchner H Mottley L
Pediatr Crit Care Med 2015 Oct16(8)e260-7 doi 101097PCC0000000000000505 Pediatric Out-of-Hospital Critical Procedures in the United States
Carlson JN1 Gannon E Mann NC Jacobson KE Dai M Colleran C Wang HE
C-spine bull C-spine injuries rare bull Take pt to closest hospital if over injuries
call for it (ie resuscitation altered mental status) primary guide
bull Mechanism ndash Altered mental status focal neuro change
torticollis substantial torso injury diving high speed auto neck pain underlying predisposing condition Acad Emerg Med 2014 Jan21(1)55-64 doi 101111acem12288
Comparison of outcomes for children with cervical spine injury based on destination hospital from scene of injury Anders JF1 Adelgais K Hoyle JD Jr Olsen C Jaffe DM Leonard JC Pediatric Emergency Care Applied Research Network
(PECARN)
Ann Emerg Med 2011 Aug58(2)145-55 doi 101016jannemergmed201008038 Epub 2010 Oct 29 Factors associated with cervical spine injury in children after blunt trauma
Leonard JC Kuppermann N Olsen C Babcock-Cimpello L Brown K Mahajan P Adelgais KM Anders J Borgialli D Donoghue A Hoyle JD Jr Kim E Leonard JR Lillis KA Nigrovic LE Powell EC Rebella
G Reeves SD Rogers AJ Stankovic C Teshome G Jaffe DM Pediatric Emergency Care Applied Research Network
- Itrsquos Hard to Put a Band-Aid on a Broken Spleen Pediatric Trauma
- Disclosures
- Objectives
- Pediatric Prehospital Care
- Mechanism
- Traumatic Pain Management
- Pediatric Trauma
- Deaths by Mechanism of Injury
- Pediatric Trauma
- Pediatric Trauma
- Airway Differences
- Pediatric-Adult Differences
- Pediatric Challenges
- Prehospital Pediatric Challenges
- Pediatric and Adult Trauma
- Scene Response
- Prehospital Intervention
- Where do you take the patient
- Patient arrives at the EDhellip
- Primary Survey
- Order is critical
- Slide Number 22
- Slide Number 23
- Airway
- Indications for Intubation
- Breathing
- ETT Intubation Basics
- Circulation
- Slide Number 29
- CirculationHemodynamic Changes
- Circulation
- Fluid Resuscitation Algorithm
- Reconsidering Crystalloid Resuscitation
- When to start MTP
- Disability
- Finishing Up the Evaluation
- Bad Scene Responses
- OHCA from Trauma
- Blunt Trauma- No Signs of Life
- OHCA with CPR on Arrival
- Pediatric Trauma
- Questions
- References 1
- References 2
- References 3
- References 4
- References 5
- References 5
- XXXXBoston study ems peds trauma procedures- limited pediatric procedural exposure (but more adult experience)
- C-spine
Questions
References 1 bull NTDB 2013 pediatric Report bull Monkey bars httpsplaygroundchroniclesfileswordpresscom201307soccerjpg bull Screaming child httpblogsbabycentercomwp-contentuploads201409screaming-child-tantrum-fitjpg bull Pediatric airway image httpwwwcelebritydiagnosiscomwp-contentuploads201003pediatric-airwayjpg bull Child on backboard httpsencrypted-tbn2gstaticcomimagesq=tbnANd9GcQscrDVc8IH4MwkNGF6F1A9p7mSVzik5zrWyNvI-
qSwQT5S3GNyVg bull Elbow fracture httpwwwimageinterpretationcoukimageselbowSUPRACONDYLAR20LAT3jpg bull Bike riding httpsmile-per-daycomwp-contentuploads201412klr03jpg bull Dad and child pic httplaughingsquidcomwp-contentuploads471160jpg bull Weigth estimation inner city Am J Emerg Med 2015 Oct33(10)1364-7 doi 101016jajem201507040 Epub 2015 Jul 29 Weight
estimation in an inner-city pediatric ED the effect of obesity Chavez H1 Peterson RE2 Lo K3 Arel M4
bull Guess weight sign httpmedialiveauctiongroupneti963110572971_1jpgv=8CDDAAF8A5B9E20 bull Broselow tape httpsuploadwikimediaorgwikipediacommons994BTape1jpg bull Parent screaming httpmommyofamonstercomwp-contentuploads201301yellingjpg bull Prehospital pain management Am J Emerg Med 2015 Mar33(3)451-4 doi 101016jajem201412012 Epub 2014 Dec 18
Prehospital pain management of injured children a systematic review of current evidence Samuel N1 Steiner IP2 Shavit I3 bull Prehospital pain ped pain assessment Prehosp Emerg Care 2008 Apr-Jun12(2)182-6 doi 10108010903120801907471 Prehospital
pain assessment in pediatric trauma Izsak E1 Moore JL Stringfellow K Oswanski MF Lindstrom DA Stombaugh HA bull Ped pain management Prehosp Emerg Care 2005 Jan-Mar9(1)40-3 Prehospital pain management in children suffering traumatic
injury Swor R1 McEachin CM Seguin D Grall KH bull Prehospital intervention Allen CJ Teisch LF et al Prehospital care and transportation of pediatric trauma patients J Surg Res 2015
Aug197(2)240-6 JAMA 2000 Feb 9283(6)783-90 bull Effect of out-of-hospital pediatric endotracheal intubation on survival and neurological outcome a controlled clinical trial
Gausche M1 Lewis RJ Stratton SJ Haynes BE Gunter CS Goodrich SM Poore PD McCollough MD Henderson DP Pratt FD Seidel JS
bull Pediatric pain management survey Pediatr Emerg Care 2015 Sep 23 [Epub ahead of print] An Assessment of Newly Identified Barriers to and Enablers for Prehospital Pediatric Pain Management Whitley DE1 Li T Jones CM Cushman JT Williams DM Shah MN
References 2 bull httpwwwuptodatecomcontentsprehospital-pediatrics-and-emergency-medical-services-emsabstract6 bull httpwwwuptodatecomcontentsprehospital-pediatrics-and-emergency-medical-services-emsabstract7 bull Pediatr Crit Care Med 2011 Jul12(4)e166-70 doi 101097PCC0b013e3181f36f6e First responder
performance in pediatric trauma a comparison with an adult cohortBankole S1 Asuncion A Ross S Aghai Z Nollah L Echols H Da-Silva S
bull Drayna pc Browne LR et al Prehospital pediatric care Oppportunities for training treatment and research Prehosp Emerg Care 2015 Jul-Sep 19(3) Epub 2015 Feb 6
bull Pediatr Emerg Care 2001 Feb17(1) 5-9Pediatric pre-hospital advanced life support care in an urban setting Babl FE1 Vinci RJ Bauchner H Mottley L
bull Pediatr Crit Care Med 2015 Oct16(8)e260-7 doi 101097PCC0000000000000505Pediatric Out-of-Hospital Critical Procedures in the United States Carlson JN1 Gannon E Mann NC Jacobson KE Dai M Colleran C Wang HE
bull Pediatr Emerg Care 2009 Aug25(8)508-12 doi 101097PEC0b013e3181b0a0da The efficacy of pediatric advanced life support training in emergency medical service providers Baker TW1 King W Soto W Asher C Stolfi A Rowin ME
bull Sutton RM Case E et al ROC investigators A quantitative analysis of out-of-hospital pediatric and adolescent resuscitation quality A report from the ROC Epistry- Cardiac Arrest Resusciation 201593150-157
bull Resuscitation 2014 Aug85(8)1059-64 doi 101016jresuscitation201403307 Epub 2014 Apr 4 Neurocognitive long term follow-up study on drowned children Suominen PK1 Sutinen N2 Valle S3 Olkkola KT4 Loumlnnqvist T3
bull J Pediatr Surg 2010 Jul45(7)1413-9 doi 101016jjpedsurg200912020 Prehospital cardiopulmonary resuscitation in the pediatric trauma patient Murphy JT1 Jaiswal K Sabella J Vinson L Megison S Maxson RT
References 3 bull Pre atv accident
httpwwwctvnewscapolopoly_fs119871591409741949httpImageimagejpg_genderivativeslandscape_960imagejpg bull atv pic httpswwwutahadvocatescomwp-contentuploads201402atvAccidentLawyerjpg bull Blunt abdominal solid organ injury adult vs pediatric trauma center J Pediatr Surg 2015 Aug 28 pii S0022-3468(15)00526-6 doi
101016jjpedsurg201508012 [Epub ahead of print] Trauma center variation in the management of pediatric patients with blunt abdominal solid organ injury a national trauma data bank analysis Safavi A1 Skarsgard ED2 Rhee P1 Zangbar B1 Kulvatunyou N1 Tang A1 OKeeffe T1 Friese RS1 Joseph B3
bull Pediatric blunt abdominal injury Curr Opin Crit Care 2015 Sep 28 [Epub ahead of print] Pediatric blunt abdominal trauma current management Notrica DM1
bull Pediatric splenic injury management Am J Surg 2015 Jul 31 pii S0002-9610(15)00417-1 doi 101016jamjsurg201506009 [Epub ahead of print] Comparative effectiveness of treatment strategies for severe splenic trauma in the pediatric population Rialon KL1 Englum BR1 Gulack BC1 Guevara CJ2 Bhattacharya SD3 Shapiro ML4 Rice HE5 Scarborough JE4 Adibe OO6
bull Liver pic httpss-media-cache-ak0pinimgcom736x7da50e7da50eb2bb603c99ef6649ff897e26b5jpg bull Solid organ injury non op in peds J Trauma Acute Care Surg 2015 Oct79(4)683-93 doi 101097TA0000000000000808
Nonoperative management of blunt liver and spleen injury in children Evaluation of the ATOMAC guideline using GRADE Notrica DM1 Eubanks JW 3rd Tuggle DW Maxson RT Letton RW Garcia NM Alder AC Lawson KA St Peter SD Megison S Garcia Filion P
