PEDIATRIC TRAUMA AND CRITICAL CARE PROVIDES SIX (6) HOURS OF CONTINUING EDUCATION CREDIT
AGENDA 0800-0830 Registration
0830-0930 Transport Pearls for the Neonate Patty Duncan, BSN, RNC
0930-0940 Break
0940-1140 Pediatric Airway and Prehospital Golden Hour Dave Duncan, MD
1145-1215 Lunch
1215-1315 State of the Art EMS Protocols are Created, Not Born That Way Paul S. Rostykus, MD, MPH, FAEMS
1315-1325 Break
1325-1525 Pediatric Trauma Heather Summerby, RN
1525-1530 Evaluation
Transport Pearls for the Neonate Patty Duncan There are not many careers where your decisions and interactions can positively impact the life of a human for up to 80 plus years. Dr. Stephen Butler
PEARLS OF NEONATAL TRANSPORT FROM A 35 YEAR NICU RN
PATTY DUNCAN BSN RNC PATTY DUNCAN BSN RNC
• ADVANCED LIFE SUPPORT COORDINATOR • ALS NICU TRANSPORT COORDINATOR • ASSISTANT NURSE MANAGER 61 BED LEVEL 3 NICU • STABLE INSTRUCTOR • NRP INSTUCTOR NICU TRANSPORT TEAM
• VIA GROUND, FIXED WING AND ROTOR • SERVE 27 COUNTIES IN NORTHERN CA • 3 OUT OF HOUSE TRANPORT ISOLETTE CONTAIN CONV VENT HFJV NITRIC OXIDE ACTIVE COOLING TECOTHERM BCPAP THE NEONATE-WHY THEY ARE SPECIAL
• OF, RELATING TO ,OR AFFECTING THE NEWBORN AND ESPECIALLY THE HUMAN INFANT DURING THE FIRST MONTH AFTER BIRTH • MERRIAM-WEBSTER
Large surface area compared to size keep them warm (BSA is 3X greater than adult) Correct ventilation is the key to solving most issue be smart Glucose is their energy source - keep them sweet NEONATES: MASTERS OF DISGUISE KEY = TREAT THE SYMPTOM!
• Tachypnea: the most common symptom! • Respiratory Distress Syndrome • Transient tachypnea of the newborn, Hyaline Membrane Disease, pneumothorax, pneumonia • Sepsis-bacterial, virus • Cardiac-ductal dependent vs non ductal dependent • Metabolic Acidosis • Hypoglycemia, • Hypothermia TREAT THE SYMPTOMS! THE DIAGNOSIS WILL FOLLOW (MAYBE)
S.T.A.B.L.E. PROGRAM • SUGAR • TEMPERATURE • AIRWAY • BLOOD PRESSURE • LABS • EMOTIONAL SUPPORT SUGAR - KEEP THEM SWEET! TIP: D10W IS YOUR FRIEND
• Glycogen stores increase dramatically the last few weeks of gestation • Neonates rely on the breakdown of this glycogen to provide energy (ATP) for the first few days of life • Very little energy is supplied in the absence of oxygenation • So ---- assume any infant who is: • Not oxygenating well • Premature (very little glycogen) • Stressed or ill NEEDS A SUPPLY OF GLUCOSE ASAP INFANT’S AT RISK FOR HYPOGLYCEMIA
• ILL/STRESSED INFANT Glycogen stores gone • PREMATURE / IUGR / SGA Inadequate Glycogen Stores • HYPERINSULINEMIA Excess Insulin
HYPERINSULINEMIA PREMATURE, IUGR, SGA STRESSED/ILL INFANT IV FLUID AND RATE
• D10W WITHOUT ELECTROLYTES • 80ML/KG/DAY • WEIGHT IN KG X 80 • DIVIDE BY 24 • EQUALS MLS PER HOUR (RUN VIA AN INFUSION PUMP) BEDSIDE GLUCOSE CHECKS TIP: D10W 2ML/KG IV PUSH
• Do with first assessment! • Follow closely - every 30 minutes until stable for 2 hours • Accept a glucose of >50 • Start IV: 10% glucose early • 80mls/kg/hr. to start • If glucose remains below 50-increase to 100ml/kg/hr. • If glucose remains below 50-increase glucose conc. to 12% • Concentrations > D12% require central line. NEONATAL TEMPERATURE RANGE TIP- CHECK TEMP Q 15 MIN
• NORMAL RANGE 36.50 – 37.40C for all infants (axillary temp) • The neonatal temperature is monitored per axilla using digital thermometers. • Flank temperatures may be monitored using skin temperature probes. • An infant’s core body temperature will generally be higher than the recorded skin temperature, with a difference of ~0.50C in term infants; the difference may be narrower in very preterm or ill infants. NEONATE’S NEED TO BE TRANSPORTED IN A NEUTRAL THERMAL ENVIRONMENT
• SICK OR PREMATURE INFANTS NEED TO BE IN A TRANSPORT ISOLETTE (SERVO CONTROLLED) • INFANTS CAN DROP 1-1.5 DEGREE’S PER MINUTE POST DELIVERY • INFANTS LOSE HEAT 4X FASTER THAN ADULTS • SKIN TEMP DROP OF 1 DEGREE FROM 97.7 (36.5C) INCREASES OXYGEN REQUIREMENT BY 10% • LOW BIRTH WEIGHT INFANTS HAVE LITTLE BODY FAT HOW TO KEEP THEM WARM TIP- NEOWRAP / PLASTIC WRAP
• IF NO ISOLETTE: • SKIN TO SKIN • SOME TYPE OF PLASTIC WRAP • HATS-WARM BLANKETS-KEEP INFANT FLEXED/TUCKED • INCREASE TEMP IN AMBULANCE/AIRCRAFT • KEEP THEIR BLOOD SUGAR NORMAL!!! (ENERGY TO PRODUCE HEAT) • KEEP OXYGEN LEVELS NORMAL (SO THEY GET MORE BANG (ATP) FROM THEIR GLYCOGEN (KREBS CYCLE) BENEFITS OF SERVO CONTROL ISOLETTE TIP - WHO IS YOUR CLOSEST NICU TRANSPORT TEAM?
• THEY CAN CONTROL TEMPERATURE OF INFANT BY FEEDBACK TEMP PROBE • IF COLD-ABLE TO SET TEMP ONE DEGREE ABOVE SKIN TEMP TO PREVENT WARMING TOO FAST. • VASODILATATION LEADS TO DECREASED BLOOD PRESSURE, INCREASED LACTATE, INCREASED OXYGEN NEED THE BIGGEST BENEFIT IS THAT THE CRITICAL VITAL SIGN TEMPERATURE IS CONSTANTLY VISIBLE – THIS ALLOWS THE TEAM TO FOCUS ON OTHER VITALS WHAT ABOUT THERAPEUTIC HYPOTHERMIA? TIP- COOLING NEEDS TO START WITHIN 6 HOURS OF BIRTH-WHERE IS THE CLOSEST COOLING CENTER??
• ONE OF THE MOST IMPORTANT TREATMENT MODALITIES IN NEONATAL MEDICINE TODAY • SIGNIFICANT IMPROVEMENT IN OUTCOMES OF INFANTS WITH MODERATE TO MILD HYPOXIC ISCHEMIC ENCEPHALOPATHY (HIE) • KNOWN PERINATAL/POSTNATAL HYPOXIC INSULT • INFANT IS >34 WKS, PH, 7.0, LACTATE >12, ABNORMAL NEURO EXAM • INFANT IS COOLED QUICKLY TO 33.5C FOR 72 HOURS IN CONTROLLED COOLING CENTER TRANSPORTS ARE 90% RESPIRATORY! TIP- NOTHING REPLACES YOUR ASSESSMENT SKILL
• Number 1 reason for neonatal transport • Difficult to determine exact diagnosis-treat the symptoms • Use every tool you have to guide your treatment • YOUR ASSESSMENT SKILLS • Vital signs • Oximetry - pre ductal / post ductal • Perfusion-cap refill / pulse • ABG / bedside glucose • XRAY AIRWAY- THE LEAST INVASIVE THE BETTER
• REDUCE VENTILATOR INDUCED DAMAGE TO THE NEONATAL LUNG • PERMISSIVE HYPERCAPNIA • DECREASED NEED FOR VENTILATION=LESS BRONCHOPULMONARY DYSPLASIA (BPD) • GREATER USE OF BUBBLE CPAP- NCPAP THE CASE FOR BCPAP (BUBBLE CPAP)
• USE BCPAP ON THE FIRST BREATH IN THE DELIVERY ROOM • IF YOUR TRANSPORT TEAM DOES NOT USE BCPAP NOW-MOVE TOWARD IT 2008 BPD 38 percentile • HIGH HUMIDITY OR HIGH FLOW NASAL 2009 BPD 25 percentile CANNULA - ok for oxygen needs, but not 2010 BPD 12 percentile effective for consistent peep
2017 BPD 13 percentile NEONATAL BCPAP KEY#INFANT NEEDS TO BE BREATHING
• CONTINUOUS POSITIVE AIRWAY PRESSURE (CPAP) • USED FOR SPONTANEOUSLY BREATHING INFANTS • FOR RDS, TTN, MEC ASPIRATION, APNEA OF PREMATURITY • FLOW OF GAS MAINTAINS EXPIRATORY PRESSURE CONTINOUSLY • CAN BE EASILY USED IN TRANSPORT LMA’S IN NEONATAL RESUSCITATION
• Reduction in upper airway obstruction • Improved oxygenation / ventilation • Reduced incidence of tracheal intubation • Reduced amount of expertise required. This Photo by Unknown Author is licensed under CC BY-NC-SA • After positioning, the LMA is quite stable and frees operator’s hands for other tasks. IF YOU MUST INTUBATE TIP- ETT TIP TO LIP-WT PLUS 6
• USE THE LOWEST PIP NEEDED TO MOVE THE CHEST • UTILIZE TCM OR END TIDAL CO2 • ABG FOR CORRELATION • ETT TIP PLACEMENT CRUCIAL- TIP TO LIP • 1KG –ETT TAPED AT 7 LIP • 2KG-ETT TAPED AT 8 ETC.ETC. • PREVENT POOR IMPROVEMENT/PNEUMOTHORAXES FOR R MAIN STEM INTUBATIONS WHAT'S NEW IN NEONATAL INTUBATION
• Uncuffed tubes – size: 2.5 - 4.0 • Use a CO2 detector! • Use tip to lip rule-weight plus 6 • Ventilate with minimal pressure to move chest • CXR for placement • Each hand off includes ETT size, where it is taped, cuffed or uncuffed? • Keep CO2 detector handy for evaluations NEONATAL CHEST XRAYS ABDOMEN XRAYS DO NOT BE DECEIVED BY A NORMAL NEONATAL BLOOD PRESSURE
• NEONATES HOLD THEIR BLOOD PRESSURE UNTIL THEY HIT THE WALL • BLOOD PRESSURE IS A VITAL SIGN-BUT A NORMAL B/P DOES NOT ELIMINATE THE POTENTIAL OF SHOCK • USE ALL OF YOUR ASSESSMENT SKILLS TO DETERMINE SHOCK • CAPILLARY REFILL TIME >3 SECS • PULSES -WEAK,FULL, THREADY • COLOR-PALE,MOTTLED • HEART RATE>180 • 3 TYPES OF NEONATAL SHOCK • HYPOVOLEMIC, SEPTIC, CARDIAC HYPOVOLEMIC SHOCK
• CAUSES OF HYPOVOLEMIC SHOCK • PLACENTAL PREVIA, ABRUPTION, CORD ACCIDENT, ORGAN LACERATION • SKULL BLEEDS-SUBGALEAL HEMORRHAGE • PNEUMOTHORAX • TREATMENT OF HYPOVOLEMIC SHOCK • FILL THE TANK! • SALINE • BLOOD SEPTIC SHOCK
•BACTERIAL •VIRAL
• SEND BLOOD CULTURES • GIVE ANTIBIOTICS • TREAT SYMPTOMS
This Photo by Unknown Author is licensed under CC BY-NC-SA CARDIAC SHOCK TIP- EPINEPHRINE DRIP
• CONGENITAL CARDIAC DISEASE • Ductal dependent lesions • Non-ductal dependent lesions • CARDIAC MYOPATHY • Viral infections • Congestive heart failure
This Photo by Unknown Author is licensed under CC BY-SA LABS BEFORE TRANSPORT
• BEDSIDE GLUCOSE • BLOOD GAS • BLOOD CULTURE • CBC WITH DIFF WHAT IS NEW IN NEONATAL RESUSCITATION- FROM THE MOMENT OF BIRTH
