Transcript - North Region EMS & Trauma Care Council

EMS For Children
Non-accidental Trauma
Brianna Enriquez, MD
Assistant Clinical Professor
Department of Pediatrics
Division of Emergency Medicine
Objectives
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Review important pediatric differences in
trauma
Review pediatric tools for assessment
Discuss upcoming state pediatric
guidelines of care
Update on child abuse in our state
Epidemiology
• 50% of all childhood deaths are due to
injuries
• 500,000 pediatric hospitalizations
• 20-30 times more ED visits
• 30,000 of injured have permanent
disabilities
Causes
• 50% Motor Vehicle Crashes
– Large proportion are pedestrians
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Falls
Submersion
Burns/Smoke inhalation
Homicide
Suicide
Causes
• Pedestrian Injuries:
– 20% of MVC fatalities
– 3 S’s
• Small, Slow, So certain they are invincible
• Teen Driver’s
– 3 U’s
• Unrestrained (29%), Under the influence (29%),
Uninsurable
Causes
• Violence
– Homicide 2nd leading cause of death 10-24yo
– 85% of all homicides in children caused by
guns
– 54% of all suicides
– 2002: 896,000 children were abuse victims
1,400 deaths
Where are the risks?
• 80% of all trauma deaths occur at the
scene or in the emergency department
• 18% of hospital trauma deaths are
avoidable
Most common….
AIRWAY
Where are the risks?
• More than 50% of major injuries have
other major organ involvement
• Most common single injury associated with
death in pediatric patients…
HEAD TRAUMA
They aren’t just small traumas….
BIG Head 
more head trauma
SOFT/THIN chest 
more lung injury
SMALL Airway 
more risk of
obstruction
POOR Abd protection 
more risk of abdominal inj.
SMALL neck muscles,
flatter/horizontal facets 
more risk of injury
VASOCONSTRICTION  init. normal BP
Kidneys are mobile  more risk of injury
Physes  Salter fractures
Pediatric Head Trauma
• Open sutures + thin calvarium = more
flexible skull  increased risk of bleed
• Incomplete myelinization = greater
plasticity, increased diffuse axonal injury
• Big head vs body
Imaging: “while they are on
the table…..”: C-spine
• Cervical spine injuries in pediatric patients
with multiple trauma….
1-2%
• 72% of pediatric spinal injuries (<8yo) are
cervical injuries
Chest Trauma
• Blunt trauma = 85% of thoracic injuries
– Motor vehicle crashes
– Falls
– Bicycle accidents
50% Rib Fractures &
Pulmonary Contusions
20% Pneumothorax
10% Hemothorax
RARE: Cardiac Contusion ~5%
Chest Trauma
• Penetrating Trauma = 15%
• Gunshot Wounds
Hemothorax
Hemorrhagic shock
• Stabbings
Tension Pneumothorax
Rare:
Cardiac injury  tamponade
Major vascular injuries
Pediatric Thoracic Trauma
• Flexible ribs
• Less overlying fat/muscle
Large force  dissipates
significant intrathoracic
injury with few external
signs of trauma
Pediatric Thoracic Trauma
• Mediastinum is highly mobile
– endures extreme excursion
– rapid ventilatory/circulatory
collapse
Proportionally larger oxygen consumption
Smaller functional residual capacity
Pediatric Thoracic Trauma
• Greater dependence on diaphragmatic
breathing  compromised with gastric
distention
• Place an NG Tube if prolonged BVM
• Rapid sequence intubation
Pediatric Abdominal Injury
• Abdominal injury = 10% of traumatic
injuries in children…but most common
unrecognized cause of fatal injuries
• Physical Exam: only 65% accurate
• Serial exams are more reliable
Pediatric patients are tough to eval
• Different vital signs for age
• Different differential diagnoses for age
• Uncooperative….
– Patient
– Parents
EMSC is born
• Studies in the 1980’s identified the need
for better services and skills devoted to the
care of pediatric patients.
• In 1984 the US congress
authorizes the Emergency Medical
Services for Children (EMSC)
program.
EMS and Pediatrics
– Gausche M, Hendersen DP, Seidel JS.
1990: (Annals of Emergency Medicine)
Vital signs as part of the prehospital
assessment of the pediatric
patient: a survey of paramedics.
1. Significant differences in frequency of field
vital sign assessment in pediatric versus
adult patients.
