The Pediatric EMS Podcast

Prehospital Pediatric Traumatic Cardiac Arrest: Priorities for Care

Episode 15: Prehospital Pediatric Traumatic Cardiac Arrest: Priorities for Care Brought to you by The National Association of EMS Physicians (NAEMSP) and Missouri Emergency Medical Services for Children (MO-EMSC). Hosts: Dr. Joelle Donofrio-Odmann and Dr. Joseph Finney Website: https://sites.libsyn.com/414020 [https://sites.libsyn.com/414020] GET CEU CREDIT THROUGH PRODIGY EMS Episode Summary Episode 15 of the Pediatric EMS Podcast focuses on the case of a pediatric out-of-hospital traumatic cardiac arrest. Dr. Finney and Dr. Romeo Ignacio discuss the unique management priorities for traumatic arrest and how it differs compared to medical cardiac arrest. The episode recounts a real-life incident involving a child struck and pinned under an SUV, detailing the prehospital response, interventions, and decision-making process. Guest Expert Romeo Ignacio Jr., MD. Dr. Romeo Ignacio is the Trauma Medical Director at Rady Children's Hospital and the Section Chief of Pediatric Surgery, affiliated with UC San Diego. A former EMT and a 24-year U.S. Navy veteran, he specializes in pediatric trauma care Takehome Points 1. Differentiate Between Traumatic and Medical Cardiac Arrest: * The approach to traumatic cardiac arrest is distinct from medical arrest, with hemorrhage control and volume resuscitation taking precedence over standard CPR and epinephrine administration. 2. Follow the MARCH Algorithm for Trauma Management: * Prioritize Massive hemorrhage, Airway, Respirations, Circulation, and Hypothermia/Head Injury, ensuring a systematic approach to treating the most life-threatening issues first. 3. Blood Products Over Crystalloids for Volume Resuscitation: * If available, whole blood or blood products should be used to restore circulation in hemorrhagic shock, as excessive crystalloid fluids can dilute clotting factors and worsen coagulopathy. 4. Minimize On-Scene Time and Focus on Rapid Transport: * Definitive care for traumatic cardiac arrest requires hospital-level interventions; therefore, providers should avoid unnecessary scene delays and focus on rapid transport while continuing interventions en route. 5. Avoid the "H-Bombs" in Pediatric Traumatic Brain Injury (TBI): * Prevent Hypoxia, Hyperventilation, and Hypotension, as these factors increase mortality in pediatric trauma patients. Controlled ventilation and maintaining adequate oxygenation and perfusion are key to improving outcomes. THANK YOU Special Thank you to Monarch Fire Protection District and the amazing paramedics who continue to care for critically ill and injured patients each and every day.

Enhancing Pediatric Pre-Hospital Care: Termination of Resuscitation Criteria and Real-World Impact

Episode 14: Prehospital Pediatric Termination of Resuscitation (TOR) Brought to you by The National Association of EMS Physicians (NAEMSP) and Missouri Emergency Medical Services for Children (MO-EMSC). Hosts: Dr. Joelle Donofrio-Odmann and Dr. Joseph Finney Website: https://sites.libsyn.com/414020 [https://sites.libsyn.com/414020] GET CEU CREDIT THROUGH PRODIGY EMS Episode Summary: In this episode of the Pediatric EMS Podcast, Dr. Joseph Finney and Dr. Joelle Donofrio-Odmann are joined by Dr. Matt Harris and Dr. Jen Anders to explore groundbreaking developments in pediatric termination of resuscitation (TOR) protocols. Together, they discuss the Maryland Pediatric TOR criteria, insights from the largest pediatric cardiac arrest study to date, and practical strategies for EMS professionals to optimize care and outcomes. The panel dives deep into the science, ethical considerations, and cultural challenges of TOR, offering actionable guidance for EMS clinicians and medical directors aiming to implement these protocols. Episode Highlights: 1. Introduction to Pediatric TOR Criteria: * Key differences between BLS and ALS TOR protocols. * Unique considerations for pediatric medical and traumatic cardiac arrests. 2. Maryland Pediatric TOR Criteria: * The specific requirements for TOR in medical and trauma cases. * Emphasis on ensuring emotional and community support during field terminations. 