• INTUBATION IS A THING OF THE PAST FOR MOST INFANTS • EXCEPTIONS INCLUDE NEONATAL DEPRESSION, EXTREMELY LOW GESTATIONAL AGE, SOME GOOD VENTILATION SURGICAL PATIENTS-EX CDH WITH A BAG AND MASK • USE LMA WHEN YOU DO NOT HAVE COMPETENT WILL INCREASE A STAFF PRESENT FOR INTUBATION-GOES DOWN TO NEONATE’S HEART RATE THE SIZE OF 0.5 (AIRQ) 99% OF THE TIME-MAKE SURE YOU HAVE STAFF • YOU CAN PROVIDE PPV FOR A PROLONGED THAT CAN ADEQUATELY PERIOD OF TIME IF NECESSARY BEFORE HAVING VENTILATE ACCORDING UNQUALIFIED STAFF PERFORM POOR TO NRP GUIDELINES INTUBATIONS • KNOW WHO YOUR SPECIALISTS ARE-ER, ANESTHESIA, NP, NURSE SPECIALIST, RCP’S • DO NOT INTUBATE FOR MECONIUM ONLY • RESUSCITATIONS ARE PERFORMED FROM 22 WEEKS AND UP • DELAYED CORD CLAMPING 90-120 SECS FOR THE PREMATURE INFANT • FETAL THERAPY PERINATAL GROUPS SCHEDULE HIGH RISK FETAL PREGNANCIES TO DELIVER IN TERTIARY CENTERS • MATERNAL TRANSPORTS ARE INCREASING ( AND INCREASINGLY DIFFICULT) • NICU TEAMS ATTEND HIGH RISK DELIVERIES AT REFERRAL HOSPITALS THANKS
Pediatric Airway And Prehospital Golden Hour Dr. David Duncan PEDIATRIC AIRWAY MANAGEMENT
Dave Duncan MD Medical Director CALSTAR / CAL FIRE
2018 The Pediatric Airway
. Introduction . Anatomy / Physiology . Positioning . Basics - Adjuncts . ALS - Intubation Introduction
Almost all pediatric “codes” are of respiratory origin
Internal Data. B.C. Children’s Hospital, Vancouver. 1989. Anatomy
Children are different than adults !!! Anatomy Pediatric Airways
Epiglottis: • Relatively large size in children • Omega shaped • Floppy – not much cartilage Anatomy: Adult vs Pediatric Airway Anatomy -- Shape
Column
Cone Anatomy Positioning Airway positioning for children <2yrs Positioning Physiology: Effect of Edema
Poiseuille’s law
R = 8 n l r4 pedi adult
When radius is halved ---- Resistance increases 16 fold Signs of Respiratory Distress
• Tachypnea • Retractions • Tachycardia • Access muscles • Grunting • Wheezing • Stridor • Prolonged exp. • Flaring • Apnea • Agitation • Cyanosis Signs of Respiratory Distress Breathing
Breathing should always be divided in two! Oxygenation Ventilation In with the new Out with the old (Inhalation) (Exhalation)
• It’s not a ventilator --- it’s an oxygenator/ventilator
Priority 1) Oxygen Delivery Priority 2) Not to hyperventilate Priority 3) Adequate ventilation Breathing: Oxygenation
Big tidal volumes and rates don’t increase oxygenation . For Hypoxemia: turn up the FiO2, or the pressure • D - O - P - E (dislodged - obstructed - PTX - Equipment) • Use a PEEP valve! • If still dropping…….. . EPIC study (Dan Spaite - Arizona) . Hypoxia is REALLY BAD for TBI: • 500 cases of hypoxia/10,000 = 4 X mortality! • A single sat <90 doubles mortality in severe TBI! • Always utilize 100% O2 on TBI patients! Oxygenation – Henry’s Law
“the quantity of a gas dissolved in liquid is proportional to the partial pressure of the gas in contact with the liquid…”
- So higher FIO2 = higher pO2 - Higher PEEP or PIP = higher pO2
Oxygen (Hg) saturation is dependent on pO2
(Note: Rate / TV have no effect here ---- “minute ventilation”) Airway Management
. Adjuncts: High Flow Nasal Canula
Preoxygenation and Prevention of Desaturation During Emergency Airway Management
Scott D. Weingart, MD Richard M. Levitan, MD Pre-oxygenation Prior to RSA (RSI)
• 3-5 minutes of 100% oxygen - non-rebreather mask • Hi Flow Nasal Cannula 15 L adults, 1 L/kg peds • Avoid positive pressure ventilation if possible 6 full volume ventilations via BVM if needed • Establishes O2 reserve via nitrogen washing • Permits prolonged apnea w/o desaturation Healthy 70kg adult >90% for over 10 minutes Healthy10kg child >90% for over 4 minutes
But! The Airway must be open! The Oxygen Dissociation Curve
Factors that Influence Oxygen Binding •Temperature- Increasing the temperature increases the amount of oxygen and hemoglobin and decreases the concentration of oxyhemoglobin (Schmidt-Nielsen, 1997). The dissociation curve shifts to the right. •pH- A decrease in pH (increase in acidity) by addition of carbon dioxide or other acids causes the dissociation curve to shift to the What about right. Fetal Hg? •Organic Phospates- 2,3- Diphosphoglycerated (DPG) is the primary organic phosphate in mammals. DPG binds to hemoglobin which decreases the affinity of oxygen for hemoglobin (T and R State). The curve shifts to the right. Breathing: Ventilation Remember tidal volume x rate = minute ventilation Minute Ventilation RAPIDLY affects pCO2 . Medical Providers all Hyperventilate! ** • We want to feel the lungs inflate! • Use a 1 liter BVM • 1 breath every 5 seconds • And flow control / counter
** O'Neill JF, Deakin CD. Do we hyperventilate cardiac arrest patients? Resuscitation. 2007 Apr;73(1):82-5. Aufderheide TP, Sigurdsson G RG, et al. Hyperventilation-induced hypotension during cardiopulmonary resuscitation. Circulation. 2004 Apr 27;109(16):1960-5. Breathing: Ventilation Remember tidal volume x rate = minute ventilation . Follow ETCO2 in all critical patients • ETCO2 is about 5mmhg less that PCO2 • Waveform capnography is best! • All that is ETCO2 is not ventilation It’s only “accurate” if there is adequate Cardiac Output . If blood is not pumped to the lungs, CO2 will not off-gas (CPR, Shock, etc)
EMMA Colorimetric Breathing: Ventilation
Do Not Hyperventilate TBI Patients! *
. We were taught to do this in the 80’s and 90’s • We killed thousands based on “expert opinion” • Goal ETCO2: 35-40 • TBI patients begin to drop off at pCO2 < 35*
*Davis, et al and Dumont, et al Breathing: Hyper-Ventilation
J Trauma. 2005 Aug;59(2):486-90. Davis DP, Stern J, Sise MJ, Hoyt DB. Follow-up analysis of factors associated with TBI mortality after paramedic RSI BACKGROUND: The San Diego Paramedic Rapid Sequence Intubation (RSI) Trial documented an increase in mortality after paramedic RSI, with hyperventilation identified as a contributing factor in a subgroup analysis. Here we explore factors affecting outcome in the entire cohort of patients undergoing paramedic RSI to confirm previous findings. METHODS: Adult trauma patients with severe head injury (Glasgow Coma Scale score, 3-8) who could not be intubated without RSI were prospectively enrolled in the trial. Each remaining trial patient was matched to two nonintubated historical controls from the county trauma registry based on: ISS, age, mechanism, etc. RESULTS: Of the 426 trial patients, 352 met inclusion criteria for this analysis and were hand-matched to 704 controls. Trial patients and controls were identical with regard to all matching variables. Mortality was increased in RSI patients versus matched controls (31.8 versus 23.7%; p < 0.01). Hyperventilation was associated with an increase in mortality, whereas transport by aeromedical crews after paramedic RSI was associated with improved outcomes. CONCLUSION: Paramedic RSI was associated with an increase in mortality compared with matched historical controls. The association between hyperventilation and mortality was confirmed. In addition, patients transported by helicopter after paramedic RSI had improved outcomes. Breathing: (Hyper)Ventilation
J Neurotrauma. 2010 Jul;27(7):1233-41. doi: 10.1089/neu.2009.1216. Inappropriate prehospital ventilation in severe traumatic brain injury increases in-hospital mortality. Dumont TM1, Visioni AJ, Rughani AI, Tranmer BI, Crookes B. Undue use of hyperventilation is thought to increase the incidence of secondary brain injury through direct reduction of cerebral blood flow. This is a retrospective review determining the effect of prehospital hyperventilation on in-hospital mortality following severe TBI. All trauma patients admitted directly to a single level 1 trauma center from January 2000 to January 2007 with an initial Glasgow Coma Scale (GCS) score
. We manage airways so we can manage breathing . Less is More! • Utilize the least invasive method that solves the problem Positioning NPA (over OPA) BVM SGA (LMA type devices) ETT Cricothyrotomy Airway Management Basics: BLS
• Positioning – head tilt/chin lift or jaw thrust • Effective BVM - most important skill – Get a good seal (two person better) – Don’t over ventilate • Adjuncts – OPA - good choice if tolerated – (no gag) – NPA – better tolerated – new better materials • SUCTION!!! • BROSELOW!!! Broselow Tape Broselow Tape …there’s an app for that
Pediatric Resuscitation Palm Pedi Airway Adjuncts
• Nasal airway
• Oral airway Basic Airway Management Techniques Airway Management: Adjuncts (NPA) Adjuncts: Oral Airway
Wrong size: Too Long Adjuncts: Oral Airway
Wrong size: Too Short Adjuncts: Oral Airway
Correct size Bag Valve Mask (BVM) Bag Valve Mask Ventilation
Pro’s Con’s • Effective adjunct • Difficult to master • Non invasive • Difficult to maintain • Feel compliance seal
Give Slow Small Breaths: 6-8 cc/kg (smallest aprop. bag) Rate: Adults: 12 Child: 16-20 Infant: 20-30 Adjunctive & Rescue Airways
• King LT (Periglottic Airways) • Supraglottic Airways (SGAs = LMAs)
SGA’s (LMA’s)
• The SGA was invented by Dr. Archie Brain at the London Hospital in Whitechapel in 1981
• The SGA consists of two parts: – The tube – The mask SGA’s (supraglottic airways)
• The SGA design:
– Provides an “oval seal around the laryngeal inlet” when cuff inflated.