The Pediatric Assessment Triangle
(Background Continued)
2. Vital signs were more likely to
be taken if base hospital
contact was made
3. Vital signs were often not
assessed in children <2
4. Paramedics less confident in
their ability to assess vital
signs in children <2 yrs.
EMS and Pediatrics
• Seidel JS, Henderson DP, et al. 1991 (Pediatrics)
– Pediatric prehospital care in urban and rural
areas
•Young pediatric patients rarely
received a full set of vitals and
neurologic assessment
•Advanced life support
treatments and procedures were
infrequently used.
EMS and Pediatrics
• Origin of PEPP curriculum:
– Began in 1990: California Pediatric
Emergency and Critical Care Coalition and
California EMSC project.
– Steering committee composed of members
from respected national organizations
concerned with children and the emergency
medical system.
– 10 years of review
The Pediatric Assessment Triangle
(Background Continued)
• In 2000 the American
Academy of
Pediatrics published a
new pediatric
educational program
for prehospital
providers.
Pediatric Education
for Prehospital
Professionals
(PEPP)
The Pediatric Assessment Triangle
(Background Continued)
• Course is centered on the use of a new rapid
assessment tool:
The Pediatric Assessment Triangle (PAT)
The Pediatric Assessment Triangle
(Background Continued)
• ACEP and AAP
Support the use of the PAT
in the emergency
department setting as
part of their
Advanced Pediatric Life
Support (APLS): The
Pediatric Emergency
Medicine Course.
The Pediatric Assessment Triangle
(Background Continued)
What is the PAT?
• “Rapid Assessment Tool” – across the
room
• Uses only visual and auditory clues
• Requires no equipment
• Only 30-60 seconds to utilize
The Pediatric Assessment Triangle
(Background Continued)
• Allows the emergency provider to:
– Formally articulate their general impression of
the child
– Establish the child’s severity
– Recognize the general category of
pathophysiology
– Determine the urgency of interventions
Appearance
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Tone
Interactiveness
Consolability
Look/Gaze
Speech/Cry
Work of Breathing
• Abnormal airway sounds
– Stridor
– Wheezing
– Grunting
• Abnormal positioning
• Retractions
• Flaring
Circulation to the Skin
• Pallor
• Mottling
• Cyanosis
The Pediatric Assessment Triangle
APPEARANCE
BREATHING
Abnormal Tone
 Interactiveness
 Consolability
Abnl. Look/Gaze
Abnl. Speech/Cry
Abnormal Sounds
Abnormal Position
Retractions
Flaring
CIRCULATION
Pallor
Mottling
Cyanosis
The Pediatric Assessment Triangle
= STABLE
= RESPIRATORY
DISTRESS
= RESPIRATORY
FAILURE
= SHOCK
= CNS/METABOLIC
= CARDIOPULMONARY
FAILURE
Case: 4 month-old infant
• Paramedics are dispatched to the home of a 4month-old girl with trouble breathing
• Baby had history of fever and cough and was
just started on an antibiotic for pneumonia
The Pediatric Assessment Triangle
4 Month-old infant
APPEARANCE
Abnormal Tone
 Interactiveness
 Consolability
Abnl. Look/Gaze
Abnl. Speech/Cry
“Lethargic, poor
tone, does not
respond to parent”
BREATHING
Abnormal Sounds
Abnormal Position
Retractions
Flaring
“Rapid, shallow,
with retractions ”
CIRCULATION
Pallor
Mottling
“Color is pale”
Cyanosis
The Pediatric Assessment Triangle
= STABLE
= SHOCK
= RESPIRATORY
DISTRESS
= CNS/METABOLIC
= RESPIRATORY
FAILURE
= CARDIOPULMONARY
FAILURE
The Pediatric Assessment Triangle
• The PAT attempts to formalize the thought
processes which occur when an
experienced pediatrician assesses a
patient.
Hello Dr. Broselow (and Luten)
• 1998 first Broselow-Luten length based
resuscitation tape.