bull Pediaric vs nonped trauma ct use J Pediatr 2015 Oct167(4)897-904e3 doi 101016jjpeds201506052 Epub 2015 Jul 29 Variation in Computed Tomography Imaging for Pediatric Injury-Related Emergency Visits Marin JR1 Wang L2 Winger DG2 Mannix RC3
bull Solid organ management in ped population J Trauma Acute Care Surg 2015 Aug79(2)206-14quiz 332 doi 101097TA0000000000000731 Management of children with solid organ injuries after blunt torso trauma Wisner DH1 Kuppermann N Cooper A Menaker J Ehrlich P Kooistra J Mahajan P Lee L Cook LJ Yen K Lillis K Holmes JF
bull Triad of death image httpimageslidesharecdncomdamage-control-resuscitation-1304253390-phpapp0195damage-control-resuscitation-14-728jpgcb=1304235553
bull Tranexamic acid study Eckert MJ Wertin TM Tyner SD et al 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 77852
bull Image care accident httpsuploadwikimediaorgwikipediacommonsthumbee1Car_crash_1jpg1280px-Car_crash_1jpg
References 4 bull httpwwwsurgeryvcuedudivisionsacutesurghtml bull Trauma management Approach to the unstable child
httpwwwuptodatecomcontentstrauma-management-approach-to-the-unstable-childsource=search_resultampsearch=pediatric+trauma+childrenampselectedTitle=17E150
bull Trauma management Unique pediatric considerations httpwwwuptodatecomcontentstrauma-management-unique-pediatric-considerationssource=search_resultampsearch=pediatric+trauma+childrenampselectedTitle=37E150
References 5 bull httpwwwetiquettehellcomsmfindexphptopic=8666360 bull httpwwwstlouischildrensorghealth-care-professionalsems-providers bull httpwwwuchicagokidshospitalorgspecialtiesemergency-medicinespecialhtml bull httpwwwsimsacademyinfoFXpatienthtm bull httptheemtspotcomwp-contentuploads200902another-burn-patient-by-annette-larsonjpg bull httplastangryfancomwp-contentuploads200910Clint-Malarchukjpg bull httpwwwtraumaorgarchiveresusmassivehtml bull httpwwwuptodatecomcontentsimageimageKey=PEDS68694amptopicKey=EM2F6389ampsourc
e=previewampsearch=pediatric+hemorrhagic+shockampselectedTitle=17E150amprank=undefined bull httptheemtspotcomwp-contentuploads200902gcsgif bull httpwwwuptodatecomcontentsimageimageKey=EM2F60409amptopicKey=EM2F6571amprank
=17E150ampsource=see_linkampsearch=traumaamputdPopup=true bull httpwwwuptodatecomcontentsimageimageKey=EM2F80874amptopicKey=EM2F6571amprank
=17E150ampsource=see_linkampsearch=traumaamputdPopup=true bull httpempracticenewswordpresscomcategorynexus-criteria bull httpswwwgooglecomsearchq=pediatric+glasgow+coma+scaleamptbm=ischamptbo=uampsource=uni
vampsa=Xampei=8TiOU7TNC5WuyATp5YG4BQampsqi=2ampved=0CDYQsAQampbiw=1426ampbih=883q=canadian+c-spine+rulesamptbm=ischampfacrc=_ampimgdii=_ampimgrc=WI94QMHgMLTQmM253A3BP5nbsFhNCXK0FM3Bhttp253A252F252Fwwwbmjcom252Fhighwire252Ffilestream252F436003252Ffield_highwire_fragment_image_l252F0jpg3Bhttp253A252F252Fwwwbmjcom252Fcontent252F339252Fbmjb41463B12803B1253
References 5 bull httpwwwuptodatecomcontentsimageimageKey=EM2F76777amptopicKey=EM2F6571amprank
=17E150ampsource=see_linkampsearch=traumaamputdPopup=true bull httpwwwdocumentingrealitycomforumattachmentsf14964898d1246625322-firework-injury-
m80injury1jpg bull httpwwwpediatriceducationorg20050620 bull httpwwwarmstrongmedicalcomindexcfmgoproductdetailsec3ssec19cat61fam515 bull httpwwwuptodatecomcontentsimageimageKey=PEDS61087amptopicKey=ID2F7661ampsource
=outline_linkampsearch=tetanus+prophylaxisamputdPopup=true bull httpwwwafsecafmilsharedmediaphotodbweb110609-F-MJ378-009jpg bull httpwwwuptodatecomcontentsimageimageKey=EM75765amptopicKey= bull EM2F6389ampsource=outline_linkampsearch=massive+transfusion+protocolamputdPopup=true bull httpwwwmotifakecomimagedemotivational-postersmall0910whats-the-question-ignorance-
calvin-and-hobbes-demotivational-poster-1255020127jpg
XXXXBoston study ems peds trauma procedures- limited pediatric procedural exposure (but more adult experience) bull Catchment area 590000
over 1 year bull 555 pediatric ALS
transport ndash 19 blunt trauma ndash 10 penetrating trauma
bull IV 33 bull BMV 5 bull Intubation 3 bull 50 ALS providers average
year ndash IV- 37 ndash Intubation- 03 ndash IO- 006
bull 7 ped ems ndash 13 trauma
bull Critical procedures ndash 101000 peds cases ndash Intubation 671000 ndash IO 51000 ndash 81 successful
Pediatr Emerg Care 2001 Feb17(1)5-9 Pediatric pre-hospital advanced life support care in an urban setting
Babl FE1 Vinci RJ Bauchner H Mottley L
Pediatr Crit Care Med 2015 Oct16(8)e260-7 doi 101097PCC0000000000000505 Pediatric Out-of-Hospital Critical Procedures in the United States
Carlson JN1 Gannon E Mann NC Jacobson KE Dai M Colleran C Wang HE
C-spine bull C-spine injuries rare bull Take pt to closest hospital if over injuries
call for it (ie resuscitation altered mental status) primary guide
bull Mechanism ndash Altered mental status focal neuro change
torticollis substantial torso injury diving high speed auto neck pain underlying predisposing condition Acad Emerg Med 2014 Jan21(1)55-64 doi 101111acem12288
Comparison of outcomes for children with cervical spine injury based on destination hospital from scene of injury Anders JF1 Adelgais K Hoyle JD Jr Olsen C Jaffe DM Leonard JC Pediatric Emergency Care Applied Research Network
(PECARN)
Ann Emerg Med 2011 Aug58(2)145-55 doi 101016jannemergmed201008038 Epub 2010 Oct 29 Factors associated with cervical spine injury in children after blunt trauma
Leonard JC Kuppermann N Olsen C Babcock-Cimpello L Brown K Mahajan P Adelgais KM Anders J Borgialli D Donoghue A Hoyle JD Jr Kim E Leonard JR Lillis KA Nigrovic LE Powell EC Rebella
G Reeves SD Rogers AJ Stankovic C Teshome G Jaffe DM Pediatric Emergency Care Applied Research Network
- Itrsquos Hard to Put a Band-Aid on a Broken Spleen Pediatric Trauma
- Disclosures
- Objectives
- Pediatric Prehospital Care
- Mechanism
- Traumatic Pain Management
- Pediatric Trauma
- Deaths by Mechanism of Injury
- Pediatric Trauma
- Pediatric Trauma
- Airway Differences
- Pediatric-Adult Differences
- Pediatric Challenges
- Prehospital Pediatric Challenges
- Pediatric and Adult Trauma
- Scene Response
- Prehospital Intervention
- Where do you take the patient
- Patient arrives at the EDhellip
- Primary Survey
- Order is critical
- Slide Number 22
- Slide Number 23
- Airway
- Indications for Intubation
- Breathing
- ETT Intubation Basics
- Circulation
- Slide Number 29
- CirculationHemodynamic Changes
- Circulation
- Fluid Resuscitation Algorithm
- Reconsidering Crystalloid Resuscitation
- When to start MTP
- Disability
- Finishing Up the Evaluation
- Bad Scene Responses
- OHCA from Trauma
- Blunt Trauma- No Signs of Life
- OHCA with CPR on Arrival
- Pediatric Trauma
- Questions
- References 1
- References 2
- References 3
- References 4
- References 5
- References 5
- XXXXBoston study ems peds trauma procedures- limited pediatric procedural exposure (but more adult experience)
- C-spine
References 1 bull NTDB 2013 pediatric Report bull Monkey bars httpsplaygroundchroniclesfileswordpresscom201307soccerjpg bull Screaming child httpblogsbabycentercomwp-contentuploads201409screaming-child-tantrum-fitjpg bull Pediatric airway image httpwwwcelebritydiagnosiscomwp-contentuploads201003pediatric-airwayjpg bull Child on backboard httpsencrypted-tbn2gstaticcomimagesq=tbnANd9GcQscrDVc8IH4MwkNGF6F1A9p7mSVzik5zrWyNvI-
qSwQT5S3GNyVg bull Elbow fracture httpwwwimageinterpretationcoukimageselbowSUPRACONDYLAR20LAT3jpg bull Bike riding httpsmile-per-daycomwp-contentuploads201412klr03jpg bull Dad and child pic httplaughingsquidcomwp-contentuploads471160jpg bull Weigth estimation inner city Am J Emerg Med 2015 Oct33(10)1364-7 doi 101016jajem201507040 Epub 2015 Jul 29 Weight
estimation in an inner-city pediatric ED the effect of obesity Chavez H1 Peterson RE2 Lo K3 Arel M4
bull Guess weight sign httpmedialiveauctiongroupneti963110572971_1jpgv=8CDDAAF8A5B9E20 bull Broselow tape httpsuploadwikimediaorgwikipediacommons994BTape1jpg bull Parent screaming httpmommyofamonstercomwp-contentuploads201301yellingjpg bull Prehospital pain management Am J Emerg Med 2015 Mar33(3)451-4 doi 101016jajem201412012 Epub 2014 Dec 18
Prehospital pain management of injured children a systematic review of current evidence Samuel N1 Steiner IP2 Shavit I3 bull Prehospital pain ped pain assessment Prehosp Emerg Care 2008 Apr-Jun12(2)182-6 doi 10108010903120801907471 Prehospital
pain assessment in pediatric trauma Izsak E1 Moore JL Stringfellow K Oswanski MF Lindstrom DA Stombaugh HA bull Ped pain management Prehosp Emerg Care 2005 Jan-Mar9(1)40-3 Prehospital pain management in children suffering traumatic