– Lube only the outside – not inside the cup area
– Direct it posteriorly and upwards – past the posterior tongue (jaw thrust will help) Then Bury It! (avoid a “flipped tip”)
– Don’t overinflate (or don’t inflate!) SGA Indications
• Failed less invasive techniques
• Failed more invasive techniques
• May be used as a:
– Rescue Device
– Bridging Device
– Destination Device Contraindications
• Intact Gag Reflex
• Patients requiring definitive airway protection:
(Swollen cords, burn, anaphylaxis, vomiting, high pressures, etc)
• Massive maxillofacial trauma
• Patients at High risk of aspiration Relative Contraindications
• Greater than 16 weeks pregnant
• Patients with multiple or massive injury
• Massive thoracic injury Preparation
• Step 1: Size selection • Step 2: Examination of the LMA • Step 3: Check the cuff • Step 4: Lubrication of the LMA • Step 5: Position the Airway Step 1: Size Selection
• Verify that the size of the LMA is correct for the patient – (Broselow or pckg insert) • Recommended Size guidelines:
– Size 1: under 5 kg – Size 1.5: 5 to 10 kg – Size 2: 10 to 20 kg – Size 2.5: 20 to 30 kg – Size 3: 30 kg to small adult – Size 4: adult – Size 5: Large adult Securing the LMA
• Insert a bite-block or roll of gauze to prevent occlusion of the tube should the patient bite down.
• Now the LMA can be secured utilizing the same techniques as those employed in the securing of
an endotracheal tube. The Air-Q sp …… no inflation The Air-Q sp …… no inflation
• Biomed Res Int. 2016;2016:6406391. doi: 10.1155/2016/6406391. Epub 2016 Jun 23. • Comparative Efficacy of the Air-Q Intubating Laryngeal Airway during General Anesthesia in Pediatric Patients: A Systematic Review and Meta-Analysis. • Ahn EJ1, Choi GJ2, Kang H2, Baek CW2, Jung YH2, Woo YC2, Bang SR1.
Air-Q® (air-Q) is a supraglottic airway device which can be used as a guidance of intubation in pediatric as well as in adult patients. We evaluated the efficacy and safety of air-Q compared to other airway devices during general anesthesia in pediatric patients by conducting a systematic review and meta- analysis. A total of 10 studies including 789 patients were included in the final analysis. Compared with other supraglottic airway devices, air-Q showed no evidence for a difference in leakage pressure and insertion time. The ease of insertion was significantly lower than other supraglottic airway devices. The success rate of intubation was significantly lower than other airway devices. However, fiberoptic view was better through the air-Q than other supraglottic airway devices. Therefore, air-Q could be a safe substitute for other airway devices and may provide better fiberoptic bronchoscopic view. The i-Gel SGA…… no inflation Prehospital Intubation The Debate on Prehospital (Pediatric) Intubation Continues…
Studies showing worse Studies showing better outcomes with ETI outcomes with ETI
Stiell: CMAJ 2008;178:1141-52 ¡ Winchell: Arch Surg 1997;132:592-7 Davis: J Trauma 2003;54:444-53 ¡ Klemen: Acta Anaesthesiol Scand Davis: J Trauma 2005;58:933-9 2006;50:1250-4 Davis: J Trauma 2005;59:486-90 ¡ Warner: Trauma 2007;9:283-89 Denninghoff: West J Emerg Med 2008;9:184-9 ¡ Davis: Resuscitation 2007;73:354-61 Murray: J Trauma 2000;49:1065-70 ¡ Davis: Ann Emerg Med 2005;46:115-22 Wang: Ann Emerg Med 2004;44:439-50 ¡ Bulger: J Trauma 2005;58:718-23 Wang: Prehosp Emerg Care 2006;10:261-71 ¡ Bernard: Ann Surg 2010;252:959-965 Eckstein: Ann Emerg Med 2005;45:504-9 Bochicchio: J Trauma 2003;54:307-11 Arbabi: J Trauma 2004;56:1029-32 Intubation: Indications
• Failure to oxygenate • Failure to ventilate – (Failure to remove CO2 = hypercarbic respiratory failure) • Failure to protect the airway - (or expected failure to protect the airway (GCS <8, etc) • Expected Course Demands ETT (prior to TOC) Intubation - Preparation
• Preoxygenate – Monitors - ECG, pulse ox – BLM (Sellick’s) – Good basics • Equipment selection – Miller (< 4) vs. Mac – Cuffed vs. uncuffed – ETT size • Positioning Airway Equipment
• Suction, Suction, Suction • Zofran • Magill forceps • Pedi Bougie (4-6) • Adult Bougie (6-8.5) • Stylet • ETT +/- one size (Parker flex tip ETT) • Tube check and securing devices Endotracheal Tube (ETT)
Age kg ETT Length
Newborn 3.5 3.5 9 3 mos 6.0 3.5 10 1 yr 10 4.0 11 2 yrs 12 4.5 12 Tube Size
• ETT size – (Age + 16) / 4 – Diameter of nare – Diameter of pinky – Broselow tape – Have one size smaller and larger Tube Placement -- Tip to Lip
• ETT depth – use the black line • (Age in years/2) + 12 • ETT size x 3 • Infants: wt (kg) + 6 Back-up Plan
• Can’t ventilate or basics not working – Consider adjuncts (OPA/NPA/positioning) – Intubation? • Can’t intubate – Rescue devices • Can’t rescue – Surgical procedure • Okay to stick with basics if working Laryngoscope Blades
Macintosh
Miller Laryngoscope Blades
Straight Better in younger children with a floppy epiglottis (<2-4) Laryngoscope Blades
Better in older Curved children who have a stiff epiglottis Intubation -Confirmation
• Visualize tube passing through cords (video?) • Breath sounds and no epigastric sounds
• End Tidal CO2 (ETCO2) – Waveform better than colorimetric (not reliable in CPR)
Masimo EMMA Device (mainstream ETCO2) Deterioration of Intubation: “DOPE”
• Displaced • Obstructed • PTX • Equipment Rapid Sequence Intubation
• Does increase intubation success • You stop intrinsic breathing – You can kill them • Again – positive and negative outcomes in the literature • If it’s not done well or not associated with exceptional “oxygenator/ventilator” use --- then it does harm RSI Medications
• Same as adults – Lidocaine – Etomidate – Succinylcholine – Rocuronium • Atropine not “required” • Consider ketamine RSA Medication Sequence
Optimal Intubation Time 120%
100%
80%
60%
40%
20%
0% Admin 15 sec 30 sec 45 sec 60 sec 75 sec 90 sec Rocuronium Etomidate In closing
• There is airway management…… and there is everything else • Know your equipment and supporting policies • A failed airway should never be unanticipated – consider all airways potentially difficult! • Have plan B and C before proceding with plan A • Practice! Practice! Practice! REMINDER:
It’s Not Okay to Continue with Failed Techniques
“HOPE is not an airway strategy” Questions ??? [email protected] Prehospital Trauma and the Golden Hour ….. a critical review
Dave Duncan MD
CAL FIRE Disclosures
DISCLOSURE INFORMATION: None (I wish I did!) Objectives
. Brief Review of Trauma Demographics . Cover Prioritization in Prehospital Trauma Management with regard to a “Golden Hour” approach 1. Safety 2. Time (The Right Care at the Right Time) 3. Massive Hemorrhage 4. Airway 5. Breathing 6. Circulation Trauma Demographics
-- A 50/50 disease -- Annual Trauma Deaths: World: 4,000,000 US: 200,000 California: 15,000
Ranking as cause of death . #1 for age group 1-46 (causes 50% of the deaths for those under 50!) . #3 as leading cause of death overall, across all age groups Trauma Demographics
But What About Life Years??? This is (oddly) the way we attach value to life! Average age for traumatic death = 36 (about 40 “life years” lost) Trauma is responsible for the most “Life Years” Lost (more than Heart Disease and Cancer combined) . Trauma accounts for 30% of all life years lost . Cancer accounts for 16% . Heart disease accounts for 12% Trauma Demographics
The Golden Hour in Trauma: Dogma or Medical Folklore? Frederick B. Rogers, MD, MS, FACS Medical Director, Trauma Program, LGH
HISTORICAL BACKGROUND
The vernacular term “golden hour” is widely attributed to R. Adams Cowley, founder of Baltimore’s famous Shock Trauma Institute. In a 1975 article, he stated, “the first hour after injury will largely determine a critically-injured person’s chances for survival.” Trauma Demographics
Sci Am. 1983 Aug;249(2):28-35. Trauma- Accidental and intentional injuries account for more years of life lost in the U.S. than cancer and heart disease. Among the prescribed remedies are improved preventive efforts, speedier surgery and further research. Trunkey DD. PMID: 6623052 Trauma Demographics
But What About the timing of a Trauma Death?? About 50% die immediately Trauma Demographics
But What About the timing of a Trauma Death?? About 30% die an “early death” (first 24 hrs) Trauma Deaths ---- 50/50’s: 50% die on scene 50% are transported then die
some of these are “preventable deaths” ---- those are the golden hour targets 50% 50%
Bleeding CNS injury 45% 41% 50% of these die in the first 2 hours
Other 4% Organ failure 10% CRASH-2 Results: bleeding
1200
1000
800 Deaths Due to Bleeding
600 Deaths Due to All Other Causes
400
200
0 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 Golden Hour Days Trajectory Deaths per Minute
The Golden Hour is where we have decided to draw an arbitrary line, (but it is a great place to draw one)
# Trauma Deaths THE EARLIER THE MINUTE, THE MORE (All Causes) LIKELY THE INTERVENTION WILL SAVE A LIFE
0 30 60 120 240 480 Minutes From Injury ------deaths taper off ZERO Preventable Deaths Program ZERO Preventable Deaths ZERO Preventable Deaths is: Evidence Based Medicine (EBM) (Levels of Evidence for Clinical Application)
Level of evidence 1
2
3
4 Evidence Based Medicine
What Really Happens! Evidence Based Medicine (How do we better implement…..)
. Know the Evidence (Read the study!!!) . Know the Arguments . Know the Controversy . Stand By the Evidence (Don’t get buried by the big dogs!)
Oh No!! These Facts and Opinions all Look so Similar!!! (PIXAR movie: Inside Out) But not everything lends itself to a prospective study! 2. Time The “Golden Hour”
The Golden Hour is hard to prove prospectively . TCCC – Tactical Combat Casualty Care: “the Correct Intervention at the Correct Time”
• Observe the “Golden Hour” • Appropriate Dispatch and Transport Decisions Appropriate Trauma/MCI System Design Appropriate Level of Care (BLS/ALS/Nurse/MD) Appropriate Transport Modality • Timely Interventions for those with preventable deaths 2. Time The “Golden Hour”
Ann Emerg Med. 2010 Mar Emergency medical services intervals and survival in trauma: assessment of the "golden hour" in a North American prospective cohort.