Length Based Resuscitation
• Initially, multiple studies showed it was useful
• Recent studies suggest it underestimates weight
due to rising obesity
• Nieman CT et al. Acad Emerg. Med. 2006 Oct;13(10)
• DuBois D et al. Pediatr Emerg Care. 2007 Apr; 23(4)
• Ped Emerg Care 2007 Dec; 23(12)
• Emerg Med J. 2009 Jan;26(1):43-7…did a
GOOD job
Length Based Resuscitation
• Bottom line…
– It is better than formulas
– Keeps you from doing math while a patient is
coding
– Decreases errors
– Decreases time to medications
Length-based resuscitation
• AAP Policy Statement : Patient Safety in
the Pediatric Emergency Care Setting
– 8. Encourage the use of clinical tools to aid in
medication dosing and administration
• a. Educate ED staff on the correct use of lengthbased tape
Pediatrics Volume 120 (6) Dec 2007
PEPP, APLS, PALS, ACEP……….
What is NEXT?
• Pediatric Technical Advisory Committee (TAC)
Charter
• Mission:
Advise and make recommendations to the Governor’s
Steering Committee on pre-hospital and hospital
pediatric issues in the statewide emergency medical
services and trauma care system.
Pediatric TAC Charter
• Purpose:
Support the EMS and trauma care system as
outlined in the State Strategic Plan by acting
as a source of pediatric professional and
technical information to the Steering
Committee and other TACs.
Pediatric TAC Charter
• Membership: (Includes but not limited to the following)
Physician with pediatric training
Emergency physician
Nurse with emergency pediatric
experience
Emergency medical technician
Current ACTIVE Members
Harborview Medical Center
Mary Bridge Children’s Hospital
Sacred Heart Children’s Hospital
Seattle Children’s
Airlift Northwest
Pediatric Guidelines of Care:
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Evidenced based guidelines (with references)
Outline current standards of care
Presented in a user friendly format
Periodically updated by pediatric TAC
Intended to be used as a reference or
tool to aid you in the formation of
county specific protocols
Pediatric Guidelines
• Important Features:
– Stream-lined, easy to follow
– Standard format with distinctive decision
points and interventions
– Generic medication names
– Include pediatric pearls, things to think about
– References
Why develop guidelines?
• 1999 Institute of Medicine Report:
To err is human: building a safer health care
system
• 2000 Society for Academic Emergency Medicine
held a meeting on errors in the ED.
• Evidence based guidelines of care developed
– reduce errors
– improve quality of care
– formalize the process of reviewing the evidence and
stay current
Non-accidental trauma
• Is there a rise in the number of abuse
cases?
2003
2004
2005
2006
2007
8
10
15
14
14
2008  34 cases of inflicted head injuries at CHRMC
& HMC.
Child Abuse Rising?
• Why?
– Economy
– Societal Stress
– Better education/surveillance
Pediatric Rules of the
Game
• The injury must fit the mechanism…and
stage of development.
– 2005: 1460 deaths from child abuse
• 77% were less than 4 years of age, 50% less than
2 yrs
– 1988 Study of inflicted fractures
• 69% were younger than 1 year
• Femur 35% > Humerus 29% > Skull 16%
(J Pediatr Orthop 1988 Sep-
Think about Child Abuse…
• Inconsistencies and/or discrepancies in
story
• Un-witnessed injuries
• Injuries attributed to the patient's siblings
• Injuries inconsistent with developmental
stage or mechanism
• Injuries of different ages
• Bruising on trunk
Think about Child Abuse…
• History involves child vomiting, soiling, “making a mess”
• Bruises
– baby <6mo or not pulling to stand
– on/behind ears
– on buttocks, genitals
– pattern bruises (hand, loop, belt)
Think about Child Abuse…
• Fractures
– Fracture in pre-verbal child
– Any fracture in child <1y
• Burns
– Especially immersion burns (stocking/glove)
Think about Child Abuse…
• Child is “found down”
– Always concerning
– Child is wet (cold shower to try to arouse)
– “choked on bottle”
– Multiple calls to others before 911
Child Abuse
• Any infant with concerns for lethargy, seizure, or
altered mental status needs a thorough physical
exam and consideration for CT
7-week-old with witnessed seizure
Metaphyseal corner fracture
Bone Scan of posterior rib fractures
Child Abuse
• IF YOU DON’T THINK OF IT…
YOU WILL MISS IT!
How can you be involved?
• Keep up your pediatric knowledge and
skills
• Use your tools (PAT and length-based
resuscitation tapes)
• Look for child abuse
PREVENTION
• Car Seats
• Helmets
• Traffic safety
programs
• Gun control
• Seatbelt laws
• Sobriety checkpoints • Suicide prevention
• Child abuse
education
• Fire Safety