injury Swor R1 McEachin CM Seguin D Grall KH bull Prehospital intervention Allen CJ Teisch LF et al Prehospital care and transportation of pediatric trauma patients J Surg Res 2015
Aug197(2)240-6 JAMA 2000 Feb 9283(6)783-90 bull Effect of out-of-hospital pediatric endotracheal intubation on survival and neurological outcome a controlled clinical trial
Gausche M1 Lewis RJ Stratton SJ Haynes BE Gunter CS Goodrich SM Poore PD McCollough MD Henderson DP Pratt FD Seidel JS
bull Pediatric pain management survey Pediatr Emerg Care 2015 Sep 23 [Epub ahead of print] An Assessment of Newly Identified Barriers to and Enablers for Prehospital Pediatric Pain Management Whitley DE1 Li T Jones CM Cushman JT Williams DM Shah MN
References 2 bull httpwwwuptodatecomcontentsprehospital-pediatrics-and-emergency-medical-services-emsabstract6 bull httpwwwuptodatecomcontentsprehospital-pediatrics-and-emergency-medical-services-emsabstract7 bull Pediatr Crit Care Med 2011 Jul12(4)e166-70 doi 101097PCC0b013e3181f36f6e First responder
performance in pediatric trauma a comparison with an adult cohortBankole S1 Asuncion A Ross S Aghai Z Nollah L Echols H Da-Silva S
bull Drayna pc Browne LR et al Prehospital pediatric care Oppportunities for training treatment and research Prehosp Emerg Care 2015 Jul-Sep 19(3) Epub 2015 Feb 6
bull Pediatr Emerg Care 2001 Feb17(1) 5-9Pediatric pre-hospital advanced life support care in an urban setting Babl FE1 Vinci RJ Bauchner H Mottley L
bull Pediatr Crit Care Med 2015 Oct16(8)e260-7 doi 101097PCC0000000000000505Pediatric Out-of-Hospital Critical Procedures in the United States Carlson JN1 Gannon E Mann NC Jacobson KE Dai M Colleran C Wang HE
bull Pediatr Emerg Care 2009 Aug25(8)508-12 doi 101097PEC0b013e3181b0a0da The efficacy of pediatric advanced life support training in emergency medical service providers Baker TW1 King W Soto W Asher C Stolfi A Rowin ME
bull Sutton RM Case E et al ROC investigators A quantitative analysis of out-of-hospital pediatric and adolescent resuscitation quality A report from the ROC Epistry- Cardiac Arrest Resusciation 201593150-157
bull Resuscitation 2014 Aug85(8)1059-64 doi 101016jresuscitation201403307 Epub 2014 Apr 4 Neurocognitive long term follow-up study on drowned children Suominen PK1 Sutinen N2 Valle S3 Olkkola KT4 Loumlnnqvist T3
bull J Pediatr Surg 2010 Jul45(7)1413-9 doi 101016jjpedsurg200912020 Prehospital cardiopulmonary resuscitation in the pediatric trauma patient Murphy JT1 Jaiswal K Sabella J Vinson L Megison S Maxson RT
References 3 bull Pre atv accident
httpwwwctvnewscapolopoly_fs119871591409741949httpImageimagejpg_genderivativeslandscape_960imagejpg bull atv pic httpswwwutahadvocatescomwp-contentuploads201402atvAccidentLawyerjpg bull Blunt abdominal solid organ injury adult vs pediatric trauma center J Pediatr Surg 2015 Aug 28 pii S0022-3468(15)00526-6 doi
101016jjpedsurg201508012 [Epub ahead of print] Trauma center variation in the management of pediatric patients with blunt abdominal solid organ injury a national trauma data bank analysis Safavi A1 Skarsgard ED2 Rhee P1 Zangbar B1 Kulvatunyou N1 Tang A1 OKeeffe T1 Friese RS1 Joseph B3
bull Pediatric blunt abdominal injury Curr Opin Crit Care 2015 Sep 28 [Epub ahead of print] Pediatric blunt abdominal trauma current management Notrica DM1
bull Pediatric splenic injury management Am J Surg 2015 Jul 31 pii S0002-9610(15)00417-1 doi 101016jamjsurg201506009 [Epub ahead of print] Comparative effectiveness of treatment strategies for severe splenic trauma in the pediatric population Rialon KL1 Englum BR1 Gulack BC1 Guevara CJ2 Bhattacharya SD3 Shapiro ML4 Rice HE5 Scarborough JE4 Adibe OO6
bull Liver pic httpss-media-cache-ak0pinimgcom736x7da50e7da50eb2bb603c99ef6649ff897e26b5jpg bull Solid organ injury non op in peds J Trauma Acute Care Surg 2015 Oct79(4)683-93 doi 101097TA0000000000000808
Nonoperative management of blunt liver and spleen injury in children Evaluation of the ATOMAC guideline using GRADE Notrica DM1 Eubanks JW 3rd Tuggle DW Maxson RT Letton RW Garcia NM Alder AC Lawson KA St Peter SD Megison S Garcia Filion P
bull Pediaric vs nonped trauma ct use J Pediatr 2015 Oct167(4)897-904e3 doi 101016jjpeds201506052 Epub 2015 Jul 29 Variation in Computed Tomography Imaging for Pediatric Injury-Related Emergency Visits Marin JR1 Wang L2 Winger DG2 Mannix RC3
bull Solid organ management in ped population J Trauma Acute Care Surg 2015 Aug79(2)206-14quiz 332 doi 101097TA0000000000000731 Management of children with solid organ injuries after blunt torso trauma Wisner DH1 Kuppermann N Cooper A Menaker J Ehrlich P Kooistra J Mahajan P Lee L Cook LJ Yen K Lillis K Holmes JF
bull Triad of death image httpimageslidesharecdncomdamage-control-resuscitation-1304253390-phpapp0195damage-control-resuscitation-14-728jpgcb=1304235553
bull Tranexamic acid study Eckert MJ Wertin TM Tyner SD et al 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 77852
bull Image care accident httpsuploadwikimediaorgwikipediacommonsthumbee1Car_crash_1jpg1280px-Car_crash_1jpg
References 4 bull httpwwwsurgeryvcuedudivisionsacutesurghtml bull Trauma management Approach to the unstable child
httpwwwuptodatecomcontentstrauma-management-approach-to-the-unstable-childsource=search_resultampsearch=pediatric+trauma+childrenampselectedTitle=17E150
bull Trauma management Unique pediatric considerations httpwwwuptodatecomcontentstrauma-management-unique-pediatric-considerationssource=search_resultampsearch=pediatric+trauma+childrenampselectedTitle=37E150
References 5 bull httpwwwetiquettehellcomsmfindexphptopic=8666360 bull httpwwwstlouischildrensorghealth-care-professionalsems-providers bull httpwwwuchicagokidshospitalorgspecialtiesemergency-medicinespecialhtml bull httpwwwsimsacademyinfoFXpatienthtm bull httptheemtspotcomwp-contentuploads200902another-burn-patient-by-annette-larsonjpg bull httplastangryfancomwp-contentuploads200910Clint-Malarchukjpg bull httpwwwtraumaorgarchiveresusmassivehtml bull httpwwwuptodatecomcontentsimageimageKey=PEDS68694amptopicKey=EM2F6389ampsourc
e=previewampsearch=pediatric+hemorrhagic+shockampselectedTitle=17E150amprank=undefined bull httptheemtspotcomwp-contentuploads200902gcsgif bull httpwwwuptodatecomcontentsimageimageKey=EM2F60409amptopicKey=EM2F6571amprank
=17E150ampsource=see_linkampsearch=traumaamputdPopup=true bull httpwwwuptodatecomcontentsimageimageKey=EM2F80874amptopicKey=EM2F6571amprank
=17E150ampsource=see_linkampsearch=traumaamputdPopup=true bull httpempracticenewswordpresscomcategorynexus-criteria bull httpswwwgooglecomsearchq=pediatric+glasgow+coma+scaleamptbm=ischamptbo=uampsource=uni
vampsa=Xampei=8TiOU7TNC5WuyATp5YG4BQampsqi=2ampved=0CDYQsAQampbiw=1426ampbih=883q=canadian+c-spine+rulesamptbm=ischampfacrc=_ampimgdii=_ampimgrc=WI94QMHgMLTQmM253A3BP5nbsFhNCXK0FM3Bhttp253A252F252Fwwwbmjcom252Fhighwire252Ffilestream252F436003252Ffield_highwire_fragment_image_l252F0jpg3Bhttp253A252F252Fwwwbmjcom252Fcontent252F339252Fbmjb41463B12803B1253
References 5 bull httpwwwuptodatecomcontentsimageimageKey=EM2F76777amptopicKey=EM2F6571amprank
=17E150ampsource=see_linkampsearch=traumaamputdPopup=true bull httpwwwdocumentingrealitycomforumattachmentsf14964898d1246625322-firework-injury-
m80injury1jpg bull httpwwwpediatriceducationorg20050620 bull httpwwwarmstrongmedicalcomindexcfmgoproductdetailsec3ssec19cat61fam515 bull httpwwwuptodatecomcontentsimageimageKey=PEDS61087amptopicKey=ID2F7661ampsource
=outline_linkampsearch=tetanus+prophylaxisamputdPopup=true bull httpwwwafsecafmilsharedmediaphotodbweb110609-F-MJ378-009jpg bull httpwwwuptodatecomcontentsimageimageKey=EM75765amptopicKey= bull EM2F6389ampsource=outline_linkampsearch=massive+transfusion+protocolamputdPopup=true bull httpwwwmotifakecomimagedemotivational-postersmall0910whats-the-question-ignorance-
calvin-and-hobbes-demotivational-poster-1255020127jpg
XXXXBoston study ems peds trauma procedures- limited pediatric procedural exposure (but more adult experience) bull Catchment area 590000
over 1 year bull 555 pediatric ALS
transport ndash 19 blunt trauma ndash 10 penetrating trauma
bull IV 33 bull BMV 5 bull Intubation 3 bull 50 ALS providers average
year ndash IV- 37 ndash Intubation- 03 ndash IO- 006
bull 7 ped ems ndash 13 trauma
bull Critical procedures ndash 101000 peds cases ndash Intubation 671000 ndash IO 51000 ndash 81 successful