3. Key Findings from the ESO Databank Analysis: * Analysis of over 1,500 pediatric cardiac arrest cases. * High specificity of TOR protocols, especially when excluding drowning cases. * The critical role of end-tidal CO2 monitoring in determining outcomes. 4. Exclusion of Drowning Cases: * Why drowning victims are not included in TOR protocols due to their high resuscitation and neurologic recovery rates. 5. Cultural Barriers to Pediatric TOR Implementation: * Addressing the belief that "everything must be done" for children. * Shifting the focus toward high-quality, on-scene resuscitation. 6. Real-World Impact of TOR in Maryland: * Adoption of TOR protocols in Maryland since 2020. * Improved ROSC and survival rates for pediatric cardiac arrest cases. * Collaborative efforts with community stakeholders to support families during TOR events. 7. Practical Guidance for EMS Agencies: * Steps to implement pediatric TOR protocols effectively. * Importance of education, community engagement, and support systems. Key Takeaway: Pediatric TOR protocols empower EMS professionals to deliver effective, evidence-based care while prioritizing the well-being of patients, families, and communities. By focusing on data-driven criteria and robust training, EMS teams can confidently navigate these critical, high-stress situations. Resources: Harris MI, Crowe RP, Anders J, D'Acunto S, Adelgais KM, Fishe J. Applying a set of termination of resuscitation criteria to paediatric out-of-hospital cardiac arrest. Resuscitation. 2021 Dec;169:175-181. doi: 10.1016/j.resuscitation.2021.09.015. Epub 2021 Sep 20. PMID: 34555488. Shetty P, Ren Y, Dillon D, Mcleod A, Nishijima D, Taylor SL; CARES Surveillance Group. Derivation of a clinical decision rule for termination of resuscitation in non-traumatic pediatric out-of-hospital cardiac arrest. Resuscitation. 2024 Nov;204:110400. doi: 10.1016/j.resuscitation.2024.110400. Epub 2024 Sep 18. PMID: 39299508. Study highlights: * Study Purpose: The study aimed to derive a Pediatric Termination of Resuscitation (PToR) rule for non-traumatic out-of-hospital cardiac arrests (OHCA) in patients under 18 years of age, utilizing data from the CARES database (2013–2022). * Study Population: * Analyzed 21,240 pediatric OHCA cases. * 11.0% of patients survived to hospital discharge, and 8.9% survived with favorable neurologic outcomes. * Criteria Derived: The PToR rule for non-survival to hospital discharge includes: * Unwitnessed cardiac arrest. * Absence of sustained ROSC (return of spontaneous circulation). * Initial rhythm of asystole. * Arrest not caused by drowning or electrocution. * Performance Metrics: * Specificity: 99.1%. * Positive Predictive Value (PPV): 99.8% for predicting non-survival to hospital discharge. * For non-survival or survival with unfavorable neurologic status, specificity was 99.1%, and PPV was 99.8%. * Significance of Drowning/Electrocution Cases: * These etiologies were excluded from PToR due to improved survival outcomes compared to other causes of cardiac arrest. * Model Validation: * The PToR criteria were validated on a test dataset, showing consistent high specificity and PPV. * Performance was stable across different age groups (infants, children, and adolescents). * Comparison with Adult ToR Rules: The PToR criteria shared similarities with adult ToR rules but were tailored to pediatric cases, emphasizing improved predictive accuracy for this population. * Implications for Practice: * The criteria provide a systematic framework to guide prehospital termination of resuscitation for pediatric patients, potentially reducing unnecessary transport and resource use. * Adoption may improve decision-making consistency among EMS providers while reducing emotional burden and ethical challenges. * Limitations: * Retrospective design limits causation analysis. * Excluded field-terminated cases may have introduced selection bias. * ROSC duration criteria may differ from typical EMS practices, necessitating further prospective validation. * Conclusions: The study offers robust PToR criteria with high specificity and PPV for prehospital decision-making. Future research should focus on prospective validation and understanding the criteria's practical implementation and impact on patient care.

