ems for children non-accidental trauma brianna enriquez, md assistant clinical professor department...
TRANSCRIPT
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EMS For ChildrenNon-accidental Trauma
Brianna Enriquez, MDAssistant Clinical ProfessorDepartment of PediatricsDivision of Emergency Medicine
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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
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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
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Causes
• 50% Motor Vehicle Crashes– Large proportion are pedestrians
• Falls
• Submersion
• Burns/Smoke inhalation
• Homicide
• Suicide
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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
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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 victims1,400 deaths
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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
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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
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They aren’t just small traumas….
BIG Head more head trauma
SMALL Airway more risk of obstruction
POOR Abd protection more risk of abdominal inj.
SOFT/THIN chest more lung injury
SMALL neck muscles, flatter/horizontal facets more risk of injury
Kidneys are mobile more risk of injury
VASOCONSTRICTION init. normal BP
Physes Salter fractures
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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
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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
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Chest Trauma
• Blunt trauma = 85% of thoracic injuries
– Motor vehicle crashes– Falls– Bicycle accidents
50% Rib Fractures & Pulmonary Contusions20% Pneumothorax
10% Hemothorax
RARE: Cardiac Contusion ~5%
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Chest Trauma
• Penetrating Trauma = 15%
• Gunshot WoundsGunshot WoundsHemothoraxHemothorax
Hemorrhagic shockHemorrhagic shock
• StabbingsStabbingsTension PneumothoraxTension Pneumothorax
Rare: Rare: Cardiac injury Cardiac injury tamponadetamponade Major vascular injuriesMajor vascular injuries
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Pediatric Thoracic Trauma
• Flexible ribs
• Less overlying fat/muscle
Large force dissipates
significant intrathoracic injury with few external signs of trauma
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Pediatric Thoracic Trauma
• Mediastinum is highly mobile– endures extreme excursion– rapid ventilatory/circulatory
collapse
Proportionally larger oxygen consumption
Smaller functional residual capacity
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Pediatric Thoracic Trauma
• Greater dependence on diaphragmatic breathing compromised with gastric distention
• Place an NG Tube if prolonged BVM
• Rapid sequence intubation
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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
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Pediatric patients are tough to eval
• Different vital signs for age
• Different differential diagnoses for age
• Uncooperative….– Patient– Parents
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EMSC is born
• Studies in the 1980’s identified the need for better services and skills devoted to the care of pediatric patients.
• In In 19841984 the US congress the US congress authorizes the Emergency authorizes the Emergency Medical Services for Medical Services for Children (EMSC) program.Children (EMSC) program.
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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.
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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.
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EMS and Pediatrics
• Seidel JS, Henderson DP, et al. 1991 (Pediatrics)
– Pediatric prehospital care in urban and rural areas•Young pediatric Young pediatric patients rarely received patients rarely received a full set of vitals and a full set of vitals and neurologic assessmentneurologic assessment
•Advanced life support Advanced life support treatments and treatments and procedures were procedures were infrequently used.infrequently used.
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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
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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)
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The Pediatric Assessment Triangle(Background Continued)
• Course is centered on the use of a new rapid assessment tool:
The Pediatric Assessment Triangle The Pediatric Assessment Triangle (PAT)(PAT)
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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.
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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
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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
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Appearance
• Tone• Interactiveness• Consolability• Look/Gaze• Speech/Cry
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Work of Breathing
• Abnormal airway sounds – Stridor– Wheezing– Grunting
• Abnormal positioning• Retractions• Flaring
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Circulation to the Skin
• Pallor
• Mottling
• Cyanosis
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The Pediatric Assessment Triangle
CIRCULATIONPallor
MottlingCyanosis
APPEARANCE
Abnormal Tone
Interactiveness Consolability Abnl. Look/Gaze
Abnl. Speech/Cry
BREATHINGAbnormal SoundsAbnormal PositionRetractionsFlaring
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The Pediatric Assessment Triangle
= STABLE= RESPIRATORY DISTRESS
= RESPIRATORY FAILURE
= SHOCK
= CNS/METABOLIC
= CARDIOPULMONARY FAILURE
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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
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The Pediatric Assessment Triangle4 Month-old infant
CIRCULATIONPallor
MottlingCyanosis
APPEARANCE
Abnormal Tone
Interactiveness Consolability Abnl. Look/Gaze
Abnl. Speech/Cry
BREATHINGAbnormal SoundsAbnormal PositionRetractionsFlaring“Lethargic,
poor tone, does not respond to parent”
“Rapid, shallow, with retractions ”
“Color is pale”
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The Pediatric Assessment Triangle
= STABLE= RESPIRATORY DISTRESS
= RESPIRATORY FAILURE
= SHOCK
= CNS/METABOLIC
= CARDIOPULMONARY FAILURE
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The Pediatric Assessment Triangle
• The PAT attempts to formalize the thought processes which occur when an experienced pediatrician assesses a patient.
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Hello Dr. Broselow (and Luten)
• 1998 first Broselow-Luten length based resuscitation tape.
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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
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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
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Length-based resuscitation
• AAP Policy Statement : Patient Safety in the Pediatric Emergency Care Setting
– 8. Encourage the use of clinical tools to aid in medication dosing and administration
• a. Educate ED staff on the correct use of length-based tape
Pediatrics Volume 120 (6) Dec 2007
PEPP, APLS, PALS, ACEP……….
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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.
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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.
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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
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Current ACTIVE Members
Harborview Medical Center
Mary Bridge Children’s Hospital
Sacred Heart Children’s Hospital
Seattle Children’s
Airlift Northwest
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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 Intended to be used as a reference or toolreference or tool to aid you to aid you in the formation of county in the formation of county specific protocolsspecific protocols
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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
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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
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Non-accidental trauma
• Is there a rise in the number of abuse cases?
2003 82004 102005 152006 142007 14
2008 34 cases of inflicted head injuries at CHRMC & HMC.
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Child Abuse Rising?
• Why?– Economy
– Societal Stress
– Better education/surveillance
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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-Oct;8(5):585-9)
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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
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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)
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Think about Child Abuse…
• Fractures– Fracture in pre-verbal child
– Any fracture in child <1y
• Burns– Especially immersion burns (stocking/glove)
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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
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Child Abuse
• Any infant with concerns for lethargy, seizure, or altered mental status needs a thorough physical exam and consideration for CT
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7-week-old with witnessed seizure
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Metaphyseal corner fracture
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Bone Scan of posterior rib fractures
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Child Abuse
• IF YOU DON’T THINK OF IT…
YOU WILL MISS IT!
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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
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PREVENTION
• Car Seats• Helmets• Traffic safety
programs• Seatbelt laws• Sobriety checkpoints
• Gun control• Suicide prevention• Child abuse
education• Fire Safety