Pre-hospital care of pediatric patients with trauma

Pediatric trauma patients in Swedish ambulance services -a retrospective observational study of assessments, interventions, and clinical outcomes

BACKGROUND

Pediatric trauma patients constitute a significant portion of the trauma population treated by Swedish Emergency Medical Services (EMS), and trauma remains a notable cause of death among Swedish children. Previous research has identified potential challenges in prehospital assessments and interventions for pediatric patients. In Sweden, there is limited information available regarding pediatric trauma patients in the EMS. The aim of this study was to investigate the prevalence of pediatric trauma patients within the Swedish EMS and describe the prehospital assessments, interventions, and clinical outcomes.

METHODS

This retrospective observational study was conducted in a region of Southwestern Sweden. A random sample from ambulance and hospital records from the year 2019 was selected. Inclusion criteria were children aged 0-16 years who were involved in trauma and assessed by EMS clinicians.

RESULTS

A total of 440 children were included in the study, representing 8.4% of the overall trauma cases. The median age was 9 years (IQR 3-12), and 60.5% were male. The leading causes of injury were low (34.8%) and high energy falls (21%), followed by traffic accidents. The children were assessed as severely injured in 4.5% of cases. A quarter of the children remained at the scene after assessment. Complete vital signs were assessed in 29.3% of children, and 81.8% of children were assessed according to the ABCDE structure. The most common intervention performed by prehospital professionals was the administration of medication. The mortality rate was 0.2%.

CONCLUSIONS

Pediatric trauma cases accounted for 8.4% of the overall trauma population with a variations in injury mechanisms and types. Vital sign assessments were incomplete for a significant proportion of children. The adherence to the ABCDE structure, however, was higher. The children remained at the scene after assessment requires further investigation for patient safety.

Pediatric Spinal Cord Injury: A Review

A spinal cord injury (SCI) can be a devastating condition in children, with profound implications for their overall health and quality of life. In this review, we aim to provide a concise overview of the key aspects associated with SCIs in the pediatric population. Firstly, we discuss the etiology and epidemiology of SCIs in children, highlighting the diverse range of causes. We explore the unique anatomical and physiological characteristics of the developing spinal cord that contribute to the specific challenges faced by pediatric patients. Next, we delve into the clinical presentation and diagnostic methods, emphasizing the importance of prompt and accurate diagnosis to facilitate appropriate interventions. Furthermore, we approach the multidisciplinary management of pediatric SCIs, encompassing acute medical care, surgical interventions, and ongoing supportive therapies. Finally, we explore emerging research as well as innovative therapies in the field, and we emphasize the need for continued advancements in understanding and treating SCIs in children to improve their functional independence and overall quality of life.

Epidemiology and Prehospital Care of Pediatric Unintentional Injuries Among Countries with Different Economic Status in Asia: A Cross-National, Multi-Center Observational Study

OBJECTIVE

Injury is a major cause of morbidity and mortality in children. However, the epidemiology and prehospital care for pediatric unintentional injuries in Asia are still unclear.

METHODS

A total of 9,737 pediatric patients aged <18 years with unintentional injuries cared for at participating centers of the Pan-Asian Trauma Outcome Study (PATOS) from October 2015 to December 2020 were reviewed retrospectively. Patients were divided into two groups: those <8 and those ≥8 years of age. Variables such as patient demographics, injury epidemiology, Injury Severity Score (ISS), and prehospital care were collected. Injury severity and administered prehospital care stratified by gross national income were also analyzed.

RESULTS

Pediatric unintentional injuries accounted for 9.4% of EMS-transported trauma cases in the participating Asian centers, and the mortality rate was 0.88%. The leading cause of injury was traffic injuries in older children aged ≥8 years (56.5%), while falls at home were common among young children aged <8 years (43.9%). Compared with younger children, older children with similar ISS tended to receive more prehospital interventions. Uneven disease severity was found in that older children in lower-middle and upper-middle-income countries had higher ISS compared with those in high-income countries. The performance of prehospital interventions also differed among countries with different gross national incomes. Immobilizations were the most performed prehospital intervention followed by oxygen administration, airway management, and pain control; only one patient received prehospital thoracentesis. Procedures were performed more frequently in high-income countries than in upper-middle-income and lower-middle-income countries.

CONCLUSIONS

The major cause of injury was road traffic injuries in older children, while falls at home were common among young children. Prehospital care in pediatric unintentional injuries in Asian countries was not standardized and might be insufficient, and the economic status of countries may affect the implementation of prehospital care.