Pediatr Emerg Care 2001 Feb17(1)5-9 Pediatric pre-hospital advanced life support care in an urban setting
Babl FE1 Vinci RJ Bauchner H Mottley L
Pediatr Crit Care Med 2015 Oct16(8)e260-7 doi 101097PCC0000000000000505 Pediatric Out-of-Hospital Critical Procedures in the United States
Carlson JN1 Gannon E Mann NC Jacobson KE Dai M Colleran C Wang HE
C-spine bull C-spine injuries rare bull Take pt to closest hospital if over injuries
call for it (ie resuscitation altered mental status) primary guide
bull Mechanism ndash Altered mental status focal neuro change
torticollis substantial torso injury diving high speed auto neck pain underlying predisposing condition Acad Emerg Med 2014 Jan21(1)55-64 doi 101111acem12288
Comparison of outcomes for children with cervical spine injury based on destination hospital from scene of injury Anders JF1 Adelgais K Hoyle JD Jr Olsen C Jaffe DM Leonard JC Pediatric Emergency Care Applied Research Network
(PECARN)
Ann Emerg Med 2011 Aug58(2)145-55 doi 101016jannemergmed201008038 Epub 2010 Oct 29 Factors associated with cervical spine injury in children after blunt trauma
Leonard JC Kuppermann N Olsen C Babcock-Cimpello L Brown K Mahajan P Adelgais KM Anders J Borgialli D Donoghue A Hoyle JD Jr Kim E Leonard JR Lillis KA Nigrovic LE Powell EC Rebella
G Reeves SD Rogers AJ Stankovic C Teshome G Jaffe DM Pediatric Emergency Care Applied Research Network
- Itrsquos Hard to Put a Band-Aid on a Broken Spleen Pediatric Trauma
- Disclosures
- Objectives
- Pediatric Prehospital Care
- Mechanism
- Traumatic Pain Management
- Pediatric Trauma
- Deaths by Mechanism of Injury
- Pediatric Trauma
- Pediatric Trauma
- Airway Differences
- Pediatric-Adult Differences
- Pediatric Challenges
- Prehospital Pediatric Challenges
- Pediatric and Adult Trauma
- Scene Response
- Prehospital Intervention
- Where do you take the patient
- Patient arrives at the EDhellip
- Primary Survey
- Order is critical
- Slide Number 22
- Slide Number 23
- Airway
- Indications for Intubation
- Breathing
- ETT Intubation Basics
- Circulation
- Slide Number 29
- CirculationHemodynamic Changes
- Circulation
- Fluid Resuscitation Algorithm
- Reconsidering Crystalloid Resuscitation
- When to start MTP
- Disability
- Finishing Up the Evaluation
- Bad Scene Responses
- OHCA from Trauma
- Blunt Trauma- No Signs of Life
- OHCA with CPR on Arrival
- Pediatric Trauma
- Questions
- References 1
- References 2
- References 3
- References 4
- References 5
- References 5
- XXXXBoston study ems peds trauma procedures- limited pediatric procedural exposure (but more adult experience)
- C-spine
References 2 bull httpwwwuptodatecomcontentsprehospital-pediatrics-and-emergency-medical-services-emsabstract6 bull httpwwwuptodatecomcontentsprehospital-pediatrics-and-emergency-medical-services-emsabstract7 bull Pediatr Crit Care Med 2011 Jul12(4)e166-70 doi 101097PCC0b013e3181f36f6e First responder
performance in pediatric trauma a comparison with an adult cohortBankole S1 Asuncion A Ross S Aghai Z Nollah L Echols H Da-Silva S
bull Drayna pc Browne LR et al Prehospital pediatric care Oppportunities for training treatment and research Prehosp Emerg Care 2015 Jul-Sep 19(3) Epub 2015 Feb 6
bull Pediatr Emerg Care 2001 Feb17(1) 5-9Pediatric pre-hospital advanced life support care in an urban setting Babl FE1 Vinci RJ Bauchner H Mottley L
bull Pediatr Crit Care Med 2015 Oct16(8)e260-7 doi 101097PCC0000000000000505Pediatric Out-of-Hospital Critical Procedures in the United States Carlson JN1 Gannon E Mann NC Jacobson KE Dai M Colleran C Wang HE
bull Pediatr Emerg Care 2009 Aug25(8)508-12 doi 101097PEC0b013e3181b0a0da The efficacy of pediatric advanced life support training in emergency medical service providers Baker TW1 King W Soto W Asher C Stolfi A Rowin ME
bull Sutton RM Case E et al ROC investigators A quantitative analysis of out-of-hospital pediatric and adolescent resuscitation quality A report from the ROC Epistry- Cardiac Arrest Resusciation 201593150-157
bull Resuscitation 2014 Aug85(8)1059-64 doi 101016jresuscitation201403307 Epub 2014 Apr 4 Neurocognitive long term follow-up study on drowned children Suominen PK1 Sutinen N2 Valle S3 Olkkola KT4 Loumlnnqvist T3
bull J Pediatr Surg 2010 Jul45(7)1413-9 doi 101016jjpedsurg200912020 Prehospital cardiopulmonary resuscitation in the pediatric trauma patient Murphy JT1 Jaiswal K Sabella J Vinson L Megison S Maxson RT
References 3 bull Pre atv accident
httpwwwctvnewscapolopoly_fs119871591409741949httpImageimagejpg_genderivativeslandscape_960imagejpg bull atv pic httpswwwutahadvocatescomwp-contentuploads201402atvAccidentLawyerjpg bull Blunt abdominal solid organ injury adult vs pediatric trauma center J Pediatr Surg 2015 Aug 28 pii S0022-3468(15)00526-6 doi
101016jjpedsurg201508012 [Epub ahead of print] Trauma center variation in the management of pediatric patients with blunt abdominal solid organ injury a national trauma data bank analysis Safavi A1 Skarsgard ED2 Rhee P1 Zangbar B1 Kulvatunyou N1 Tang A1 OKeeffe T1 Friese RS1 Joseph B3
bull Pediatric blunt abdominal injury Curr Opin Crit Care 2015 Sep 28 [Epub ahead of print] Pediatric blunt abdominal trauma current management Notrica DM1
bull Pediatric splenic injury management Am J Surg 2015 Jul 31 pii S0002-9610(15)00417-1 doi 101016jamjsurg201506009 [Epub ahead of print] Comparative effectiveness of treatment strategies for severe splenic trauma in the pediatric population Rialon KL1 Englum BR1 Gulack BC1 Guevara CJ2 Bhattacharya SD3 Shapiro ML4 Rice HE5 Scarborough JE4 Adibe OO6
bull Liver pic httpss-media-cache-ak0pinimgcom736x7da50e7da50eb2bb603c99ef6649ff897e26b5jpg bull Solid organ injury non op in peds J Trauma Acute Care Surg 2015 Oct79(4)683-93 doi 101097TA0000000000000808
Nonoperative management of blunt liver and spleen injury in children Evaluation of the ATOMAC guideline using GRADE Notrica DM1 Eubanks JW 3rd Tuggle DW Maxson RT Letton RW Garcia NM Alder AC Lawson KA St Peter SD Megison S Garcia Filion P
bull Pediaric vs nonped trauma ct use J Pediatr 2015 Oct167(4)897-904e3 doi 101016jjpeds201506052 Epub 2015 Jul 29 Variation in Computed Tomography Imaging for Pediatric Injury-Related Emergency Visits Marin JR1 Wang L2 Winger DG2 Mannix RC3
bull Solid organ management in ped population J Trauma Acute Care Surg 2015 Aug79(2)206-14quiz 332 doi 101097TA0000000000000731 Management of children with solid organ injuries after blunt torso trauma Wisner DH1 Kuppermann N Cooper A Menaker J Ehrlich P Kooistra J Mahajan P Lee L Cook LJ Yen K Lillis K Holmes JF
bull Triad of death image httpimageslidesharecdncomdamage-control-resuscitation-1304253390-phpapp0195damage-control-resuscitation-14-728jpgcb=1304235553
bull Tranexamic acid study Eckert MJ Wertin TM Tyner SD et al 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 77852
bull Image care accident httpsuploadwikimediaorgwikipediacommonsthumbee1Car_crash_1jpg1280px-Car_crash_1jpg
References 4 bull httpwwwsurgeryvcuedudivisionsacutesurghtml bull Trauma management Approach to the unstable child
httpwwwuptodatecomcontentstrauma-management-approach-to-the-unstable-childsource=search_resultampsearch=pediatric+trauma+childrenampselectedTitle=17E150
bull Trauma management Unique pediatric considerations httpwwwuptodatecomcontentstrauma-management-unique-pediatric-considerationssource=search_resultampsearch=pediatric+trauma+childrenampselectedTitle=37E150
References 5 bull httpwwwetiquettehellcomsmfindexphptopic=8666360 bull httpwwwstlouischildrensorghealth-care-professionalsems-providers bull httpwwwuchicagokidshospitalorgspecialtiesemergency-medicinespecialhtml bull httpwwwsimsacademyinfoFXpatienthtm bull httptheemtspotcomwp-contentuploads200902another-burn-patient-by-annette-larsonjpg bull httplastangryfancomwp-contentuploads200910Clint-Malarchukjpg bull httpwwwtraumaorgarchiveresusmassivehtml bull httpwwwuptodatecomcontentsimageimageKey=PEDS68694amptopicKey=EM2F6389ampsourc
e=previewampsearch=pediatric+hemorrhagic+shockampselectedTitle=17E150amprank=undefined bull httptheemtspotcomwp-contentuploads200902gcsgif bull httpwwwuptodatecomcontentsimageimageKey=EM2F60409amptopicKey=EM2F6571amprank
=17E150ampsource=see_linkampsearch=traumaamputdPopup=true bull httpwwwuptodatecomcontentsimageimageKey=EM2F80874amptopicKey=EM2F6571amprank
=17E150ampsource=see_linkampsearch=traumaamputdPopup=true bull httpempracticenewswordpresscomcategorynexus-criteria bull httpswwwgooglecomsearchq=pediatric+glasgow+coma+scaleamptbm=ischamptbo=uampsource=uni