STUDY OBJECTIVE: The first hour after the onset of out-of-hospital traumatic injury is referred to as the "golden hour," yet the relationship between time and outcome remains unclear. We evaluate the association between emergency medical services (EMS) intervals and mortality among trauma patients with field-based physiologic abnormality. METHODS: This was a secondary analysis of an out-of-hospital, prospective cohort registry of adult (aged > or =15 years) trauma patients transported by 146 EMS agencies to 51 Level I and II trauma hospitals in 10 sites across North America from December 1, 2005, through March 31, 2007. Inclusion criteria were systolic blood pressure less than or equal to 90 mm Hg, respiratory rate less than 10 or greater than 29 breaths/min, Glasgow Coma Scale score less than or equal to 12, or advanced airway intervention. The outcome was in-hospital mortality. We evaluated EMS intervals (activation, response, on-scene, transport, and total time) with logistic regression and 2-step instrumental variable models, adjusted for field-based confounders. RESULTS: There were 3,656 trauma patients available for analysis, of whom 806 (22.0%) died. In multivariable analyses, there was no significant association between time and mortality for any EMS interval: activation (odds ratio [OR] 1.00; 95% confidence interval [CI] 0.95 to 1.05), response (OR 1.00; 95% CI 9.97 to 1.04), on-scene (OR 1.00; 95% CI 0.99 to 1.01), transport (OR 1.00; 95% CI 0.98 to 1.01), or total EMS time (OR 1.00; 95% CI 0.99 to 1.01). Subgroup and instrumental variable analyses did not qualitatively change these findings. CONCLUSION: In this North American sample, there was no association between EMS intervals and mortality among injured patients with physiologic abnormality in the field. 2. Time The “Golden Hour” 2. Time The “Golden Hour” 2. Time The “Golden Hour” Time…. The “Golden Hour”….. …………and the Gates Effect
With the premise that battlefield casualties would benefit from reduced time between injury and care, and a firm belief that one hour was a matter of “A morale obligation to the troops,”…
…on June 15, 2009, Sec Def Robert M. Gates directed a ≤60-minute standard, from call to treatment facility arrival, for prehospital helicopter transport of U.S. military casualties with critical injury…cutting in half the previous goal of two hours, and aligning with the “GoldenThe Hour”DoD Joint concept. Trauma System evaluated compliance with this new ≤60-minute mandate and described patient injury, treatment, and transport time relative to morbidity and mortality outcomes. 25 Time…. The “Golden Hour”….. …………and the Gates Effect
26 Time The “Golden Hour” JAMA Surg. 2016 Jan;151(1):15-24. doi: 10.1001/jamasurg.2015.3104. The Effect of a Golden Hour Policy on the Mortality of Combat Casualties. OBJECTIVES: To compare morbidity and mortality for casualties before vs after the mandate (2009) and for those who underwent prehospital helicopter transport in < 60 minutes, vs >60 minutes. DESIGN, SETTING, AND PARTICIPANTS: A retrospective analysis of battlefield data examined 21,089 US military casualties that occurred during the Afghanistan conflict from September 11, 2001, to March 31, 2014. RESULTS: There was a decrease in median transport time from 90 min to 43 min; P < .001)
For the total casualty population, the percentage killed in action went from: 16.0% to 9.9% - after golden hour mandate; P < .001 Missions achieving helicopter transport in <60 minutes was 25% before vs 75% after mandate, P < .001). When adjusted for injury severity score, the percentage killed in action was lower for those critically injured who received a blood transfusion 6.8% after mandate [40 of 589] vs 51.0% before mandate [249 of 488]; P < .001) Trauma Deaths - Timing J.Trauma.1997 Sep;43(3):433-40. Fatal trauma: the modal distribution of time to death is a function of patient demographics and regional resources.
BACKGROUND: Unlike previous studies in an urban environment, this study examines traumatic death in a geographically diverse county in the southwestern United States. METHODS: All deaths from blunt and penetrating trauma between November 15, 1991, and November 14, 1993, were included. 150 variables were collected on each patient, including time of injury and time of death. RESULTS: A total of 710 traumatic deaths were analyzed. Approximately half of the victims, 52%, were pronounced dead at the scene. Of the 48% who were hospitalized, the most frequent mechanism of injury was a fall. Neurologic dysfunction was the most common cause of death. Two distinct peaks of time were found on analysis: 23% of patients died within the first 60 minutes and 35% of patients died at 24 to 48 hours after injury. Trauma Deaths - Timing Baylor University: 2010 Oct;23(4):349-54. Changing epidemiology of trauma deaths leads to a bimodal distribution.
Injury mortality was classically described with a trimodal distribution, with immediate deaths at the scene, early deaths due to hemorrhage, and late deaths from organ failure. We hypothesized that the development of trauma systems has improved prehospital care, early resuscitation, and critical care and altered this pattern. This population-based study of all trauma deaths in an urban county with a mature trauma system reviewed data for 678 patients (median age, 33 years; 81% male; 43% gunshot, 20% motor vehicle crashes). Deaths were classified as immediate (scene), early (in hospital, ≤4 hours from injury), or late (>4 hours after injury). Multinomial regression was used to identify independent predictors of immediate and early versus late deaths, adjusted for age, gender, race, intention, mechanism, toxicology, and cause of death. Results showed 416 (61%) immediate, 199 (29%) early, and 63 (10%) late deaths. Compared with the classical description, the percentage of immediate deaths remained unchanged ----- and early deaths occurred much earlier (median 52 vs 120 minutes). Time - The “Golden Hour” (and “homie” transport)
Arch Surg. 1996 Feb;131(2):133-8. Paramedic vs private transportation of trauma patients. Effect on outcome. BACKGROUND: Prehospital emergency medical services (EMS) play a major role in any trauma system. However, there is very little information regarding the role of prehospital emergency care in trauma. To investigate this issue, we compared the outcome of severely injured patients transported by paramedics (EMS group) with the outcome of those transported by friends, relatives, bystanders, or police (non-EMS group). DESIGN: We compared 4856 EMS patients with 926 non-EMS patients. General linear model analysis was performed to test the hypothesis that hospital mortality is the same in EMS and non-EMS cases, controlling for confounding factors. SETTING: Large, urban, academic level I trauma center. RESULTS: The two groups were similar with regard to mechanism of injury and the need for surgery or intensive care unit admission. The crude mortality rate was 9.3% in the EMS group and 4.0% in the non-EMS group (relative risk, 2.32; P < .001). After adjustment for ISS, the relative risk was 1.60 (P = .002). Subgroup analysis showed that among patients with ISS greater than 15, those in the EMS group had a mortality rate twice that of those in the non-EMS group (28.8% vs 14.1%). The adjusted mortality among patients with ISS greater than 15 was 28.2% for the EMS group and 17.9% for the non-EMS group (P < .001). (Mortality for EMS transport was twice that of homie transport) CONCLUSIONS: Patients with severe trauma transported by private means in this setting have better survival than those transported via the EMS system. Large prospective studies are needed to identify the factors responsible for this difference ----- What????? 2. Time The “Golden Hour”
Injury. 2014 Sep;45(9):1320-6. doi: 10.1016/j.injury.2014.05.032. Epub 2014 Jun 5. Increased mortality associated with EMS transport of gunshot wound victims when compared to private vehicle transport.
BACKGROUND: Recent studies suggest that mode of transport affects survival in penetrating trauma patients. We hypothesised that there is wide variation in transport mode for patients with gunshot wounds (GSW) and there may be a mortality difference for GSW patients transported by emergency medical services (EMS) vs. private vehicle (PV). STUDY DESIGN: We studied adult (≥16 years) GSW patients in the National Trauma Data Bank (2007-2010). Level 1 and 2 trauma centres (TC) receiving ≥50 GSW patients per year were included. Proportions of patients arriving by each transport mode for each TC were examined. In-hospital mortality was compared between the two groups, PV and EMS, using multivariable regression analyses. Models were adjusted for patient demographics and injury severity RESULTS: 74,187 GSW patients were treated at 182 TCs. The majority (76%) were transported by EMS while 12.6% were transported by PV. Unadjusted mortality was significantly different between PV and EMS (2.1% vs. 9.7%, p<0.001). After adjustment for ISS and demographics: EMS transported patients had a greater than twofold odds of dying when compared to PV (OR=2.0, 95% CI 1.73-2.35). Time The “Golden Hour” Scand J Trauma Resusc Emerg Med. 2016 Apr 27;24:60. doi: 10.1186/s13049-016-0252-1.
Effect of private vs EMS transportation in trauma patients in a mostly physician based system- a retrospective multicenter study based on the TraumaRegister DGU®.
BACKGROUND: The effects of private transportation (PT) to definitive trauma care in comparison to transportation using Emergency Medical Services (EMS) have so far been addressed by a few studies, with some of them finding a beneficial effect on survival. The aim of the current study was to investigate epidemiology, pre- and in-hospital times as well as outcomes in patients after PT as compared to EMS recorded in the TraumaRegister DGU®. METHODS: All patients in the database of the TraumaRegister DGU® (TR-DGU) from participating European trauma centers treated in 2009 to 2013 with available data on the mode of transportation, ISS ≥ 4 and ICU treatment were included in the study. Epidemiological data, pre- and in-hospital times were analysed. Outcomes were analysed after adjustment for RISC-II scores. RESULTS: 76,512 patients were included in the study, of which 1,085 (1.4 %) were private transports). Median pre-hospital times were also reduced following PT (59 min for EMS vs. 46 for PT). In-hospital time in the trauma room (66 for EMS vs. 103 min for PT) was prolonged following PT. Outcome analysis after adjustment for RISC-II scores showed a survival benefit of PT over EMS transport: EMS 1.07 vs PT 0.85 = (20% lower mortality by private transport)
DISCUSSION: The current study shows a distinct pattern concerning epidemiology and mechanism of injury following PT. PT accelerates the median pre-hospital times, but prolongs time to diagnostic measures and time in the trauma room. CONCLUSIONS: In this distinct collective, PT seemed to lead to a small benefit in terms of mortality, which may reflect pre-hospital times, pre-hospital interventions or other confounders. SAFETY & TIME --- Safety First!
Tactical Combat Casualty Care (TCCC) . The goals of (TCCC) are: 1) Save preventable deaths 2) Prevent additional casualties . There are three categories of casualties on the battlefield: 1. Those who will live regardless 2. Those who will die regardless 3. Those who will die from preventable deaths unless………
This is the group MEDICS can help the most. • 60% Hemorrhage • 33% Tension Pneumothorax • 6% Airway Obstruction Massive Hemorrhage
Patients can exsanguinate in a few minutes! (Really)
. Prioritize Methods of Hemorrhage Control . Direct Pressure . Pressure Dressing . Wound Packing . Hemostatic Agents . Combat Application Tourniquet (CAT) . TXA?? Junctional Tourniquets? Reboa?? Massive Hemorrhage (an NAEMSP evidence based algorithm)
https://www.facs.org/~/media/files/quality%20programs/trauma/education/acscot%20evidenceb ased%20prehospital%20guidelines%20for%20external%20hemmorrhage%20control.ashx Hemorrhage Control
Hemostatic Agent (EMSA approved products) Massive Hemorrhage Control (pressure dressing, trauma dressing, Israeli Bandage) Impact of Tourniquet Use Kragh - Annals of Surgery 2009
• Ibn Sina Hospital, Baghdad, 2006 • Tourniquets saved lives on the battlefield. • Survival was better when tourniquets were applied BEFORE casualties went into shock. • 31 lives were saved in this study by applying tourniquets in the prehospital setting rather than in the ED • An estimated 1000-2000 lives have been saved in this war to date by tourniquets. (Data provided to Army Surgeon General) 6. Circulation . Different tissues have different life spans with ischemia: (keep the brain alive) • Brain 6 minutes • Heart 30 – 60 minutes • Gut 1 - 2 hours • Skeleton 6 hours . No more high volume crystalloid resuscitation (except maybe with TBI - more to come) . Blood Product Resuscitation: “1:1:1” (or 2:1:1) ( Thanks to the DOD – whole blood is the ticket ) • 1-2 PRBC • 1 FFP • 1 PLT 6. Circulation
. Permissive hypotension (or low volume fluid resuscitation) was first studied in 1994,
. But in 1918…..
“Injection of a fluid that will increase blood pressure has dangers in itself. … If the pressure is raised before the surgeon is ready to check any bleeding that might take place, blood that is sorely needed may be lost.” — Walter Cannon, 1918 6. Circulation (Permissive Hypotension) 6. Circulation (Permissive hypotension)
Crit Care Med. 2014 Apr;42(4):954-61. doi: 10.1097/CCM.0000000000000050.
Liberal versus restricted fluid resuscitation strategies in trauma patients: a systematic review and meta-analysis of randomized controlled trials and observational studies
OBJECTIVE: Hemorrhage is responsible for most deaths that occur during the first few hours after trauma. Animal models of trauma have shown that restricting fluid administration can reduce the risk of death; however, studies in patients are difficult to conduct due to logistical and ethical problems. To maximize the value of the existing evidence, we performed a meta-analysis to compare liberal versus restricted fluid resuscitation strategies in trauma patients.