Prehospital Pediatric Respiratory Distress

Episode 11: Prehospital Pediatric Respiratory Distress Brought to you by The National Association of EMS Physicians (NAEMSP) and Missouri Emergency Medical Services for Children (MO-EMSC). Hosts: Dr. Joelle Donofrio-Odmann and Dr. Joseph Finney Website: https://sites.libsyn.com/414020 [https://sites.libsyn.com/414020] GET CEU CREDIT THROUGH PRODIGY EMS Content Experts: Joelle Donofrio-Odmann, DO and Joseph Finney, MD Overview: This podcast episode focuses on pediatric respiratory distress in prehospital settings, providing key insights for EMS providers to assess and manage these cases effectively. Dr. Joelle Donofrio-Odmann emphasizes the importance of recognizing early signs of respiratory failure and understanding pediatric anatomy, which makes young children more vulnerable to airway obstruction. The episode introduces practical tools, such as the Pediatric Assessment Triangle, to differentiate distress from failure and ensure timely interventions. Highlighted Teaching Points * Pediatric Respiratory Distress is Common * Pediatric calls constitute 12-15% of EMS cases, with respiratory distress being the top reason for calls in children under two years old. * Anatomy Makes Kids Vulnerable * Young children have smaller airways, large heads, and obligate nose-breathing, increasing their risk of obstruction. * Minor nasal congestion can cause significant breathing issues, so suctioning the nose is often lifesaving. * Pediatric Assessment Triangle (PAT) * Work of Breathing: Look for signs such as retractions, nasal flaring, tracheal tugging, and head bobbing. * Mental Status: Lethargy or a lack of responsiveness indicates a worsening condition. * Circulation: Cyanosis, poor perfusion, and pallor signal late stages of respiratory failure. * PAT allows providers to identify patients at risk of crashing early and intervene before "all three sides of the triangle fail" (referred to as the Triangle of Death). * Respiratory Distress Progression * Retractions progress from intercostal (mild) to severe patterns like head bobbing and sternal rocking, which indicate respiratory failure. * Recognize these signs early to prevent hypoxia, bradycardia, and arrest. * Common Upper Airway Conditions * Croup: Most common cause of stridor; responds well to inhaled epinephrine and steroids. * Bacterial Tracheitis: Consider if croup-like symptoms persist despite treatments. * Epiglottitis: Rare due to vaccinations but still possible; presents with fever, drooling, and tripod positioning. * Foreign Body Aspiration * Common in toddlers (12-24 months); consider aspiration in recurrent respiratory cases. * EMS providers should practice airway maneuvers and foreign body removal techniques with tools like Magill forceps. * Management and Reassessment * Intervene early with oxygen, suction, and positive pressure ventilation as needed. * Reassess interventions regularly (e.g., after nasal suctioning or oxygen delivery) to ensure improvement or escalate care. This episode provides practical, actionable guidance for EMS providers to master pediatric airway management and prevent rapid deterioration in respiratory emergencies. Check out The Medic Mindset! https://medicmindset.com/ [https://medicmindset.com/] Resources: EMSC Innovation and Improvement Center https://emscimprovement.center/ [https://emscimprovement.center/] Pediatric Emergency Applied Care Research Network (PECARN) [https://pecarn.org/] PEDI-PART [https://www.uab.edu/medicine/cis/pedipart-columbus-ohio] NAEMSP Airway Compendium Position Statement [https://www.tandfonline.com/doi/full/10.1080/10903127.2021.1988776] Check out https://www.prodigyems.com/ [https://www.prodigyems.com/] and create a free account to access EMSC resources on pediatric respiratory distress and more.