vampsa=Xampei=8TiOU7TNC5WuyATp5YG4BQampsqi=2ampved=0CDYQsAQampbiw=1426ampbih=883q=canadian+c-spine+rulesamptbm=ischampfacrc=_ampimgdii=_ampimgrc=WI94QMHgMLTQmM253A3BP5nbsFhNCXK0FM3Bhttp253A252F252Fwwwbmjcom252Fhighwire252Ffilestream252F436003252Ffield_highwire_fragment_image_l252F0jpg3Bhttp253A252F252Fwwwbmjcom252Fcontent252F339252Fbmjb41463B12803B1253
References 5 bull httpwwwuptodatecomcontentsimageimageKey=EM2F76777amptopicKey=EM2F6571amprank
=17E150ampsource=see_linkampsearch=traumaamputdPopup=true bull httpwwwdocumentingrealitycomforumattachmentsf14964898d1246625322-firework-injury-
m80injury1jpg bull httpwwwpediatriceducationorg20050620 bull httpwwwarmstrongmedicalcomindexcfmgoproductdetailsec3ssec19cat61fam515 bull httpwwwuptodatecomcontentsimageimageKey=PEDS61087amptopicKey=ID2F7661ampsource
=outline_linkampsearch=tetanus+prophylaxisamputdPopup=true bull httpwwwafsecafmilsharedmediaphotodbweb110609-F-MJ378-009jpg bull httpwwwuptodatecomcontentsimageimageKey=EM75765amptopicKey= bull EM2F6389ampsource=outline_linkampsearch=massive+transfusion+protocolamputdPopup=true bull httpwwwmotifakecomimagedemotivational-postersmall0910whats-the-question-ignorance-
calvin-and-hobbes-demotivational-poster-1255020127jpg
XXXXBoston study ems peds trauma procedures- limited pediatric procedural exposure (but more adult experience) bull Catchment area 590000
over 1 year bull 555 pediatric ALS
transport ndash 19 blunt trauma ndash 10 penetrating trauma
bull IV 33 bull BMV 5 bull Intubation 3 bull 50 ALS providers average
year ndash IV- 37 ndash Intubation- 03 ndash IO- 006
bull 7 ped ems ndash 13 trauma
bull Critical procedures ndash 101000 peds cases ndash Intubation 671000 ndash IO 51000 ndash 81 successful
Pediatr Emerg Care 2001 Feb17(1)5-9 Pediatric pre-hospital advanced life support care in an urban setting
Babl FE1 Vinci RJ Bauchner H Mottley L
Pediatr Crit Care Med 2015 Oct16(8)e260-7 doi 101097PCC0000000000000505 Pediatric Out-of-Hospital Critical Procedures in the United States
Carlson JN1 Gannon E Mann NC Jacobson KE Dai M Colleran C Wang HE
C-spine bull C-spine injuries rare bull Take pt to closest hospital if over injuries
call for it (ie resuscitation altered mental status) primary guide
bull Mechanism ndash Altered mental status focal neuro change
torticollis substantial torso injury diving high speed auto neck pain underlying predisposing condition Acad Emerg Med 2014 Jan21(1)55-64 doi 101111acem12288
Comparison of outcomes for children with cervical spine injury based on destination hospital from scene of injury Anders JF1 Adelgais K Hoyle JD Jr Olsen C Jaffe DM Leonard JC Pediatric Emergency Care Applied Research Network
(PECARN)
Ann Emerg Med 2011 Aug58(2)145-55 doi 101016jannemergmed201008038 Epub 2010 Oct 29 Factors associated with cervical spine injury in children after blunt trauma
Leonard JC Kuppermann N Olsen C Babcock-Cimpello L Brown K Mahajan P Adelgais KM Anders J Borgialli D Donoghue A Hoyle JD Jr Kim E Leonard JR Lillis KA Nigrovic LE Powell EC Rebella
G Reeves SD Rogers AJ Stankovic C Teshome G Jaffe DM Pediatric Emergency Care Applied Research Network
- Itrsquos Hard to Put a Band-Aid on a Broken Spleen Pediatric Trauma
- Disclosures
- Objectives
- Pediatric Prehospital Care
- Mechanism
- Traumatic Pain Management
- Pediatric Trauma
- Deaths by Mechanism of Injury
- Pediatric Trauma
- Pediatric Trauma
- Airway Differences
- Pediatric-Adult Differences
- Pediatric Challenges
- Prehospital Pediatric Challenges
- Pediatric and Adult Trauma
- Scene Response
- Prehospital Intervention
- Where do you take the patient
- Patient arrives at the EDhellip
- Primary Survey
- Order is critical
- Slide Number 22
- Slide Number 23
- Airway
- Indications for Intubation
- Breathing
- ETT Intubation Basics
- Circulation
- Slide Number 29
- CirculationHemodynamic Changes
- Circulation
- Fluid Resuscitation Algorithm
- Reconsidering Crystalloid Resuscitation
- When to start MTP
- Disability
- Finishing Up the Evaluation
- Bad Scene Responses
- OHCA from Trauma
- Blunt Trauma- No Signs of Life
- OHCA with CPR on Arrival
- Pediatric Trauma
- Questions
- References 1
- References 2
- References 3
- References 4
- References 5
- References 5
- XXXXBoston study ems peds trauma procedures- limited pediatric procedural exposure (but more adult experience)
- C-spine
References 3 bull Pre atv accident
httpwwwctvnewscapolopoly_fs119871591409741949httpImageimagejpg_genderivativeslandscape_960imagejpg bull atv pic httpswwwutahadvocatescomwp-contentuploads201402atvAccidentLawyerjpg bull Blunt abdominal solid organ injury adult vs pediatric trauma center J Pediatr Surg 2015 Aug 28 pii S0022-3468(15)00526-6 doi
101016jjpedsurg201508012 [Epub ahead of print] Trauma center variation in the management of pediatric patients with blunt abdominal solid organ injury a national trauma data bank analysis Safavi A1 Skarsgard ED2 Rhee P1 Zangbar B1 Kulvatunyou N1 Tang A1 OKeeffe T1 Friese RS1 Joseph B3
bull Pediatric blunt abdominal injury Curr Opin Crit Care 2015 Sep 28 [Epub ahead of print] Pediatric blunt abdominal trauma current management Notrica DM1
bull Pediatric splenic injury management Am J Surg 2015 Jul 31 pii S0002-9610(15)00417-1 doi 101016jamjsurg201506009 [Epub ahead of print] Comparative effectiveness of treatment strategies for severe splenic trauma in the pediatric population Rialon KL1 Englum BR1 Gulack BC1 Guevara CJ2 Bhattacharya SD3 Shapiro ML4 Rice HE5 Scarborough JE4 Adibe OO6
bull Liver pic httpss-media-cache-ak0pinimgcom736x7da50e7da50eb2bb603c99ef6649ff897e26b5jpg bull Solid organ injury non op in peds J Trauma Acute Care Surg 2015 Oct79(4)683-93 doi 101097TA0000000000000808
Nonoperative management of blunt liver and spleen injury in children Evaluation of the ATOMAC guideline using GRADE Notrica DM1 Eubanks JW 3rd Tuggle DW Maxson RT Letton RW Garcia NM Alder AC Lawson KA St Peter SD Megison S Garcia Filion P
bull Pediaric vs nonped trauma ct use J Pediatr 2015 Oct167(4)897-904e3 doi 101016jjpeds201506052 Epub 2015 Jul 29 Variation in Computed Tomography Imaging for Pediatric Injury-Related Emergency Visits Marin JR1 Wang L2 Winger DG2 Mannix RC3
bull Solid organ management in ped population J Trauma Acute Care Surg 2015 Aug79(2)206-14quiz 332 doi 101097TA0000000000000731 Management of children with solid organ injuries after blunt torso trauma Wisner DH1 Kuppermann N Cooper A Menaker J Ehrlich P Kooistra J Mahajan P Lee L Cook LJ Yen K Lillis K Holmes JF
bull Triad of death image httpimageslidesharecdncomdamage-control-resuscitation-1304253390-phpapp0195damage-control-resuscitation-14-728jpgcb=1304235553
bull Tranexamic acid study Eckert MJ Wertin TM Tyner SD et al 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 77852
bull Image care accident httpsuploadwikimediaorgwikipediacommonsthumbee1Car_crash_1jpg1280px-Car_crash_1jpg
References 4 bull httpwwwsurgeryvcuedudivisionsacutesurghtml bull Trauma management Approach to the unstable child
httpwwwuptodatecomcontentstrauma-management-approach-to-the-unstable-childsource=search_resultampsearch=pediatric+trauma+childrenampselectedTitle=17E150
bull Trauma management Unique pediatric considerations httpwwwuptodatecomcontentstrauma-management-unique-pediatric-considerationssource=search_resultampsearch=pediatric+trauma+childrenampselectedTitle=37E150
References 5 bull httpwwwetiquettehellcomsmfindexphptopic=8666360 bull httpwwwstlouischildrensorghealth-care-professionalsems-providers bull httpwwwuchicagokidshospitalorgspecialtiesemergency-medicinespecialhtml bull httpwwwsimsacademyinfoFXpatienthtm bull httptheemtspotcomwp-contentuploads200902another-burn-patient-by-annette-larsonjpg bull httplastangryfancomwp-contentuploads200910Clint-Malarchukjpg bull httpwwwtraumaorgarchiveresusmassivehtml bull httpwwwuptodatecomcontentsimageimageKey=PEDS68694amptopicKey=EM2F6389ampsourc
e=previewampsearch=pediatric+hemorrhagic+shockampselectedTitle=17E150amprank=undefined bull httptheemtspotcomwp-contentuploads200902gcsgif bull httpwwwuptodatecomcontentsimageimageKey=EM2F60409amptopicKey=EM2F6571amprank
=17E150ampsource=see_linkampsearch=traumaamputdPopup=true bull httpwwwuptodatecomcontentsimageimageKey=EM2F80874amptopicKey=EM2F6571amprank