STUDY SELECTION: We selected randomized controlled trials and observational studies that compared different fluid administration strategies in trauma patients. There were no restrictions for language, population, or publication year. DATA SYNTHESIS: The quantitative synthesis indicated that liberal fluid resuscitation strategies might be associated with higher mortality than restricted fluid strategies, both in randomized controlled trials (risk ratio, 1.25; 95% CI, 1.01-1.55; three trials; I(2), 0) and observational studies (odds ratio, 1.14; 95% CI, 1.01-1.28; seven studies; I(2), 21.4%). When adjusted odds ratios were pooled for observational studies, odds for mortality with liberal fluid resuscitation strategies increased 26.3% CONCLUSIONS: Current evidence indicates that initial liberal fluid resuscitation strategies may be associated with higher mortality in injured patients. However, available studies are subject to a high risk of selection bias and clinical heterogeneity. “Brain Circulation” - a battle against ICP
. The survival of the patient with significant TBI is directly proportional to their SBP: . Up to about 120 . 10% increased mortality for each 10 pt drop in SBP!
Spaite, et al 6. Circulation
. How about medications to help maintain blood volume in trauma ???? 274 Hospitals 20,211 Patients
40 Countries CRASH-2 Results: bleeding
1200
1000
800 Deaths Due to Bleeding
600 Deaths Due to All Other Causes
400
200
0 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 Days CRASH-2 Results “the results weren’t that impressive”
Cause of TXA Placebo Risk of Death P-Value Death 10,060 10,067
------Bleeding 489 574 0.85 (0.76–0.96) 0.0077
Thrombosis 33 48 0.69 (0.44–1.07) 0.096
Organ failure 209 233 0.90 (0.75–1.08) 0.25
Head injury 603 621 0.97 (0.87–1.08) 0.60
Other 129 137 0.94 (0.74–1.20) 0.63
Any death 1463 1613 0.91 (0.85–0.97) 0.0035 ------CRASH-2 Results: bleeders
RR (99% CI)
≤1 hour 0.68 (0.54–0.86), p = 0.0001
>1 to ≤ 3 hours 0.79 (0.60–1.04), p = 0.033
>3 hours 1.44 (1.04–1.99) p = 0.004 All Bleeding Patients 0.85 (0.76–0.96) P=.0077
.7 .8 .9 1 1.1 1.2 1.3 1.4 1.5 “CRASH was done in 3rd World Countries” Reduces mortality everywhere - particularly well in modern countries RR (95% CI) Hospitals Asia 114
Latin America 56
Africa 52
EU, Australia, Canada 48
World 0.72 (0.63–0.83)
.5 .6 .7 .8 .9 1 1.1 TXA Better TXA *** Note: High Income Countries mortality risk reduction = 37% Worse (3/4 of participants were moderate or high income countries) TXA in the Military - MATTERS
Military Application of TXA in Trauma Emergency Resuscitation (293/896 consecutive patients received TXA)
RESULTS: The TXA group had lower unadjusted mortality than the non-TXA group (17.4% vs. 23.9%, respectively; P = .03) despite being more severely injured (mean ISS = 25.2 vs. 22.5, respectively; P < .001). This benefit was greatest in the massive transfusion group (TXA group mortality = 14.4% vs 28.1% in non-TXA group; P=.004). TXA in Pediatric Trauma – Combat Setting
J Trauma Acute Care Surg. 2014 Dec;77(6):852-8; Tranexamic acid administration to pediatric trauma patients in a combat setting: the pediatric trauma and tranexamic acid study (PED-TRAX)
SUMMARY: . 766 patients < 18 yrs admitted to NATO hospital: 2008-2012 . Average age = 11 . 76% required surgery / 35% required Transfusion = SICK!!! . 66 (9%) received TXA . TXA group had > ISS, Hypotension, Acidosis, Coagulopathy . TXA group had markedly and significantly reduced mortality: Odds Ratio = 0.3 (P < .03) . (30% mortality reduction) Case #1 ----- MVA/Polytrauma
. 4/17/14 . 8 year old female . 29.5kg . Restrained front passenger in a “Razor” off road vehicle . Helmeted / Belted . Initial GCS 7 . Unresponsive with minimal respiratory effort ---- Dad gave rescue breaths Initial Assessment
. Head 2” lac above left eye Blood in mouth and nose . Neck Trachea midline, no JVD . Chest 6” full thickness lac Right shoulder toward right nipple Right clavicle crepitus . Neuro - GCS 7 5 Initial Assessment
. ABD Soft Pelvis stable . Extremities Open right tib/fib fracture with 5” full thickness lac Multiple exposed bone segments No distal pulse
Significant bleeding controlled Treatment En Route
. NRB 15lpm . Spinal immobilization . PIV- 18g Left AC, 20g right AC . 100ml NS . Repositioning right leg = positive pulses . Transport to local hospital for airway management and stabilization . Decorticate posturing / GCS 4 . Intubated
Lidocaine 30mg
Etomidate 9mg
Succs 45mg . Propofol gtt 20mcg/kg/min
. 1320: pH 7.21, PCO2 51.3 PO2 324, Bicarb 20.7/-7 H/H: 9.9/29 . 1325: 500ml LR bolus . 1330: TXA 1gram/ 10mins . 1 unit PRBC Diagnosis and Findings
. Subarachnoid Hemorrhage, Subdural Hemorrhage, and diffuse axonal brain injury . Closed fracture clavicle . Open Comminuted Tib/ Fib fx with tissue loss . Lung contusion . Pneumothorax . Hemothorax . Small Liver Laceration . C7, T6-8 spinal fx Blood Products . CRMC
2 unit PRBC’s (3 total)
1 unit FFP and 60ml Cryoprecipitate The Golden Hour: In Summary…. The early minutes save preventable deaths
“the Correct Intervention at the Correct Time” . ABOVE ALL DO NO HARM – Unnecessary procedures and lengthy scene times do harm . Remember we can only save those that have preventable deaths…. . The correct time for the correct intervention is different for every injury that is about to kill you: Consider this MCA vs Tree case: 1) Facial Crush with Airway compromise and 2) Expanding anterior neck hematoma: 15 Minutes for RSI 3) Tension Pneumothorax: 20 Minutes for needle thoracostomy 4) TBI with Hypoxemia and Hypotension: Correction ASAP to minimize secondary brain injury 5) Grade 4 spleen and liver injury 1 hour for Transfusion and to the OR Questions ???
Contact: Dave Duncan [email protected]
State of the Art EMS Protocols Are Created, Not Born That Way Dr. Paul Rostykus State of the Art EMS protocols are created, not born that way
Paul S. Rostykus, MD, MPH, FAEMS [email protected] @TeleDoc FAEMS Fellow of the Academy of Emergency Medical Services
✓NAEMSP member (Oregon 43) ✓ABEM EMS subspecialty certification (Oregon 8+1) ✓Medical Director ≥ 2 years ✓Contribution to NAEMSP ✓Contribution to specialty practice organizations, operations ✓Contribution to specialty development teaching, research, testing, reviewer What makes a good EMS protocol? Good EMS protocols? Useful to EMS providers
Best patient care - EBG
Reviewed regularly - annually? & prn
Local circumstances Today
EMS Protocols
Evidence Based Guidelines (EBG)
Protocol variability
Creating State of the Art protocols Protocols from 280 agencies >1500 pages
ANAPHYLACTIC REACTION ANAPHYLACTIC REACTION (cont.)
DESIGNATION OF CONDITION d. Pediatric - administer DIPHENHYDRAMINE [1mg/kg] slow IV/IO or deep IM with a max dose of 50 mg. Signs and symptoms may include any one or all of the following: wheezing associated with bronchoconstriction and/or stridor associated with upper airway edema, tachycardia, tachypnea, 7. En-route, initiate a large bore IV of an isotonic solution titrate to maintain adequate vital dyspnea, diminished lung sounds, diaphoresis, tripod positioning, facial swelling, hives, shock and signs. perhaps a history of severe allergies. Respiratory involvement may or may not occur in all cases of anaphylaxis. Be aware of “silent chest” presentation in cases of severe respiratory distress 8. Consider administration of SOLUMEDROL: associated with poor air exchange. a. Adult - [125-250 mg] IV/IO EMPHASIS ON PATIENT CARE b. Pediatric - [1-2mg/kg] IV/IO
Maintenance of airway, adequate oxygenation, adequate perfusion. 9. If there is a marked decrease in BP, or the patient is displaying signs & symptoms of respiratory and/or cardiovascular collapse (paramedic only): FR and BASIC PRE-HOSPITAL MANAGEMENT a. Adult - administer EPINEPHRINE 1:10,000 [0.1 mg] IV/IO over 5 minutes and 1. Primary assessment - Assess airway, breathing and circulation and manage as indicated. initiate epinephrine infusion at 1.0-4.0 mcg/minute. b. Pediatric - administer EPINEPHRINE 1:10,000 [0.01 mg/kg] IV/IO over 5 minutes. 2. Rapidly transport the patient to an appropriate medical facility. Consider ILS or ALS intercept. Note: Cardiac monitoring (at all levels) should be done for all patients receiving Epinephrine. 3. History, physical exam, vital signs.
4. Remove injection mechanism if still present and treat wound.
5. If patient exhibits respiratory distress administer EPINEPHRINE 1:1,000: a. Adult - [0.3mg] SQ or IM from {an auto-injection device – FR} {a pre-measured, pre- filled device or 0.3 ml dose limiting syringe – Basic}. b. Pediatric - [0.01mg/kg] SQ or IM from{a pediatric auto-injection device – FR} {a pre- measured, pre-filled pediatric device, or 0.3 dose limiting syringe – Basic}. Not to exceed the adult dose. c. Consider administration of ALBUTEROL [2.5 – 5.0 mg] with or without IPRATROPIUM [0.5 mg], or XOPENEX [0.63 – 1.25 mg] with or without IPRATOPIUM [0.5 mg.].
INTERMEDIATE and PARAMEDIC PRE-HOSPITAL MANAGEMENT
6. Treatment should continue at the Intermediate and Paramedic level as follows: a. Adult - administer EPINEPHRINE 1:1000 [0.3mg] SQ or IM. May be repeated once in 10 minutes if hypotension or severe dyspnea is still present. b. Pediatric - administer EPINEPHRINE 1:1000 [0.01 mg/kg] SQ or IM. c. Adult - administer DIPHENHYDRAMINE [12.5-50 mg] slow IV/IO at a rate of 1ml/min. or deep IM. (Continued next page) 8 7
Pennsylvania Department of Health Respiratory 4011 – ALS – Adult/Peds
ALLERGIC REACTION STATEWIDE ALS PROTOCOL
Initial Patient Contact - see Protocol #201
Look for Medic Alert bracelet/necklace
Manage Airway/ Ventilate, if needed Apply Oxygen if needed
Monitor ECG (unless mild reaction) and Pulse Oximetry, remove stinger if visible1, keep part dependent if possible, apply cold pack as available
Severe Respiratory Distress/ Wheezing or Hypotension (BP < 90 systolic) 2
NO YES
Initiate IV NSS for moderate reactions 3 Adult Patient Pediatric
EPINEPHrine 1:1000; EPINEPHrine 1:1000;
Adult Patient Pediatric 0.3 mg IM 0.01 mg/kg IM (max dose 0.3 mg)
Initiate IV/IO NSS Initiate IV/IO NSS 6 If Hypotension is present, If Hypotension is present, 1000 mL wide open 20 mL /kg wide open
Diphenhydramine Diphenhydramine Diphenhydramine Diphenhydramine 50 mg IV/IM/PO 3,4 1 mg/kg IV/IM/PO 3 4,5 4,5 50 mg IV/IO 1 mg/kg IV/IO (max. dose 50 mg) 4 (max. dose 50 mg)
If wheezing, Nebulized If wheezing, Nebulized Bronchodilator (see box) Bronchodilator (see box)
Contact Medical Command May repeat continuously, May repeat if needed continuously, if needed
BRONCHODILATOR OPTIONS Methylprednisolone Methylprednisolone (if available) (if available) Albuterol (approx. 2.5 mg) nebulized 125 mg IV 2 mg/kg IV OR Albuterol (approx 3 mg)/ ipratropium (500 mcg) combination nebulized. [H alf dose if ≤ 14 y/o] Contact Medical Contact Medical Command Command
Repeat EPINEPHrine IM Repeat EPINEPHrine IM or push dose (diluted) IV 6 or push dose (diluted) IV 6 Repeat IV/IO NSS bolus Repeat IV/IO NSS bolus (up to 2000 mL total) (up to 60 mL/kg total)
Effective 09/01/15 4011-1 of 2 ALS protocols Mandatory A – required use Mandatory B – required use, may alter protocol Mandatory C - required use, may use own protocols Model Guidelines – statewide protocols may be used
Kupas DF, Schenk E, Sholl JM, Kamin R. Characteristics of statewide protocols for emergency medical services in the United States. Prehosp Emerg Care. 2015;19(2):292-301 EMS in Oregon #Counties 36 # EMS Providers 12,779* #Ambulance Agencies 136* # Non-transporting Agencies 199 #EMS Medical Directors 141
OHA - EMS & Trauma – January 30, 2015 OHA - EMS & Trauma – April11, 2017* ASA map Oregon Medical Board EMS Scope of Practice - OAR 847 Supervising Physician Written Standing Orders (Protocols)
EMS Provider Practice Evidence
Based Guidelines
National Model EMS Clinical Guidelines
Abstract
These guidelines will be maintained by NASEMSO to facilitate the creation of state and local EMS system clinical guidelines, protocols or operating procedures. System medical directors and other leaders are invited to harvest content as will be useful. These guidelines are either evidence-based or consensus-based and have been formatted for use by field EMS professionals.