How To Approach Pediatric Traumatic Brain Injury: The Evidence and the Anatomy

This episode is brought to you by Styker Medical Corporation with their comittment to improving medical education. In this episode we discuss the priorities of pediatric head and cervical spine imagine with the experts in the fields of Pediatric Emergency Medicine and Neurosurgery. Learn from those who know about how to manage your next pediatric patient with traumatic brain injury or cervical spine injury. With TBI a major cause of pediatric death, you don't want to miss this episode with all you need to know. Rememer: Avoid the H bombs * Hypotension ( * Hypoxia ( * Hyperventilation (Goal ETCO2 35-45) Serious mechanism + LOC: * 15L NRB * 1L Bolus (20cc/kg for peds) * Goal ETCO2 35-45 Brought to you by The National Association of EMS Physicians (NAEMSP) and Missouri Emergency Medical Services for Children (MO-EMSC). Hosts: Dr. Joelle Donofrio-Odmann and Dr. Joseph Finney Website: https://sites.libsyn.com/414020/how-to-approach-pediatric-traumatic-brain-injury-the-evidence-and-the-anatomy [https://sites.libsyn.com/414020/how-to-approach-pediatric-traumatic-brain-injury-the-evidence-and-the-anatomy] GET CEU CREDIT THROUGH PRODIGY EMS Content Experts: Joelle Donofrio-Odmann, DO and Joseph Finney, MD Guest Experts: Joshua B. Gaither, MD, FACEP Dr. Joshua Gaither is a professor in the Department of Emergency Medicine with fellowship training in Emergency Medical Services (EMS) and Disaster Medicine. He is the EMS Fellowship Director the Medical Director for Tucson Fire Department as well as several EMS training programs. Dr. Gaither also teaches in and is the director for the EMS Degree Program. Dr. David Gonda Dr. Gonda is the director of Epilepsy Surgery at Rady Children's Hospital-San Diego and an assistant clinical professor of neurosurgery at UC San Diego School of Medicine. He comes to Rady Children's from Texas Children's Hospital, where he was a pediatric neurosurgery fellow, and Baylor College of Medicine, where he was a clinical instructor. Dr. Gonda completed his residency training at UC San Diego and earned his medical degree at The Ohio State University. Dr. Gonda's clinical areas of expertise are epilepsy surgery, MRI laser thermal ablation surgery, pediatric spine abnormalities and craniovertebral junction abnormalities. His research area of expertise is minimally invasive epilepsy surgery. Sources: Association of Statewide Implementation of the Prehospital Traumatic Brain Injury Treatment Guidelines With Patient Survival Following Traumatic Brain Injury: The Excellence in Prehospital Injury Care (EPIC) Study. [https://emergencymed.arizona.edu/biblio/association-statewide-implementation-prehospital-traumatic-brain-injury-treatment-guidelines], Spaite, Daniel W., Bobrow Bentley J., Keim Samuel M., Barnhart Bruce, Chikani Vatsal, Gaither Joshua B., Sherrill Duane, Denninghoff Kurt R., Mullins Terry, P Adelson David, et al. , JAMA Surg, 2019 07 01, Volume 154, Issue 7, p.e191152, (2019) In reply. [https://emergencymed.arizona.edu/biblio/reply-5], Spaite, Daniel W., Bobrow Bentley J., Gaither Joshua B., and Hu Chengcheng , Ann Emerg Med, 2017 Aug, Volume 70, Issue 2, p.263-264, (2017) Association of Out-of-Hospital Hypotension Depth and Duration With Traumatic Brain Injury Mortality. [https://emergencymed.arizona.edu/biblio/association-out-hospital-hypotension-depth-and-duration-traumatic-brain-injury-mortality], Spaite, Daniel W., Hu Chengcheng, Bobrow Bentley J., Chikani Vatsal, Barnhart Bruce, Gaither Joshua B., Denninghoff Kurt R., P Adelson David, Keim Samuel M., Viscusi Chad, et al. , Ann Emerg Med, 2017 May 27, (2017) Mortality and Prehospital Blood Pressure in Patients With Major Traumatic Brain Injury: Implications for the Hypotension Threshold. [https://emergencymed.arizona.edu/biblio/mortality-and-prehospital-blood-pressure-patients-major-traumatic-brain-injury-implications], Spaite, Daniel W., Hu Chengcheng, Bobrow Bentley J., Chikani Vatsal, Sherrill Duane, Barnhart Bruce, Gaither Joshua B., Denninghoff Kurt R., Viscusi Chad, Mullins Terry, et al. , JAMA Surg, 2016 Dec 07, (2016) The Effect of Combined Out-of-Hospital Hypotension and