=17E150ampsource=see_linkampsearch=traumaamputdPopup=true bull httpempracticenewswordpresscomcategorynexus-criteria bull httpswwwgooglecomsearchq=pediatric+glasgow+coma+scaleamptbm=ischamptbo=uampsource=uni
vampsa=Xampei=8TiOU7TNC5WuyATp5YG4BQampsqi=2ampved=0CDYQsAQampbiw=1426ampbih=883q=canadian+c-spine+rulesamptbm=ischampfacrc=_ampimgdii=_ampimgrc=WI94QMHgMLTQmM253A3BP5nbsFhNCXK0FM3Bhttp253A252F252Fwwwbmjcom252Fhighwire252Ffilestream252F436003252Ffield_highwire_fragment_image_l252F0jpg3Bhttp253A252F252Fwwwbmjcom252Fcontent252F339252Fbmjb41463B12803B1253
References 5 bull httpwwwuptodatecomcontentsimageimageKey=EM2F76777amptopicKey=EM2F6571amprank
=17E150ampsource=see_linkampsearch=traumaamputdPopup=true bull httpwwwdocumentingrealitycomforumattachmentsf14964898d1246625322-firework-injury-
m80injury1jpg bull httpwwwpediatriceducationorg20050620 bull httpwwwarmstrongmedicalcomindexcfmgoproductdetailsec3ssec19cat61fam515 bull httpwwwuptodatecomcontentsimageimageKey=PEDS61087amptopicKey=ID2F7661ampsource
=outline_linkampsearch=tetanus+prophylaxisamputdPopup=true bull httpwwwafsecafmilsharedmediaphotodbweb110609-F-MJ378-009jpg bull httpwwwuptodatecomcontentsimageimageKey=EM75765amptopicKey= bull EM2F6389ampsource=outline_linkampsearch=massive+transfusion+protocolamputdPopup=true bull httpwwwmotifakecomimagedemotivational-postersmall0910whats-the-question-ignorance-
calvin-and-hobbes-demotivational-poster-1255020127jpg
XXXXBoston study ems peds trauma procedures- limited pediatric procedural exposure (but more adult experience) bull Catchment area 590000
over 1 year bull 555 pediatric ALS
transport ndash 19 blunt trauma ndash 10 penetrating trauma
bull IV 33 bull BMV 5 bull Intubation 3 bull 50 ALS providers average
year ndash IV- 37 ndash Intubation- 03 ndash IO- 006
bull 7 ped ems ndash 13 trauma
bull Critical procedures ndash 101000 peds cases ndash Intubation 671000 ndash IO 51000 ndash 81 successful
Pediatr Emerg Care 2001 Feb17(1)5-9 Pediatric pre-hospital advanced life support care in an urban setting
Babl FE1 Vinci RJ Bauchner H Mottley L
Pediatr Crit Care Med 2015 Oct16(8)e260-7 doi 101097PCC0000000000000505 Pediatric Out-of-Hospital Critical Procedures in the United States
Carlson JN1 Gannon E Mann NC Jacobson KE Dai M Colleran C Wang HE
C-spine bull C-spine injuries rare bull Take pt to closest hospital if over injuries
call for it (ie resuscitation altered mental status) primary guide
bull Mechanism ndash Altered mental status focal neuro change
torticollis substantial torso injury diving high speed auto neck pain underlying predisposing condition Acad Emerg Med 2014 Jan21(1)55-64 doi 101111acem12288
Comparison of outcomes for children with cervical spine injury based on destination hospital from scene of injury Anders JF1 Adelgais K Hoyle JD Jr Olsen C Jaffe DM Leonard JC Pediatric Emergency Care Applied Research Network
(PECARN)
Ann Emerg Med 2011 Aug58(2)145-55 doi 101016jannemergmed201008038 Epub 2010 Oct 29 Factors associated with cervical spine injury in children after blunt trauma
Leonard JC Kuppermann N Olsen C Babcock-Cimpello L Brown K Mahajan P Adelgais KM Anders J Borgialli D Donoghue A Hoyle JD Jr Kim E Leonard JR Lillis KA Nigrovic LE Powell EC Rebella
G Reeves SD Rogers AJ Stankovic C Teshome G Jaffe DM Pediatric Emergency Care Applied Research Network
- Itrsquos Hard to Put a Band-Aid on a Broken Spleen Pediatric Trauma
- Disclosures
- Objectives
- Pediatric Prehospital Care
- Mechanism
- Traumatic Pain Management
- Pediatric Trauma
- Deaths by Mechanism of Injury
- Pediatric Trauma
- Pediatric Trauma
- Airway Differences
- Pediatric-Adult Differences
- Pediatric Challenges
- Prehospital Pediatric Challenges
- Pediatric and Adult Trauma
- Scene Response
- Prehospital Intervention
- Where do you take the patient
- Patient arrives at the EDhellip
- Primary Survey
- Order is critical
- Slide Number 22
- Slide Number 23
- Airway
- Indications for Intubation
- Breathing
- ETT Intubation Basics
- Circulation
- Slide Number 29
- CirculationHemodynamic Changes
- Circulation
- Fluid Resuscitation Algorithm
- Reconsidering Crystalloid Resuscitation
- When to start MTP
- Disability
- Finishing Up the Evaluation
- Bad Scene Responses
- OHCA from Trauma
- Blunt Trauma- No Signs of Life
- OHCA with CPR on Arrival
- Pediatric Trauma
- Questions
- References 1
- References 2
- References 3
- References 4
- References 5
- References 5
- XXXXBoston study ems peds trauma procedures- limited pediatric procedural exposure (but more adult experience)
- C-spine
References 4 bull httpwwwsurgeryvcuedudivisionsacutesurghtml bull Trauma management Approach to the unstable child
httpwwwuptodatecomcontentstrauma-management-approach-to-the-unstable-childsource=search_resultampsearch=pediatric+trauma+childrenampselectedTitle=17E150
bull Trauma management Unique pediatric considerations httpwwwuptodatecomcontentstrauma-management-unique-pediatric-considerationssource=search_resultampsearch=pediatric+trauma+childrenampselectedTitle=37E150
References 5 bull httpwwwetiquettehellcomsmfindexphptopic=8666360 bull httpwwwstlouischildrensorghealth-care-professionalsems-providers bull httpwwwuchicagokidshospitalorgspecialtiesemergency-medicinespecialhtml bull httpwwwsimsacademyinfoFXpatienthtm bull httptheemtspotcomwp-contentuploads200902another-burn-patient-by-annette-larsonjpg bull httplastangryfancomwp-contentuploads200910Clint-Malarchukjpg bull httpwwwtraumaorgarchiveresusmassivehtml bull httpwwwuptodatecomcontentsimageimageKey=PEDS68694amptopicKey=EM2F6389ampsourc
e=previewampsearch=pediatric+hemorrhagic+shockampselectedTitle=17E150amprank=undefined bull httptheemtspotcomwp-contentuploads200902gcsgif bull httpwwwuptodatecomcontentsimageimageKey=EM2F60409amptopicKey=EM2F6571amprank
=17E150ampsource=see_linkampsearch=traumaamputdPopup=true bull httpwwwuptodatecomcontentsimageimageKey=EM2F80874amptopicKey=EM2F6571amprank
=17E150ampsource=see_linkampsearch=traumaamputdPopup=true bull httpempracticenewswordpresscomcategorynexus-criteria bull httpswwwgooglecomsearchq=pediatric+glasgow+coma+scaleamptbm=ischamptbo=uampsource=uni
vampsa=Xampei=8TiOU7TNC5WuyATp5YG4BQampsqi=2ampved=0CDYQsAQampbiw=1426ampbih=883q=canadian+c-spine+rulesamptbm=ischampfacrc=_ampimgdii=_ampimgrc=WI94QMHgMLTQmM253A3BP5nbsFhNCXK0FM3Bhttp253A252F252Fwwwbmjcom252Fhighwire252Ffilestream252F436003252Ffield_highwire_fragment_image_l252F0jpg3Bhttp253A252F252Fwwwbmjcom252Fcontent252F339252Fbmjb41463B12803B1253
References 5 bull httpwwwuptodatecomcontentsimageimageKey=EM2F76777amptopicKey=EM2F6571amprank
=17E150ampsource=see_linkampsearch=traumaamputdPopup=true bull httpwwwdocumentingrealitycomforumattachmentsf14964898d1246625322-firework-injury-
m80injury1jpg bull httpwwwpediatriceducationorg20050620 bull httpwwwarmstrongmedicalcomindexcfmgoproductdetailsec3ssec19cat61fam515 bull httpwwwuptodatecomcontentsimageimageKey=PEDS61087amptopicKey=ID2F7661ampsource
=outline_linkampsearch=tetanus+prophylaxisamputdPopup=true bull httpwwwafsecafmilsharedmediaphotodbweb110609-F-MJ378-009jpg bull httpwwwuptodatecomcontentsimageimageKey=EM75765amptopicKey= bull EM2F6389ampsource=outline_linkampsearch=massive+transfusion+protocolamputdPopup=true bull httpwwwmotifakecomimagedemotivational-postersmall0910whats-the-question-ignorance-
calvin-and-hobbes-demotivational-poster-1255020127jpg
XXXXBoston study ems peds trauma procedures- limited pediatric procedural exposure (but more adult experience) bull Catchment area 590000
over 1 year bull 555 pediatric ALS
transport ndash 19 blunt trauma ndash 10 penetrating trauma
bull IV 33 bull BMV 5 bull Intubation 3 bull 50 ALS providers average
year ndash IV- 37 ndash Intubation- 03 ndash IO- 006
bull 7 ped ems ndash 13 trauma
bull Critical procedures ndash 101000 peds cases ndash Intubation 671000 ndash IO 51000 ndash 81 successful
Pediatr Emerg Care 2001 Feb17(1)5-9 Pediatric pre-hospital advanced life support care in an urban setting
Babl FE1 Vinci RJ Bauchner H Mottley L
Pediatr Crit Care Med 2015 Oct16(8)e260-7 doi 101097PCC0000000000000505 Pediatric Out-of-Hospital Critical Procedures in the United States
Carlson JN1 Gannon E Mann NC Jacobson KE Dai M Colleran C Wang HE
C-spine bull C-spine injuries rare bull Take pt to closest hospital if over injuries
call for it (ie resuscitation altered mental status) primary guide
bull Mechanism ndash Altered mental status focal neuro change