NASEMSO Medical Directors Council
All Rights Reserved V.11-14 www.nasemso.org Evidence-based Prehospital Guideline for: Pediatric Seizure Management Analgesia in Trauma Air Medical Transportation of Trauma Patients External Hemorrhage Control 2015 AHA ECC & CPR
Resuscitation – November 3, 2015 Class of Recommendation I STRONG - Benefit >>> Risk recommended/indicated/effective/beneficial IIa MODERATE - Benefit >> Risk reasonable/can be useful, effective, beneficial IIb WEAK - Benefit ? Risk might/may be reasonable/beneficial III No Benefit (MODERATE) Risk = Benefit not recommended/indicated/effective/beneficial III Harm (STRONG) Risk > Benefit causes harm/excess morbidity or mortality
Level of Evidence (LOE)
A > 1 high quality RCT B-R ≥ 1 moderate quality RCT B-NR ≥ 1 moderate quality non-RCT C-LD studies with limitations C-EO expert opinion
Protocol variability Hypoglycemia OHCA, STEMI, Stroke Fluid in trauma 911 “Person Down” S unconscious PMH – IDDM Took insulin Didn’t eat & exercised O GCS = 3 CBG = 35 A Hypoglycemia – severe P ? D50? D50 (25 g/50 ml) Effective Textbooks Tradition Blood volume 70 ml/kg
Blood glucose 100 mg/dl
Body glucose 70 mg/kg
5 g Adult blood glucose 5/14/2013 © Paul S. Rostykus, MD, MPH 2013 31 EMSOverkill? glucose
1010X Blood Glucose Content Glucose dose PALS
55X CBG ~ 100 1X 0 0 5/14/2013Adult 25 g © Paul S. Rostykus, MD, MPH0.5g/kg 2013 1 g/kg32 Glucose Transporter
GLUT © Paul S. Rostykus, MD, MPH 2013 Glucose uptake vs Blood glucose
GLUT3 (brain)
0 36 72 108 144 180
Rate of glucose uptake (% of max) of (% uptake glucose of Rate Glucose (mg/dl) © Paul S. Rostykus, MD, MPH 2013 Glucose Uptake (maximal) 6 mg/kg/min = 0.006 g/kg/min 0.36 g/kg/hour
D50 dose IV Adult: 0.33 g/kg/1-3 minutes PALS: 0.5-1 g/kg/1-3 minutes 35 Glucose used vs Glucose administered (Administered over 2 minutes) 0.6 83X
0.4 42X Glucose Uptake
0.2 28X Glucose g /kg/min g Glucose
0 Adult Ped 0.5 g/kg Ped 1 g/kg pediatric med calculation errors
D50 D25 D12.5 D10
Hoyle, Jr. JD, Davis AT, Putman KK, Trytko JA, Fales WD. Medication Dosing Errors in Pediatric Patients Treated by Emergency Medical Services. Prehospital Emergency Care 2012;16:59-66
© Paul S. Rostykus, MD, MPH 2013 © Paul S. Rostykus, MD, MPH 2013 38 © Paul S. Rostykus, MD, MPH 2013 RCT – D10 vs D50
Hypoglycemic adults Aliquots of 5g IV – maximum 25 g Similar time to GCS = 15 D10 less total glucose D10 less hyperglycemia afterwards*
Moore C, Woollard M. Dextrose 10% or 50% in the treatment of hypoglycaemia out of hospital? A randomized controlled trial. Emerg Med J 2005;22:512–515 UK Ambulance Service
• D10 since ~2000 Adults - 10g = 100 ml (~0.1g/kg) Pediatrics < 40 kg 0.5 g/kg = 5 ml/kg Jackson County Fire EMS Hypoglycemia protocol (started July 1, 2013) D10 Adults 0.1 g/kg = 1 ml/kg Pediatric 0.1 g/kg = 1 ml/kg Repeat every 3-5 minutes based on: CBG & GCS D10 Experience
• 1,323 hypoglycemic adults/24 months • 871 full data obtained • 100 ml of D10 IV – 23% repeated dose • Effective • No adverse events
Hern HG, Kiefer M,, Louie D , Barger J, Alter HJ. D10 in the treatment of prehospital hypoglycemia: a 24 month month observational cohort study. PEC 2017;21(1):63-67 Retire D50? D10 – 0.1 g/kg Effective – titrate Safer – less hypertonic Easier – no dilutions Variability in the treatment of prehospital hypoglycemia: a structured review of EMS protocols in the United States Rostykus P Kennel J Adair K Fillinger M Palmberg R Quinn A Ripley J Daya M
PEC July/Aug 2016 185 US EMS Agency Protocols Hypertonic Glucose Usage Hypoglycemia Treatment Descriptive Study Data Collection Tool OIT IRB approval EMS Protocols
www.emsprotocols.org US 50 largest (172) (47)
Both (34) 5/14/2013 © Paul S. Rostykus, MD, MPH 2013 48 D50 vs D10
D10 D50 (55)
(170) Both (40) Pediatric Dilutions (D50 only)
Yes Not listed 85% No 2% 13% Neonatal Concentration
Not listed 26% D10 D50 46% D25 1% 11% D12.5 17% Initial Adult Dextrose Dose D50 D10 25 g 78% Titrate 25 g 19% 73% < 25 g 0.1 g/kg 3% 4% < 25 g Titrate 16% 7% Initial Pediatric Dextrose Dose
1 g/kg 22%
Not 0.5 g/kg listed 74% 5% < 0.5 g/kg 3% Initial Neonatal Dextrose Dose
0.5 g/kg 45% 1 g/kg 9%
Not listed 28% <0.25 g/kg 0.25-0.4 g/kg 12% 5% IV or IO
IV 34%
Both 66% Follow-up CBG or GCS
Not Both Listed 31% 33%
CBG GCS 32% 4% Glucagon Protocol
No Yes 3% 97% Non-transport Protocol
No Yes 52% 48% Limitations
Point in time Protocols, not practice Sampling of EMS protocols “Not listed” data Protocol variablility Conclusions
Protocols vary!
Best treatment? Adequacy of EMS systems of care protocols for OHCA, STEMI & stroke in Oregon: a structured review
Disclosure
This project is supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) under grant number H54RH00049, Rural Hospital Flexibility Program. * This information or content and conclusions are those of the author and should not be construed as the official position or policy of, nor should any endorsements be inferred by HRSA, HHS or the U.S. Government. Care elements OHCA - 28 STEMI - 21 Stroke - 10
OHCA, STEMI Stroke protocol review
121 Oregon licensed ambulance agencies
95 protocol sets
60 rural agencies 35 non-rural agencies
31 distinct 9 distinct protocol sets protocol sets
No protocols received 1 EMS agency 2-5 EMS agencies 6-10 EMS agencies
Figure 2. Map of Oregon counties showing the number of ambulance agencies which provided protocols
Out of Hospital Cardiac Arrest • Unresponsive • Apneic Identification • Pulseless • 911 T-CPR • Chest compressions 100-120 • AED/defibrillation • Rotate compressors Resuscitation • Airway & ventilations • IV/IO • Medications
• Hospital bypass Transport • Notification Out-of-Hospital Cardiac Arrest (OHCA) care elements in protocols (28)
Initial advanced airway Initial vasopressor Initial anti-arrhythmic Defibrillation energy Early AED/defibrillator use Magnesium if Torsades § Chest compression rate § End Tidal CO2 monitoring § Termination of Resuscitation (TOR) protocol § IV or IO established Chest compression type Ventilation rate - airway Chest compression depth § Ventilation rate - BVM § 12 lead ECG if ROSC § High flow oxygen § EMS Cooling Subsequent anti-arrhythmic Initial cardiac rhythm Rotate compressors Hospital bypass specified Subsequent vasopressor Time of cardiac arrest Back-up advanced airway Rural Non-rural Rapid determination of cardiac arrest Tidal volume Mechanical CPR Time CPR started 0% 20% 40% 60% 80% 100% Out of Hospital Cardiac Arrest (28)
Care elements > 90% protocols Initial advanced airway, vasopressor, anti- arrhythmic Early AED/defibrillator use Defibrillation energy Chest compression rate Care elements < 60% protocols Initial cardiac rhythm Rotate compressors Hospital bypass specified Time of cardiac arrest, CPR started Tidal volume STEMI
• Chest pain Identification • 12 lead ECG
• Titrate oxygen Treatment • ASA, NTG, analgesic • IV
• Hospital bypass Transport • Notification STEMI care elements in protocols (21)
Analgesic administration Nitroglycerin (NTG) administration IV established 12 lead ECG required Aspirin administration Nitroglycerin BP limit NTG Erectile Dysfunction contraindication 12 lead ECG interpretation Hospital bypass specified § STEMI notification required Determination of cardiac chest pain equivalent § 12 lead ECG delivered to hospital Oxygen to keep the SpO2 ≥ 94% EKG transmitted Time of onset of symptoms No NTG if RV MI Time of initial 12 lead Rural Time of EMS on scene § Time of STEMI notification Non-Rural Right-sided ECG leads if inferior MI § EMS fibrinolytics administration 0% 20% 40% 60% 80% 100% STEMI (21)
Care elements > 90% protocols ASA, NTG, analgesic administration IV established 12 lead ECG obtained & interpreted Care elements < 60% protocols Titrate oxygen Time of symptom onset, EMS on scene, 12 lead ECG Time of STEMI notification Stroke
• Stroke score/scale Identification • Time last known well
• Titrate oxygen • Elevate head of bed Treatment • IV • Treat hypoglycemia
• Hospital bypass Transport • Notification Stroke care elements in protocols (10)
Time of onset of symptoms IV established Stroke evaluation method § Hypoglycemia treatment Head of bed elevated § Blood glucose determination… Stroke notification required Rural Oxygen to keep the SpO2 ≥ 94% 12 lead ECG Non- rural Hospital bypass specified
0% 20% 40% 60% 80% 100% Stroke (10)
Care elements > 90% protocols Time of symptom onset IV established Stroke scale/score Hypoglycemia treatment Care elements < 60% protocols Stroke notification required Titrate oxygen 12 lead ECG Hospital bypass specified Protocol effective date Dated Within 4 years OHCA Within 1 year
Dated Within 4 years STEMI Within 1 year Rural Non-… Dated Within 4 years Within 1 year Stroke 0% 50% 100% Limitations
Missing protocols Denominator Data abstraction Protocols, not practice Conclusions Protocol variability! Rural ? 2 L SBP goal: 70-110 mm Hg or “avoid shock” HR < 120 If head injury 90-120 • What is best patient care?