Hypoxia on Mortality in Major Traumatic Brain Injury. [https://emergencymed.arizona.edu/biblio/effect-combined-out-hospital-hypotension-and-hypoxia-mortality-major-traumatic-brain-injury-0], Spaite, Daniel W., Hu Chengcheng, Bobrow Bentley J., Chikani Vatsal, Barnhart Bruce, Gaither Joshua B., Denninghoff Kurt R., P Adelson David, Keim Samuel M., Viscusi Chad, et al. , Ann Emerg Med, 2016 Sep 27, (2016) The Effect of Combined Out-of-Hospital Hypotension and Hypoxia on Mortality in Major Traumatic Brain Injury [https://emergencymed.arizona.edu/biblio/effect-combined-out-hospital-hypotension-and-hypoxia-mortality-major-traumatic-brain-injury], Spaite, Daniel W., Hu Chengcheng, Bobrow Bentley J., Chikani Vatsal, Barnhart Bruce, Gaither Joshua B., Denninghoff Kurt R., P. Adelson David, Keim Samuel M., Viscusi Chad, et al. , Annals of Emergency Medicine, Jan-09-2016, (2016) Lulla A, Lumba-Brown A, Totten AM, Maher PJ, Badjatia N, Bell R, Donayri CTJ, Fallat ME, Hawryluk GWJ, Goldberg SA, Hennes HMA, Ignell SP, Ghajar J, Krzyzaniak BP, Lerner EB, Nishijima D, Schleien C, Shackelford S, Swartz E, Wright DW, Zhang R, Jagoda A, Bobrow BJ. Prehospital Guidelines for the Management of Traumatic Brain Injury - 3rd Edition. Prehosp Emerg Care. 2023;27(5):507-538. doi: 10.1080/10903127.2023.2187905. Epub 2023 Apr 20. PMID: 37079803.

Pediatric Prehospital Trauma Overview: Hitting the Highlights

This series is a collaboration with the EMS for Children Innovation and Improvement Center (EIIC) and will be part of the pre-hospital resources for its Pediatric Education and Advocacy Kit (PEAK) for multisystem trauma. Click on the link to learn more! https://emscimprovement.center/education-and-resources/peak/ [https://emscimprovement.center/education-and-resources/peak/]. In this episode we kick off a multipart series on pediatric trauma just in time for summer and trauma season. Join your two hosts as they tackle the prehospital management of pediatric trauma. Everything from head to toe and the pathophysiology that makes pediatric trauma unique from the adult population. Below are the episode talking points you don't want to miss. Objectives * Assess the current landscape of pediatric trauma. * Recognize the physiologic differences between adults and children in trauma. * Evaluate how the mechanism of injury informs the management. * Analyze how to approach a pediatric trauma patient. * Summary and take-home points. Brought to you by The National Association of EMS Physicians (NAEMSP) and Missouri Emergency Medical Services for Children (MO-EMSC). Hosts: Dr. Joelle Donofrio-Odmann and Dr. Joseph Finney Website: https://sites.libsyn.com/414020 [https://sites.libsyn.com/414020] GET CEU CREDIT THROUGH PRODIGY EMS Content Experts: Joelle Donofrio-Odmann, DO and Joseph Finney, MD Pediatric Assessment Triangle The Changing Landscape of Traumatic Pediatric Death Goldstick, 2022 Trimodal Distribution of Death From McLaughlin et al, 2017: 74% of pediatric deaths age 1-14y were in first 24 hours. Of children who die from traumatic injuries, most die within 24 hours of arriving to the hospital. When compared to adult trauma patients, children are more likely to die in the emergency department (ED) rather than surviving long enough for hospital admission or transfer to the operating room. Where you are treated matters Theodorou et al in 2021 reviewed over 7000 pediatric trauma admissions and found, of the 134 patients who died, Traumatic brain injury was the most common cause of death (66%), followed by anoxia (9.7%) and hemorrhage (8%). 54% died in the ED. More likely to die if suffered penetrating trauma. Pediatric Trauma: ATC vs PTC The United States Government Accountability Office found 57 percent of the nation's 74 million children lived within 30 miles of a pediatric trauma center that can treat pediatric injuries, regardless of severity. The presence of pediatric trauma centers was associated with lower rates of MVC death in children. Adult level 1/2 trauma centers appear to offer comparable risk reduction. Where population differences in pediatric trauma mortality are observed, addressing disparities in county-level access to pediatric trauma care may