torticollis substantial torso injury diving high speed auto neck pain underlying predisposing condition Acad Emerg Med 2014 Jan21(1)55-64 doi 101111acem12288
Comparison of outcomes for children with cervical spine injury based on destination hospital from scene of injury Anders JF1 Adelgais K Hoyle JD Jr Olsen C Jaffe DM Leonard JC Pediatric Emergency Care Applied Research Network
(PECARN)
Ann Emerg Med 2011 Aug58(2)145-55 doi 101016jannemergmed201008038 Epub 2010 Oct 29 Factors associated with cervical spine injury in children after blunt trauma
Leonard JC Kuppermann N Olsen C Babcock-Cimpello L Brown K Mahajan P Adelgais KM Anders J Borgialli D Donoghue A Hoyle JD Jr Kim E Leonard JR Lillis KA Nigrovic LE Powell EC Rebella
G Reeves SD Rogers AJ Stankovic C Teshome G Jaffe DM Pediatric Emergency Care Applied Research Network
- Itrsquos Hard to Put a Band-Aid on a Broken Spleen Pediatric Trauma
- Disclosures
- Objectives
- Pediatric Prehospital Care
- Mechanism
- Traumatic Pain Management
- Pediatric Trauma
- Deaths by Mechanism of Injury
- Pediatric Trauma
- Pediatric Trauma
- Airway Differences
- Pediatric-Adult Differences
- Pediatric Challenges
- Prehospital Pediatric Challenges
- Pediatric and Adult Trauma
- Scene Response
- Prehospital Intervention
- Where do you take the patient
- Patient arrives at the EDhellip
- Primary Survey
- Order is critical
- Slide Number 22
- Slide Number 23
- Airway
- Indications for Intubation
- Breathing
- ETT Intubation Basics
- Circulation
- Slide Number 29
- CirculationHemodynamic Changes
- Circulation
- Fluid Resuscitation Algorithm
- Reconsidering Crystalloid Resuscitation
- When to start MTP
- Disability
- Finishing Up the Evaluation
- Bad Scene Responses
- OHCA from Trauma
- Blunt Trauma- No Signs of Life
- OHCA with CPR on Arrival
- Pediatric Trauma
- Questions
- References 1
- References 2
- References 3
- References 4
- References 5
- References 5
- XXXXBoston study ems peds trauma procedures- limited pediatric procedural exposure (but more adult experience)
- C-spine
References 5 bull httpwwwetiquettehellcomsmfindexphptopic=8666360 bull httpwwwstlouischildrensorghealth-care-professionalsems-providers bull httpwwwuchicagokidshospitalorgspecialtiesemergency-medicinespecialhtml bull httpwwwsimsacademyinfoFXpatienthtm bull httptheemtspotcomwp-contentuploads200902another-burn-patient-by-annette-larsonjpg bull httplastangryfancomwp-contentuploads200910Clint-Malarchukjpg bull httpwwwtraumaorgarchiveresusmassivehtml bull httpwwwuptodatecomcontentsimageimageKey=PEDS68694amptopicKey=EM2F6389ampsourc
e=previewampsearch=pediatric+hemorrhagic+shockampselectedTitle=17E150amprank=undefined bull httptheemtspotcomwp-contentuploads200902gcsgif bull httpwwwuptodatecomcontentsimageimageKey=EM2F60409amptopicKey=EM2F6571amprank
=17E150ampsource=see_linkampsearch=traumaamputdPopup=true bull httpwwwuptodatecomcontentsimageimageKey=EM2F80874amptopicKey=EM2F6571amprank
=17E150ampsource=see_linkampsearch=traumaamputdPopup=true bull httpempracticenewswordpresscomcategorynexus-criteria bull httpswwwgooglecomsearchq=pediatric+glasgow+coma+scaleamptbm=ischamptbo=uampsource=uni
vampsa=Xampei=8TiOU7TNC5WuyATp5YG4BQampsqi=2ampved=0CDYQsAQampbiw=1426ampbih=883q=canadian+c-spine+rulesamptbm=ischampfacrc=_ampimgdii=_ampimgrc=WI94QMHgMLTQmM253A3BP5nbsFhNCXK0FM3Bhttp253A252F252Fwwwbmjcom252Fhighwire252Ffilestream252F436003252Ffield_highwire_fragment_image_l252F0jpg3Bhttp253A252F252Fwwwbmjcom252Fcontent252F339252Fbmjb41463B12803B1253
References 5 bull httpwwwuptodatecomcontentsimageimageKey=EM2F76777amptopicKey=EM2F6571amprank
=17E150ampsource=see_linkampsearch=traumaamputdPopup=true bull httpwwwdocumentingrealitycomforumattachmentsf14964898d1246625322-firework-injury-
m80injury1jpg bull httpwwwpediatriceducationorg20050620 bull httpwwwarmstrongmedicalcomindexcfmgoproductdetailsec3ssec19cat61fam515 bull httpwwwuptodatecomcontentsimageimageKey=PEDS61087amptopicKey=ID2F7661ampsource
=outline_linkampsearch=tetanus+prophylaxisamputdPopup=true bull httpwwwafsecafmilsharedmediaphotodbweb110609-F-MJ378-009jpg bull httpwwwuptodatecomcontentsimageimageKey=EM75765amptopicKey= bull EM2F6389ampsource=outline_linkampsearch=massive+transfusion+protocolamputdPopup=true bull httpwwwmotifakecomimagedemotivational-postersmall0910whats-the-question-ignorance-
calvin-and-hobbes-demotivational-poster-1255020127jpg
XXXXBoston study ems peds trauma procedures- limited pediatric procedural exposure (but more adult experience) bull Catchment area 590000
over 1 year bull 555 pediatric ALS
transport ndash 19 blunt trauma ndash 10 penetrating trauma
bull IV 33 bull BMV 5 bull Intubation 3 bull 50 ALS providers average
year ndash IV- 37 ndash Intubation- 03 ndash IO- 006
bull 7 ped ems ndash 13 trauma
bull Critical procedures ndash 101000 peds cases ndash Intubation 671000 ndash IO 51000 ndash 81 successful
Pediatr Emerg Care 2001 Feb17(1)5-9 Pediatric pre-hospital advanced life support care in an urban setting
Babl FE1 Vinci RJ Bauchner H Mottley L
Pediatr Crit Care Med 2015 Oct16(8)e260-7 doi 101097PCC0000000000000505 Pediatric Out-of-Hospital Critical Procedures in the United States
Carlson JN1 Gannon E Mann NC Jacobson KE Dai M Colleran C Wang HE
C-spine bull C-spine injuries rare bull Take pt to closest hospital if over injuries
call for it (ie resuscitation altered mental status) primary guide
bull Mechanism ndash Altered mental status focal neuro change
torticollis substantial torso injury diving high speed auto neck pain underlying predisposing condition Acad Emerg Med 2014 Jan21(1)55-64 doi 101111acem12288
Comparison of outcomes for children with cervical spine injury based on destination hospital from scene of injury Anders JF1 Adelgais K Hoyle JD Jr Olsen C Jaffe DM Leonard JC Pediatric Emergency Care Applied Research Network
(PECARN)
Ann Emerg Med 2011 Aug58(2)145-55 doi 101016jannemergmed201008038 Epub 2010 Oct 29 Factors associated with cervical spine injury in children after blunt trauma
Leonard JC Kuppermann N Olsen C Babcock-Cimpello L Brown K Mahajan P Adelgais KM Anders J Borgialli D Donoghue A Hoyle JD Jr Kim E Leonard JR Lillis KA Nigrovic LE Powell EC Rebella
G Reeves SD Rogers AJ Stankovic C Teshome G Jaffe DM Pediatric Emergency Care Applied Research Network
- Itrsquos Hard to Put a Band-Aid on a Broken Spleen Pediatric Trauma
- Disclosures
- Objectives
- Pediatric Prehospital Care
- Mechanism
- Traumatic Pain Management
- Pediatric Trauma
- Deaths by Mechanism of Injury
- Pediatric Trauma
- Pediatric Trauma
- Airway Differences
- Pediatric-Adult Differences
- Pediatric Challenges
- Prehospital Pediatric Challenges
- Pediatric and Adult Trauma
- Scene Response
- Prehospital Intervention
- Where do you take the patient
- Patient arrives at the EDhellip
- Primary Survey
- Order is critical
- Slide Number 22
- Slide Number 23
- Airway
- Indications for Intubation
- Breathing
- ETT Intubation Basics
- Circulation
- Slide Number 29
- CirculationHemodynamic Changes
- Circulation
- Fluid Resuscitation Algorithm
- Reconsidering Crystalloid Resuscitation
- When to start MTP
- Disability
- Finishing Up the Evaluation
- Bad Scene Responses
- OHCA from Trauma
- Blunt Trauma- No Signs of Life
- OHCA with CPR on Arrival
- Pediatric Trauma
- Questions
- References 1
- References 2
- References 3
- References 4
- References 5
- References 5
- XXXXBoston study ems peds trauma procedures- limited pediatric procedural exposure (but more adult experience)
- C-spine
References 5 bull httpwwwuptodatecomcontentsimageimageKey=EM2F76777amptopicKey=EM2F6571amprank
=17E150ampsource=see_linkampsearch=traumaamputdPopup=true bull httpwwwdocumentingrealitycomforumattachmentsf14964898d1246625322-firework-injury-
m80injury1jpg bull httpwwwpediatriceducationorg20050620 bull httpwwwarmstrongmedicalcomindexcfmgoproductdetailsec3ssec19cat61fam515 bull httpwwwuptodatecomcontentsimageimageKey=PEDS61087amptopicKey=ID2F7661ampsource
=outline_linkampsearch=tetanus+prophylaxisamputdPopup=true bull httpwwwafsecafmilsharedmediaphotodbweb110609-F-MJ378-009jpg bull httpwwwuptodatecomcontentsimageimageKey=EM75765amptopicKey= bull EM2F6389ampsource=outline_linkampsearch=massive+transfusion+protocolamputdPopup=true bull httpwwwmotifakecomimagedemotivational-postersmall0910whats-the-question-ignorance-
calvin-and-hobbes-demotivational-poster-1255020127jpg
XXXXBoston study ems peds trauma procedures- limited pediatric procedural exposure (but more adult experience) bull Catchment area 590000