Dadoo S, et al. Prehospital fluid administration in trauma patients: A survey of state protocols. PEC 2017:21;605-609 EMS medical directors write protocols
EMS medical director survey Factors in D? decision 185 EMS agencies
160 EMS medical directors emailed
85 opened email
72 completed survey Factors in D? decision Extravasation Effectiveness Post-treatment hyperglycemia Patient
Errors EMS EMS Availability Tradition medical agency/ Cost Science director provider Ease of use Evidence
Based Guidelines
National Model EMS Clinical Guidelines
Abstract
These guidelines will be maintained by NASEMSO to facilitate the creation of state and local EMS system clinical guidelines, protocols or operating procedures. System medical directors and other leaders are invited to harvest content as will be useful. These guidelines are either evidence-based or consensus-based and have been formatted for use by field EMS professionals.
NASEMSO Medical Directors Council
All Rights Reserved V.11-14 www.nasemso.org
Evidence-based Prehospital Guideline for: Pediatric Seizure Management Analgesia in Trauma Air Medical Transportation of Trauma Patients External Hemorrhage Control Pediatric Seizure Management • Monitor and transport if NOT actively seizing or recurring seizures • Treatment for active or recurring seizures • Evaluate and treat hypoglycemia • Initial dose benzodiazepine Midazolam: 0.2 mg/kg - buccal, IN or IM • 2nd dose benzodiazepine If no IV Midazolam: 0.2 mg/kg - buccal, IN or IM If IV Midazolam, Lorazepam or Diazepam 0.1 mg/kg
Shah M, et al. An Evidence-based Guideline for Pediatric Prehospital Seizure Management Using GRADE Methodology. PEC 2014:18 Sup 1;15-24 Pain Management in Trauma • Assess pain < 4 years, 4-12 years, > 12 years • Narcotic analgesic (opioid) Morphine IV: 0.1 mg/kg Fentanyl IV or IN: 1.0 mcg/kg • Cautions & Relative contraindications • Reassess pain every 5 minutes • Redose if significant pain (1/2 dose?)
Gausche-Hill M, et al. An Evidence-based Guideline for Prehospital Analgesia in Trauma. PEC 2014:18 Sup 1;25-34 External Hemorrhage Control • Prehospital tourniquet If direct pressure ineffective or impractical • Commercial tourniquets Improvised tourniquet only if commercial not available Release only with definitive care • Junctional device – no recommendation • Hemostatic Agents Use if direct pressure ineffective or no tourniquet possible Gauze format & tested for effectiveness & safety in lab
Bulger EM, et al. An Evidence-based Prehospital Guideline for External Hemorrhage Control: ACS COT. PEC 2014:18 Sup 1;163-173 If you’ve seen one EMS system….. ….then you’ve seen one EMS system. Creating State of the Art EMS protocols State of the Art EMS Protocols Useful to EMS providers Best patient care - EBG Reviewed regularly - annually & prn Local circumstances What you can do Follow the literature PEC, JEMS, AHA, NEJM, JAMA, AJEM, Annals EM, NASEMSO, #FOAMems, Prehospital & Disaster Medicine Review your EMS protocols
Talk with your EMS medical director Thanks for attending Questions? Discussion?
Paul Rostykus, MD, MPH, FAEMS [email protected] @TeleDoc
Pediatric Trauma Heather Summerby Pediatric Trauma Presented by Heather Summerby RN, CCRN, CFRN Flight Nurse, CALSTAR “If a disease were killing our children in the proportions that injuries are, people would be outraged and demand that this killer be stopped.” -C. Everett Koop, MD Pediatric Trauma
Trauma is the leading cause of childhood death and disability in the US. On average 12,175 deaths annually! (CDC) • Traumatic brain injury (TBI) is the most common cause. • Chest Trauma ~ second. • Abdominal injuries rank third as a cause of traumatic death. Mechanisms of Injury
The transfer of kinetic energy arises from several sources: – Blunt (injury to internal organs), – Penetrating (disruption of skin and organ integrity), – Acceleration-Deceleration (abrupt, forceful back and forth movement), – Crushing (direct compression of body structures). Epidemiology
• Blunt trauma accounts for more than 80% of all pediatric injuries • External evidence of injury may be minimal as energy is often absorbed by underlying structures. • Must suspect underlying potential injuries! 90 80 70 60 50 40 30 20 10 0 Blunt Penetrating Crush Other Blunt Force Trauma
1. Falls 2. Motor Vehicle Crashes 3. Car vs. Pedestrian Crashes 4. Bicycle Crashes 5. Skateboarding Injuries 6. Infant Walker – Related Injuries 7. Sledding Injuries Mechanism of Injury
Knowledge of the Mechanism of Injury allows for a high index of suspicion for the resultant injuries in the child. Initial Trauma Assessment and Intervention
Primary Assessment Identify life-threatening injuries to the airway, breathing, circulatory and neurologic systems
Secondary Assessment Identify injuries to the remaining body systems. Primary Assessment
1. Assess the Airway and Cervical Spine
2. Assess Breathing
3. Assess Circulation
4. Assess Disability (Neurologic System) Airway
• Oral airway • Nasopharyngeal airway • Endotracheal intubation • Needle cricothyroidotomy Breathing
• Rate and depth of respiration • Breath sounds, exhaled air • Crepitus, tracheal position • Oxygen saturation Circulation
• Tachycardia early • Capillary refill • External blood loss • Hypotension late finding – Kids lose 25% of blood volume before hypotension • O2 sat probe not reading IV access
• Peripheral vein – Largest bore possible • Intraosseous line Secondary Assessment
5. Expose the patient.
6. Fahrenheit – keep patient warm.
7. Get vital signs with pain scale.
8. Head-to-Toe Assessment/ History.
9. Inspect the Back. Head Injury
• Traumatic brain injury (TBI) is the most common cause of traumatic childhood death and disability in the US. • Major cause of TBIs are motor vehicle related incidents in which the child is a passenger, a pedestrian or on a bicycle. • Other head injuries result from falls, sports and play injuries. Traumatic Brain Injury
• #1 cause of trauma death
• 30% of childhood trauma deaths
• 30,000 permanent disabilities TBI
• Airway – Normo ventilation vs hyperventilation? • Maximize cerebral perfusion • Intracranial pressure monitor Head CT’s Bony Structures
Superior articular process Transverse process
Spinous process
Inferior articular process
Spinous process Lamina Posterior Superior articulating Arch process Transverse process Pedicle Vertebral foramen
McQuillan, K., Von Rueden, K., Hartsock, R., Flynn, M., & Whalen, E. (eds.). (2002). Trauma Nursing: From Resuscitation Through Rehabilitation. Philadelphia: W. B. Saunders Company. Reprinted with permission. Spinal Nerves
Spinal Nerve Area Innervated
– C4 Diaphragm – C5 Deltoids and biceps – C6 Wrist extensors – C7 Triceps – C8 Hands – T2 – T7 Chest muscles
Types of Spinal Injury
• Fracture
• Fracture with subluxation
• Subluxation alone
• SCIWORA ~ Spinal cord injury without radiographic abnormality SCI
• One study that looked at 122 injured children birth to 16 years old revealed – 41% had fracture alone – 33% fracture with subluxation – 10% with subluxation alone – 16% with SCIWORA • When subdivided further by age: Subluxation and SCIWORA are more likely to affect younger children and fractures being more common in older children (Proctor, 2002) Mechanism of Injury
• Hyperflexion • Hyperextension • Axial loading or vertical compression • Rotation • Penetrating trauma
Classification of SCI
• Complete • Incomplete*
– A total motor and – There is a partial sensory loss distal preservation of to the injury sensory and/or motor function below the level of the injury
*classified as spinal cord syndromes Classification of SCI
• Unstable Spine injury – Anatomic elements of the spine are disrupted, with deformity. – The spine can no longer maintain normal alignment – The vertebral and ligamentous structures are unable to support or protect the injured area Cervical Spine Injury
• Uncommon in young children and are associated with multiple injuries. • Child’s large head takes most of impact. • Highly elastic neck ligaments and incompletely calcified vertebral bodies allow for more pliancy of the neck. • Subluxation is more common in children. • Spinal Cord Injury Without Radiographic Abnormalities (SCIWORA) can occur.