serve as a viable target for system-level improvement. Pediatric patients Why Does All This Matter: Anatomic and Physiologic Differences in Pediatric Trauma A Case A 5-year-old boy injured while crossing the street when he was struck by a vehicle at city speeds (w50 km/h). He is crying and pale, with a hematoma to the right forehead; bruising to the left side of the upper abdomen; and an obvious, closed, deformity of his femur. His vital signs are heart rate (HR), 135 beats/min, respiration rate (RR), 30 breaths/min; blood pressure (BP), 95/65 mm Hg; and O2 saturations of 91% on room air, which improve to 97% with supplemental O2 Factors to Consider when approaching pediatric trauma: Head and Neck • Large head on short weak neck with fulcrum out away from the center of gravity • Traumatic brain injury likely present and must be investigated. • 80% of pediatric multisystem trauma involves the head. • Remember TBI is a major cause of trauma mortality. • Heavy head compared to body, often first impact point so affected by rapid acceleration deceleration forces. Also, higher risk of axonal injury from shearing forces given limited myelin development. Prehospital management focused on H bombs. Airway • Airway is crowded and easily obstructed. • Use a shoulder roll anytime you are managing a pediatric airway under 8 years. • Intubation is for your ego; SGA is for your patient • Cuffed tubes are both safe and effective for pediatric patients. Pediatric Airway Considerations: Head: In the supine position, a young child's head will cause a natural flexion of the neck due to its large size. This neck flexion can create a potential airway obstruction. Patients usually benefit from a towel to elevate the shoulders as well as someone to assist to help hold the head, as it can be floppy. Nose: Tongue: A child's tongue is proportionally larger in the oropharynx when compared to adults, and it may obstruct the airway due to this size. Larynx: Located opposite C2—C3, a child's larynx is higher up than in an adult, creating a more anterior location that often results in difficulty when a provider attempts to visualize a child's airway. HARDER TO INTUBATE. Epiglottis: The adult epiglottis is flat and flexible, while a child's is U-shaped, shorter and stiffer. This makes it more difficult to manipulate and is a common reason providers can't visualize an airway with a curved blade in a pediatric patient. Vocal cords: The anterior attachment of a pediatric patient's vocal cords is lower than the posterior attachment, which creates an upward slant, whereas in adults, the vocal cords are horizontal. This concave shape may affect ventilation, and it's important for providers to use a jaw-lift maneuver to open the arytenoids. Trachea: The trachea is shorter in pediatric patients, which increases the likelihood of right mainstem intubation and of the tube becoming dislodged. At birth, 1/3 the diameter of an adult (narrow the tube and increase resistance by a power of 4: Poiseuilles law) Airway diameter: A child's airway is narrowest at the cricoid ring. As a result, secretions can easily obstruct the airway, due to its small size, and even a small amount of cricoid pressure can cause complete airway obstruction. Residual lung capacity: Smaller lung capacity in pediatric patients means that a child can become hypoxic more quickly than an adult. Providers should make sure to closely monitor oxygen saturation and avoid prolonged periods without ventilation. Children also have higher respiratory rates than adults making them more susceptible to agents in the air. The ribs in infants and young children are oriented more horizontally than in adults and older children lessening the movement of the chest. Rib cartilage is more springy in children making the chest wall less rigid. This can allow the chest wall to retract during episodes of respiratory distress and decrease tidal volume. The intercostal muscles that run between the ribs are not fully developed until a child reaches school age. This can make it difficult to lift the rib cage especially when lying flat on the back or if the diaphragm is inhibited by blood in the abdominal cavity or air in the belly. Spinal