over 1 year bull 555 pediatric ALS
transport ndash 19 blunt trauma ndash 10 penetrating trauma
bull IV 33 bull BMV 5 bull Intubation 3 bull 50 ALS providers average
year ndash IV- 37 ndash Intubation- 03 ndash IO- 006
bull 7 ped ems ndash 13 trauma
bull Critical procedures ndash 101000 peds cases ndash Intubation 671000 ndash IO 51000 ndash 81 successful
Pediatr Emerg Care 2001 Feb17(1)5-9 Pediatric pre-hospital advanced life support care in an urban setting
Babl FE1 Vinci RJ Bauchner H Mottley L
Pediatr Crit Care Med 2015 Oct16(8)e260-7 doi 101097PCC0000000000000505 Pediatric Out-of-Hospital Critical Procedures in the United States
Carlson JN1 Gannon E Mann NC Jacobson KE Dai M Colleran C Wang HE
C-spine bull C-spine injuries rare bull Take pt to closest hospital if over injuries
call for it (ie resuscitation altered mental status) primary guide
bull Mechanism ndash Altered mental status focal neuro change
torticollis substantial torso injury diving high speed auto neck pain underlying predisposing condition Acad Emerg Med 2014 Jan21(1)55-64 doi 101111acem12288
Comparison of outcomes for children with cervical spine injury based on destination hospital from scene of injury Anders JF1 Adelgais K Hoyle JD Jr Olsen C Jaffe DM Leonard JC Pediatric Emergency Care Applied Research Network
(PECARN)
Ann Emerg Med 2011 Aug58(2)145-55 doi 101016jannemergmed201008038 Epub 2010 Oct 29 Factors associated with cervical spine injury in children after blunt trauma
Leonard JC Kuppermann N Olsen C Babcock-Cimpello L Brown K Mahajan P Adelgais KM Anders J Borgialli D Donoghue A Hoyle JD Jr Kim E Leonard JR Lillis KA Nigrovic LE Powell EC Rebella
G Reeves SD Rogers AJ Stankovic C Teshome G Jaffe DM Pediatric Emergency Care Applied Research Network
- Itrsquos Hard to Put a Band-Aid on a Broken Spleen Pediatric Trauma
- Disclosures
- Objectives
- Pediatric Prehospital Care
- Mechanism
- Traumatic Pain Management
- Pediatric Trauma
- Deaths by Mechanism of Injury
- Pediatric Trauma
- Pediatric Trauma
- Airway Differences
- Pediatric-Adult Differences
- Pediatric Challenges
- Prehospital Pediatric Challenges
- Pediatric and Adult Trauma
- Scene Response
- Prehospital Intervention
- Where do you take the patient
- Patient arrives at the EDhellip
- Primary Survey
- Order is critical
- Slide Number 22
- Slide Number 23
- Airway
- Indications for Intubation
- Breathing
- ETT Intubation Basics
- Circulation
- Slide Number 29
- CirculationHemodynamic Changes
- Circulation
- Fluid Resuscitation Algorithm
- Reconsidering Crystalloid Resuscitation
- When to start MTP
- Disability
- Finishing Up the Evaluation
- Bad Scene Responses
- OHCA from Trauma
- Blunt Trauma- No Signs of Life
- OHCA with CPR on Arrival
- Pediatric Trauma
- Questions
- References 1
- References 2
- References 3
- References 4
- References 5
- References 5
- XXXXBoston study ems peds trauma procedures- limited pediatric procedural exposure (but more adult experience)
- C-spine
XXXXBoston study ems peds trauma procedures- limited pediatric procedural exposure (but more adult experience) bull Catchment area 590000
over 1 year bull 555 pediatric ALS
transport ndash 19 blunt trauma ndash 10 penetrating trauma
bull IV 33 bull BMV 5 bull Intubation 3 bull 50 ALS providers average
year ndash IV- 37 ndash Intubation- 03 ndash IO- 006
bull 7 ped ems ndash 13 trauma
bull Critical procedures ndash 101000 peds cases ndash Intubation 671000 ndash IO 51000 ndash 81 successful
Pediatr Emerg Care 2001 Feb17(1)5-9 Pediatric pre-hospital advanced life support care in an urban setting
Babl FE1 Vinci RJ Bauchner H Mottley L
Pediatr Crit Care Med 2015 Oct16(8)e260-7 doi 101097PCC0000000000000505 Pediatric Out-of-Hospital Critical Procedures in the United States
Carlson JN1 Gannon E Mann NC Jacobson KE Dai M Colleran C Wang HE
C-spine bull C-spine injuries rare bull Take pt to closest hospital if over injuries
call for it (ie resuscitation altered mental status) primary guide
bull Mechanism ndash Altered mental status focal neuro change
torticollis substantial torso injury diving high speed auto neck pain underlying predisposing condition Acad Emerg Med 2014 Jan21(1)55-64 doi 101111acem12288
Comparison of outcomes for children with cervical spine injury based on destination hospital from scene of injury Anders JF1 Adelgais K Hoyle JD Jr Olsen C Jaffe DM Leonard JC Pediatric Emergency Care Applied Research Network
(PECARN)
Ann Emerg Med 2011 Aug58(2)145-55 doi 101016jannemergmed201008038 Epub 2010 Oct 29 Factors associated with cervical spine injury in children after blunt trauma
Leonard JC Kuppermann N Olsen C Babcock-Cimpello L Brown K Mahajan P Adelgais KM Anders J Borgialli D Donoghue A Hoyle JD Jr Kim E Leonard JR Lillis KA Nigrovic LE Powell EC Rebella
G Reeves SD Rogers AJ Stankovic C Teshome G Jaffe DM Pediatric Emergency Care Applied Research Network
- Itrsquos Hard to Put a Band-Aid on a Broken Spleen Pediatric Trauma
- Disclosures
- Objectives
- Pediatric Prehospital Care
- Mechanism
- Traumatic Pain Management
- Pediatric Trauma
- Deaths by Mechanism of Injury
- Pediatric Trauma
- Pediatric Trauma
- Airway Differences
- Pediatric-Adult Differences
- Pediatric Challenges
- Prehospital Pediatric Challenges
- Pediatric and Adult Trauma
- Scene Response
- Prehospital Intervention
- Where do you take the patient
- Patient arrives at the EDhellip
- Primary Survey
- Order is critical
- Slide Number 22
- Slide Number 23
- Airway
- Indications for Intubation
- Breathing
- ETT Intubation Basics
- Circulation
- Slide Number 29
- CirculationHemodynamic Changes
- Circulation
- Fluid Resuscitation Algorithm
- Reconsidering Crystalloid Resuscitation
- When to start MTP
- Disability
- Finishing Up the Evaluation
- Bad Scene Responses
- OHCA from Trauma
- Blunt Trauma- No Signs of Life
- OHCA with CPR on Arrival
- Pediatric Trauma
- Questions
- References 1
- References 2
- References 3
- References 4
- References 5
- References 5
- XXXXBoston study ems peds trauma procedures- limited pediatric procedural exposure (but more adult experience)
- C-spine
C-spine bull C-spine injuries rare bull Take pt to closest hospital if over injuries
call for it (ie resuscitation altered mental status) primary guide
bull Mechanism ndash Altered mental status focal neuro change
torticollis substantial torso injury diving high speed auto neck pain underlying predisposing condition Acad Emerg Med 2014 Jan21(1)55-64 doi 101111acem12288
Comparison of outcomes for children with cervical spine injury based on destination hospital from scene of injury Anders JF1 Adelgais K Hoyle JD Jr Olsen C Jaffe DM Leonard JC Pediatric Emergency Care Applied Research Network
(PECARN)
Ann Emerg Med 2011 Aug58(2)145-55 doi 101016jannemergmed201008038 Epub 2010 Oct 29 Factors associated with cervical spine injury in children after blunt trauma
Leonard JC Kuppermann N Olsen C Babcock-Cimpello L Brown K Mahajan P Adelgais KM Anders J Borgialli D Donoghue A Hoyle JD Jr Kim E Leonard JR Lillis KA Nigrovic LE Powell EC Rebella
G Reeves SD Rogers AJ Stankovic C Teshome G Jaffe DM Pediatric Emergency Care Applied Research Network
- Itrsquos Hard to Put a Band-Aid on a Broken Spleen Pediatric Trauma
- Disclosures
- Objectives
- Pediatric Prehospital Care
- Mechanism
- Traumatic Pain Management
- Pediatric Trauma
- Deaths by Mechanism of Injury
- Pediatric Trauma
- Pediatric Trauma
- Airway Differences
- Pediatric-Adult Differences
- Pediatric Challenges
- Prehospital Pediatric Challenges
- Pediatric and Adult Trauma
- Scene Response
- Prehospital Intervention
- Where do you take the patient
- Patient arrives at the EDhellip
- Primary Survey
- Order is critical
- Slide Number 22
- Slide Number 23
- Airway
- Indications for Intubation
- Breathing
- ETT Intubation Basics
- Circulation
- Slide Number 29
- CirculationHemodynamic Changes
- Circulation
- Fluid Resuscitation Algorithm
- Reconsidering Crystalloid Resuscitation
- When to start MTP
- Disability
- Finishing Up the Evaluation
- Bad Scene Responses
- OHCA from Trauma
- Blunt Trauma- No Signs of Life
- OHCA with CPR on Arrival
- Pediatric Trauma
- Questions
- References 1
- References 2
- References 3
- References 4
- References 5
- References 5
- XXXXBoston study ems peds trauma procedures- limited pediatric procedural exposure (but more adult experience)
- C-spine
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