Cervical Spine Fractures
• All patients involved in traumatic injury must be immobilized – Assume injured unless cleared – Hard collar – Miami-J – Log roll, Circulation, Motor, Sensory (CMS) exams – No high dose steroids – Spinal cord center for children
• The upper cervical spine C-1 and C-2 accounts for 20% of all c-spine fractures and the lower C-3 thru C- 7 accounts for 80%. Spinal Alignment Cervical Spine Clearance
• Conscious patient – Alert, cooperative, no neck pain, no neck tenderness, distracting injury? • Unconscious patient – Plain film - Lateral c-spine with collar on • If unable to visualize to T1 on lateral film, obtain multi-detector complete cervical spine CT – Maintain in collar – Follow guideline: "Routine Management of the Patient in a cervical collar” – MRI if not expected to awaken Neurological Assessment
• Sensorimotor exam
• Reflex function Spinal Shock
• Spinal shock is manifested by
– Flaccid paralysis – Absence of cutaneous and/or proprioceptive sensation – Loss of autonomic function – Cessation of all reflex activity below the site of injury Neurogenic Shock
Injury to T6 and above Loss of sympathetic innervation Increase in venous capacitance
Bradycardia Decrease in venous return
Hypotension
Decreased cardiac output
Decreased tissue perfusion Cardiovascular Implications
• Hypotension – Maintain SBP > 90 mmHg for transport – establish adequate pressure for systemic perfusion • Bradycardia – Treat only if symptomatic • Temperature regulation – Will become hypothermic – Frequent to continuous monitoring – Warming strategies Surgical Intervention
• Physician preference • Decision driven by mechanism of injury, neurological deficit, and structural dysfunction • Timing is controversial – Within the first 72 hours – After 7 days • Emergent surgical intervention is required for neurologic deterioration with evidence of cord compression (bone or disc fragments, malalignment, or hematoma) Critical Care Phase
• Respiratory Complications • Cardiovasular – Bradycardia – Vasovagal response • Poikilothermia • Gastrointestinal • Pain and anxiety Thoracic & Abdominal Injuries
• Musculature of the child’s chest and abdomen is less developed than in the adult. • Ribs are flexible and more anterior, thus are less protective of underlying organs. • Child’s protuberant abdomen along with its thin abdominal wall places organs close to impacting forces during a traumatic event. • Child’s small body size is predisposed to multiple injuries rather than isolated injury. Mechanism of Injury
• Should heighten suspicion regarding certain injuries • Blunt injury and types of forces • Use of restraint devices • Penetrating trauma Thoracic Trauma
• Penetrating verses Blunt – Pulmonary Contusion – Pneumothorax – Open Pneumothorax – Hemothorax – Flail Chest – Pericardial Tamponade – Traumatic Asphyxia – Traumatic Diaphragmatic Hernia Thoracic Injury
• Most common ~ pulmonary contusion and pneumothorax • Rib fractures are not that common because of the child’s pliable rib cage. • If a rib fracture occurs, serious underlying organ damage should be presumed. • In penetrating injuries, the degree of injury depends on the type of gun and bullets used, the bullet trajectory and the distance of the victim from the weapon. Pulmonary Contusion
• Results from blunt trauma to the chest that transmits energy to the underlying lung tissue. • Pulmonary edema, alveolar hemorrhage, desquamative alveolitis and subsequent RDS may result. – RDS generally within first few hours of injury • Impaired gas exchange • VQ mismatch • ↓ lung compliance • Positive pressure ventilation with PEEP and oxygen support may be required. Pneumothorax
• Collection of air into the pleural space with partial or complete collapse of the lung. – Usually caused by blunt trauma to the chest causing alveoli rupture with a resultant escape of air, thus collapsing the lung. • This injury is closed and the lung seals, preventing further leakage. – May progress to tension pneumothorax. • Needle decompression to 2nd ICS midclavicular line or chest tube management may be necessary. Open Pneumothorax
• Results from penetrating thoracic injury. • May lead to tension pneumothorax or hemothorax. • There is progressive air entry into the pleural space without a means of escape. • Lung on affected side collapses and pushes toward the unaffected side producing a mediastinal shift and compression of heart and great vessels. • Treatment includes a 3-sided occlusive dressing over the wound and chest tube placement. Tension Pneumothorax Hemothorax
• Blood collection in pleural space as a result of blunt or penetrating injury • Clinical presentation – Respiratory distress • ↓ breath sounds on affected side • Dullness with percussion – CXR suggestive – Needle aspiration definitive • Management – Chest tube – Volume resuscitation – Thoracotomy for continued blood loss Pericardial Tamponade
• Occurs when a significant amount of blood, fluid or air accumulates in the pericardial sac. • In children, as little as 25 to 50 mL can compromise ventricular function. • Findings include hypotension, neck vein distention, elevated CVP, muffled heart sounds, pulsus paradoxis (fall in BP 8-10 mm Hg during inspiration). • Pericardiocentesis provides temporary relief until surgical repair is performed. Pericardial Tamponade Abdominal Trauma Abdominal Trauma
Physical assessment: Abdominal distention or pain Dermal evidence of trauma Abdominal Trauma
. Injury to the Solid Organs . Dense and less strongly held together . Prone to contusion .Bleeding .Fracture (rupture) . Unrestricted hemorrhage if organ capsule is ruptured . Spleen: pain referred to left shoulder . Liver: pain referred to the right shoulder Abdominal Injury
• Most common MOI is blunt trauma from an MVC-related event whether as an occupant, pedestrian or bicycle rider • Other causes include sports injuries, falls and child abuse • Organs usually involved are the liver, spleen, kidneys and GI tract • Injuries to the major vessels and the pancreas are less common Organ Injury Scaling
• Injury scale • Grades I-V • Injury description • Hematoma • Laceration • Vascular • Dependent on severity and location of injury Splenic Injury
• Spleen is most commonly injured organ during blunt traumatic event. • Located on left side of abdomen below the ribs. • Injuries are classified by severity and the by the splenic structure involved (capsule, hilar vessels or parenchyma). • Signs include flank ecchymosis (Turner’s sign), umbilical ecchymosis (Cullin’s sign), left abdominal or flank pain with referred left shoulder pain (Kehr’s sign). • Treatment includes observation with serial HCTs and/or surgery. Indications for Non-operative Management
• Hemodynamically stable
• Appropriate monitoring
• Experienced personnel Liver Injury
• Liver is located in the right upper abdomen and is protected by the ribs. • Liver injuries are graded depending on the severity and location. • Clinical findings include abdominal abrasions, tenderness, distention, hypotension, and elevated SGOT and SGPT enzymes. • Treatment may include observation with serial HCTs, or surgical repair. Liver Injury
• Incidence – Second most commonly injured organs – MVC most common cause – Mortality 10% to 15% Liver
• Largest intra-abdominal organ in the body • Extremely vascular • Divided into the left and right lobes • Function – Stores products helpful to digestion of food – Filters toxins from the bloodstream • 75% of blood to the liver is delivered by the portal vein • Uncontrolled hemorrhage is the primary cause of death Pancreatic Injury
• Blunt abdominal trauma accounted for 100% of pancreatic injuries in children • Relatively uncommon in Pediatrics Pancreas Anatomy
• Large, complex gland that lies outside of alimentary tract walls • Parallel to stomach at first and second lumbar vertebrae • Not encapsulated, so tears in tissue permits digestive enzymes to leak into the peritoneal cavity Pancreatic Injury
• Clinical Manifestations – Vague abdominal pain, exacerbated by eating – Nausea/vomiting – Classic sign in adults ~ abdominal pain radiating to back is rare in children • Diagnosis – Serum amylase (non- specific) – Lipase & trypsinogen (specific) – CT Kidney Injury
• Children have relatively large kidneys, underdeveloped abdominal wall and lesser rib cage protection. • Damage is directly related to the blunt force trauma. • Clinical findings include hematuria, abdominal pain and bruising, palpable flank mass and hypovolemia. • Treatment may include observation, surgical repair or nephrectomy. Kidney Injuries Bowel Injury
• Result from direct blunt trauma or penetrating forces. • Children are at greater risk because of their protuberant abdomens, thin wall, and propensity to swallow air. • A full stomach is more prone to injury. • Injuries include bowel transection, laceration and perforation. • Clinical findings include abdominal pain, vomiting and pneumoperitoneum (free air in abdomen). • Treatment may include observation and/or surgical repair. Traumatic Diaphragmatic Hernia
• Results from severe abdominal compression. • Diaphragm ruptures, allowing abdominal contents to enter the chest cavity. • Common MOIs include a lap belt injury and pedestrian injury where the child is run over by the vehicle. • Treatment is surgical repair. Traumatic Diaphragmatic Hernia Drowning
• Drowning – Death from asphyxia by water submersion • Near-drowning – Survival after asphyxia from water submersion • Dry-drowning – Non-aspirating asphyxia during water submersion Drowning
• Most common in summer months • 50% in swimming pools • Bathtub drowning is most common in children with seizure disorders • Bucket drowning Drowning
• Pathophysiology – Pulmonary effects – Cardiovascular effects – CNS Effects • Management – EMS – Emergency Department – ICU Child Maltreatment
• Shaken Baby Syndrome – Head injury – SDH, DAI – Retinal hemorrhages – Skeletal fractures – Mortality 13-30% • Munchausen Syndrome by Proxy (MSBP) – Parent simulates or causes disease in a child • Usually preverbal children – Pattern/response doesn’t correlate with disease • Symptoms associated with proximity of parent Abuse
• Defined as (1) any act or failure to act on the part of a parent or caretaker which results in the death, serious physical or emotional harm, sexual abuse or exploitation; or (2) an act or failure to act which present an imminent risk of serious harm. • 3 Types: – Physical (bruises, hitting, choking, cigarette burns) – Emotional (constant criticism, rejection, threats) – Sexual (fondling, penetration, indecent exposure, exploitation) Neglect
• Defined as the failure to provide for a child’s basic needs • Examples: – Food, shelter, supervision, medical care, education Statistics
• Five or six children die per day in the U.S. of neglect and/or abuse. Most are under the age of six. • One in every seven victims of sexual assault is under the age of six. 90% of these victims know their offender. • 40% of the offenders of sexual abuse were under the age of 18. Disturbing Stats
• According to a 1992 study sponsored by the National Institute of Justice (NIJ), maltreatment in childhood increases the likelihood of arrest as: – A juvenile by 53 percent – An adult by 38 percent and for a violent crime by 38 percent – Being abused or neglected in childhood increases the likelihood of arrest for females by 77 percent. • A related 1995 NIJ report indicated that children who were sexually abuse were 28 times more likely than a control group of non-abused children to be arrested for prostitution as an adult Abuse and Neglect
• The actual number of abuse and neglect cases are estimated to be 3 times greater than the number reported
• Although we see more abuse cases, more than twice as many cases of neglect are reported Reporting
• Verbal Report immediately upon suspicion – Police or Sheriff’s Department (Does not include a school policy or security department) – County Probation Department (If County Designated) – County Welfare/County CPS Department • Follow up in writing – General Standard within 48 hours or as soon as possible – California Form 8572 Mandated Reporting
• Good Faith reporters are protected under the law from civil or criminal liability • Failure to report may result in fine up to $1,000
Additional Information and Training: http://mandatedreporterca.com Questions Credits
• Reid AB. Letts RM. Black GB. Journal of Trauma. [JC:kaf] 30(4):384-91, 1990 Apr • Diagnostic Imaging in Infant Abuse, Am J Roentgenol, Kleinman 155 (4):703 • The metaphyseal lesion in abused infants; a radiologic-histopathologic study, PK Kleinman, SC Marks, and B. Blackbourne, AM J Roentgenol., May 1986; 146; 895-905. Current Topics
• Some Issues Unique to Children – Reducing diagnostic radiation exposure – Family presence during resuscitation – Availability of child life specialists during care – JUMP START Triage – Fluid and electrolyte management – Blood transfusions – TXA Current Topics
Unintentional and Intentional Traumatic injury is still the #1 killer in patients age 1-18, than all other causes combined. (AAP, 2017)
The presence of pediatric trauma centers with in a state, is associated with lower pediatric injury mortality rates. Current Topics
• Younger and more seriously injured children have improved outcomes at a trauma center within a children’s hospital, or at trauma centers with both pediatric and adult trauma specialty services – MDs are trained in Pediatric: • Emergency Medicine, medical subspecialties, anesthesiology, critical care, traumatic stress, rehab and substance abuse counseling – RNs are competent in the care of pediatric trauma patients, and provide care in a well equipped and staffed PICU – Child life specialists and family support staff are present Current Topics
• START Triage vs JUMP START Triage for Peds <8 yrs – Objective tool – Not yet scientifically validated – Supported by EMSC/ current topic
1.(R) RR <15 or >40 = Reposition Airway and give 5 rescue breaths 2.(P) Cap Refill < 2 3.(M) Use AVPU 4. ANY CHILD CARRIED BY AN ADULT MUST BE IMMEDIATELY ASSESSED Current Topics
Fluid and Electrolyte management • Hemorrhage – Loss in intravascular fluid volume decrease in pre-load decreased cardiac output inadequate delivery of oxygen and nutrients to tissues and organs hypovolemic shock Treatment of Pediatric Hypovolemic Shock • The main treatment for the critically ill child with hypovolemic shock is fluid resuscitation – Rapid boluses of isotonic crystalloid IV fluids (NS-normal saline or LR-lactated Ringer’s). This treatment is primarily focused on correcting the intravascular fluid volume loss Current Topics
• Minimum dosing is at least three fluid boluses of 20 ml/kg each. As each 20 ml/kg fluid bolus is given, the Evaluate → Identify→ Intervene • Each bolus should be given over 5-10 minutes and reevaluation should take place • Typical signs that would indicate improvement are decrease in heart rate, improved urine output, decreased respiratory rate, and improved level of consciousness. (Remember, BP changes are less timely)
For hemorrhagic hypovolemic shock boluses of isotonic crystalloid IV fluids are indicated, but the shock may not improve significantly • Packed red blood cells (PRBCs) are indicated, and the standard dosing of PRBCs for refractory hemorrhagic hypovolemic shock is 10 mL/kg
(2015-2020 AHA PALS Guidelines) Current topics
Pediatric Burn Resuscitation
• Important conceptual differences • Intravenous fluid resuscitations are usually required for patients with smaller burns (in the range of 10-20%) • An IO line is an acceptable alternative in the short term • TBSA burns must be estimated using pediatric modifications. • Larger head & smaller thighs • This results in higher weight-based calculations. • Modified Parkland formula in addition to maintenance fluid rates • Modest glycogen reserves which can be exhausted quickly. • LR dextrose 5% in LR to prevent life- threatening hypoglycemia. • AccuChecks as part of Vital signs Current Topics
• TXA – Now being used for pediatrics with severe uncontrolled bleeding, 8yrs and up (With Pediatric Trauma physician consult) Given the evidence that TXA is effective at controlling bleeding during elective surgeries and may decrease mortality due to trauma in pediatric patients, some medical groups have recommended the pragmatic use of TXA in children with major trauma
• KEEP PEDIATRIC TRAUMA PATIENTS WARM!!