EMS For Children Nonaccidental Trauma Brianna Enriquez MD

EMS For Children Non-accidental Trauma Brianna Enriquez, MD Assistant Clinical Professor Department of Pediatrics Division of Emergency Medicine

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

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 • • • 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 2 nd leading cause of death 10 -24 yo – 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 (<8 yo) 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

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 • • • 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 = SHOCK = RESPIRATORY DISTRESS = RESPIRATORY FAILURE = CNS/METABOLIC = CARDIOPULMONARY FAILURE

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

The Pediatric Assessment Triangle 4 Month-old infant APPEARANCE BREATHING Abnormal Tone Interactiveness Consolability Abnl. Look/Gaze Abnl. Speech/Cry “Lethargic, poor tone, does not respond to parent” Abnormal Sounds Abnormal Position Retractions Flaring CIRCULATION Pallor Mottling Cyanosis “Rapid, shallow, with retractions ” “Color is pale”

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

The Pediatric Assessment Triangle • The PAT attempts to formalize 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) • Du. Bois 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: • • 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 <6 mo 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 <1 y • 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