Injuries • Overall uncommon, but devastating if they do occur. • Primarily due to high-speed blunt trauma • Associated with birth trauma (Forceps extraction) • Higher cervical spine (C1-C2) • Chance Fractures common in pediatrics • High suspicion for internal organ injury with thoracolumbar injury • To Collar or Not To Collar • Consider in the following situations. • AMS • Neck pain • Neck stiffness • Neurologic deficit • High speed MVC • Diving injury (not drowning) • Substantial torso injury present Cardiovascular Considerations • Hypotension occurs after 30% blood loss. • Decompensated potentially irreversible shock. • Tachycardia is the pediatric body screaming at you. • Always investigate tachycardia. • Do not assume pain. • Compensation Chest and Abdominal Anatomy • Compliant and cartilaginous skeletal structure • Force is transferred internally. • May be no broken ribs or external signs of trauma. • Maintain high suspicion for internal injury. • Pulmonary contusion common • Horizontal ribs, exposed organs • Low set pelvis, higher risk of hollow organ injury • Shortened AP diameter meaning retroperitoneal structures closer to front of body and more exposed. • Minimal peri-organ fat and subcutaneous tissue Back to our case: What are your priorities? A 5-year-old boy injured while crossing the street when he was struck by a vehicle at city speeds (w50 km/h). He is crying and pale, with a hematoma to the right forehead; bruising to the left side of the upper abdomen; and an obvious, closed, deformity of his femur. His vital signs are heart rate (HR), 135 beats/min, respiration rate (RR), 30 breaths/min; blood pressure (BP), 95/65 mm Hg; and O2 saturations of 91% on room air, which improve to 97% with supplemental O2 • Lethal Triad (hypothermia, acidosis, coagulopathy): Hypothermia is a modifiable prehospital factor • Large surface area to body mass ratioà rapid heat loss • Large head • Prioritize warming the patient both prehospital and in the ED • Turn on the heat in the ambulance. • Resuscitation: On-scene Priorities • C-ABC Common Prehospital Pitfalls • Failure to recognize/investigate/act on tachycardia. • Fear and stress are diagnoses of exclusion in the tachycardic pediatric trauma. • Failure to identify abnormal behavior for age. • Sleeping or tired or quiet is NOT NORMAL • Should be assumed to be impaired cerebral perfusion. • Failure to suspect/assume internal injury in the absence of external signs of trauma. • Mechanism informs the injuries. • Treat Pain • Numerous studies underscore the failures of EMS to adequately address and treat pediatric pain • Worse for minority populations • Get pain medication on board early • Delayed pain treatment can have devastating psychologic effects long term • PTSD • Chronic pain syndrome • Behavioral abnormalities Non-Accidental Trauma • Always consider NAT in your altered pediatric patient • Even without a history to support it. • Watch for red flags (TEN4FACES) • History doesn't match developmental level. • Delayed presentation • Unwitnessed • Vague story • We are all mandated reporters if we suspect abuse. Where to transport • Take a stroke to a stroke center. • Take a pediatric trauma to a pediatric trauma center whenever possible. This will decrease mortality and exposure to radiation and unnecessary procedures. Review of The Pediatric Traumatic Hemorrhagic Shock Consensus Conference Research Priorities Whole Blood in Pediatric Hemorrhagic Shock • 100% Agreement among experts • Practical application • Severe cases-->straight to blood • Less severe patients-->one bolus of crystalloid with close monitoring and immediate transition to blood if worsens/fails to improve. • Use Low Titer O Whole Blood if available. • If LTWOWB not available, use 1:1:1 plasma to RBCs to platelets. • MTP with balanced blood product administration • Consider calcium when giving blood: Siegler's Lethal Diamond • Prehospital Blood in Pediatric Hemorrhagic Shock: "Reasonable based on availability and clinical judgement" • 100% Expert Agreement • Death due to bleeding most common early after injury • Delays in transfusion associated with increased mortality and prolonged time to hemostasis. • Current evidence supports both the safety and feasibility of prehospital pediatric blood product. Tranexamic Acid in Pediatric Hemorrhagic Shock • Use within 3 hours might be considered. • 80% agreement among experts • Strong evidence in adults: CRASH-2 • No high-quality evidence in pediatrics Tourniquet Application in PHS • 88% Agreement • Has shown benefit. • Biggest issues • Applied when unnecessary. • Applied incorrectly. • Inadequate training There is no such thing as permissive hypotension in pediatrics Resources and Sources: • Khalil M, Alawwa G, Pinto F, O'Neill PA. Pediatric Mortality at Pediatric versus Adult Trauma Centers. J Emerg Trauma Shock. 2021 Jul-Sep;14(3):128-135. doi: 10.4103/JETS.JETS_11_20. Epub 2021 Sep 30. PMID: 34759630; PMCID: PMC8527062. • McLaughlin C, Zagory JA, Fenlon M, Park C, Lane CJ, Meeker D, Burd RS, Ford HR, Upperman JS, Jensen AR. Timing of mortality in pediatric trauma patients: A National Trauma Data Bank analysis. J Pediatr Surg. 2018 Feb;53(2):344-351. doi: 10.1016/j.jpedsurg.2017.10.006. Epub 2017 Oct 8. PMID: 29111081; PMCID: PMC5828917. • Theodorou CM, Galganski LA, Jurkovich GJ, Farmer DL, Hirose S, Stephenson JT, Trappey AF. Causes of early mortality in pediatric trauma patients. J Trauma Acute Care Surg. 2021 Mar 1;90(3):574-581. doi: 10.1097/TA.0000000000003045. PMID: 33492107; PMCID: PMC8008945. • Mikrogianakis A, Grant V. The Kids Are Alright: Pediatric Trauma Pearls. Emerg Med Clin North Am. 2018 Feb;36(1):237-257. doi: 10.1016/j.emc.2017.08.015. PMID: 29132580. • Andrade EG, Onufer EJ, Thornton M, Keller MS, Schuerer DJE, Punch LJ. Racial disparities in triage of adolescent patients after bullet injury. J Trauma Acute Care Surg. 2022 Feb 1;92(2):366-370. doi: 10.1097/TA.0000000000003407. PMID: 34538831. • Calhoun A, Keller M, Shi J, Brancato C, Donovan K, Kraus D, Leonard JC. Do Pediatric Teams Affect Outcomes of Injured Children Requiring Inter-hospital Transport? Prehosp Emerg Care. 2017 Mar-Apr;21(2):192-200. doi: 10.1080/10903127.2016.1218983. Epub 2016 Sep 16. PMID: 27636186. • Byrne JP, Nance ML, Scantling DR, Holena DN, Kaufman EJ, Nathens AB, Reilly PM, Seamon MJ. Association between access to pediatric trauma care and motor vehicle crash death in children: An ecologic analysis of United States counties. J Trauma Acute Care Surg. 2021 Jul 1;91(1):84-92. doi: 10.1097/TA.0000000000003110. PMID: 33605706. • Träff H, Hagander L, Salö M. Association of transport time with adverse outcome in paediatric trauma. BJS Open. 2021 May 7;5(3):zrab036. doi: 10.1093/bjsopen/zrab036. PMID: 33963365; PMCID: PMC8105622. • Frank Lodeserto MD, "Approach to the Critically Ill Child: Shock", REBEL EM blog, October 15, 2018. Available at: https://rebelem.com/approach-to-the-critically-ill-child-shock/ [https://rebelem.com/approach-to-the-critically-ill-child-shock/]. • Dai LN, Chen CD, Lin XK, Wang YB, Xia LG, Liu P, Chen XM, Li ZR. Abdominal injuries involving bicycle handlebars in 219 children: results of 8-year follow-up. Eur J Trauma Emerg Surg. 2015 Oct;41(5):551-5. doi: 10.1007/s00068-014-0477-5. Epub 2014 Nov 26. PMID: 26038003. • Ten-4 bruising rule [https://faceitabuse.org/ten4rule]. Face It website. Accessed January 20, 2023, • Newgard, Craig D. MD, MPH, FACEP; Fischer, Peter E. MD; Gestring, Mark MD; Michaels, Holly N. MPH; Jurkovich, Gregory J. MD, FACS; Lerner, E. Brooke PhD, FAEMS; Fallat, Mary E. MD; Delbridge, Theodore R. MD, MPH; Brown, Joshua B. MD, MSc, FACS; Bulger, Eileen M. MD; the Writing Group for the 2021 National Expert Panel on Field Triage. National guideline for the field triage of injured patients: Recommendations of the National Expert Panel on Field Triage, 2021. Journal of Trauma and Acute Care Surgery 93(2):p e49-e60, August 2022. | DOI: 10.1097/TA.0000000000003627 • Russell RT, Bembea MM, Borgman MA, Burd RS, Gaines BA, Jafri M, Josephson CD, Leeper CM, Leonard JC, Muszynski JA, Nicol KK, Nishijima DK, Stricker PA, Vogel AM, Wong TE, Spinella PC. Pediatric traumatic hemorrhagic shock consensus conference research priorities. J Trauma Acute Care Surg. 2023 Jan 1;94(1S Suppl 1):S11-S18. doi: 10.1097/TA.0000000000003802. Epub 2022 Oct 7. PMID: 36203242; PMCID: PMC9805504.