Epidemiology of prehospital trauma deaths in Malawi: A retrospective cohort study

Introduction

Trauma is among the leading causes of death and disability in both adults and children worldwide. In Malawi, trauma patients are commonly brought in dead (BID). We aimed to describe the prevalence, sociodemographic, and injury-related characteristics of patients BID to Kamuzu Central Hospital (KCH), a referral hospital in Lilongwe, Malawi.

Methods

We retrospectively reviewed records of all patients BID in the trauma surveillance registry at KCH from February 2008 to September 2019. We excluded patients BID that did not present to the emergency centre, and were instead taken to the mortuary directly. We used descriptive statistics to evaluate the epidemiology of patients BID.

Results

We reviewed 106,198 trauma records and 1889 (1.8%) were BID patients. Most patients BID were male, in both adult (n = 1337/1528, 88.4%) and children (n = 231/360, 64.9%) cohorts. The mean age was 34.7 (SD 11.9) years in adults and 7.8 (SD 5.4) years in children. Among the adult BID patients, 33.2% were unemployed, 25.6% were construction workers, and 10.1% were small business owners or managers. The common injury mechanisms in adults were road traffic-related injuries (RTIs) (47.1%) and assaults (23.6%). In children, injuries resulted from RTIs (39.7%), with 74.4% of those were pedestrians hit by cars, drowning (22.9%), and burns (12.4%). In both groups, most injuries occurred on roads (60.2%) or at home (22.1%). Reported alcohol use at the time of trauma was present in 6.3%. The police (57.9%) and privately-owned vehicles (26.6%) transported most BID patients to KCH.

Conclusion

Efforts to reduce prehospital trauma mortality must focus on improving prehospital care, including training the police and community in basic life support and improving resources towards prehospital trauma care. Further efforts to reduce prehospital mortality must aim to decrease injuries on the roads and at home.

Field triage of children with abdominal trauma

Objective

Identify physical findings in children with abdominal trauma to inform prehospital providers regarding appropriate hospital destinations.

Methods

This is a secondary analysis of the Pediatric Emergency Care Applied Research Network Abdominal Trauma Public Use Dataset. Children involved in motor vehicle collisions; struck by motor vehicles at >20 mph; involved in all-terrain vehicle, motorcycle, or scooter accidents; or who fell from >10 ft ( n = 5575) were included. Stepwise multivariable multinomial logistic regression was used to compare clinical findings at presentation between children with no intra-abdominal injury, intra-abdominal injury without intervention, and intra-abdominal injury with intervention (laparoscopy/laparotomy, embolization, red blood cell transfusion, or admission >48 h on intravenous fluids).

Results

Compared to children with no intra-abdominal injury, children with intra-abdominal injury (with and without intervention) were more likely to have evidence of abdominal wall trauma, abdominal tenderness, peritoneal irritation, decreased breath sounds, distracting painful injury, and evidence of thoracic trauma. Children with intra-abdominal injury requiring intervention were more likely to have evidence of abdominal wall trauma (OR 3.32, 95% CI 2.03–5.44) and be intubated (OR 4.93, 95% CI 3.17–7.65) when compared to children with intra-abdominal injury without intervention.

Conclusions

The findings of abdominal tenderness, peritoneal irritation, decreased breath sounds, distracting painful injury, and thoracic trauma may be used to identify children who warrant evaluation at any trauma center because of increased risk of intra-abdominal injury, whereas intubation and evidence of abdominal wall trauma help identify children with intra-abdominal injury in need of transport to a pediatric trauma center due to risk of undergoing intervention.

The assessment and management of thermal burn injuries in a UK ambulance service: a clinical audit

Background:

Although burn emergencies are infrequently encountered, the ambulance service is often the first point of contact for patients in these situations. It is therefore important that these potentially devastating injuries are managed in accordance with the evidence base. Appropriate assessment and management of these patients in the pre-hospital phase will have a significant impact upon their long-term outcomes, such as scarring cosmesis and functionality.

Aim and objectives:

This audit was conducted to determine if patients presenting to one UK ambulance service with thermal burn injuries were managed safely, effectively and in a timely manner. Areas highlighted for improvement will assist in directing future pre-hospital research and educational requirements. Epidemiological data will also be provided.

Results:

278 thermal burn incidents occurring from June 2017 to May 2018 (inclusive) were included in this audit. A larger proportion of burn patients were paediatrics who fell into the 0–10 age category, most burn patients were injured at a home address and only nine of the overall sample were major burns. Only 35% of patients received adequate cooling of their burns, an essential first aid intervention. The assessment of pain (87%) and provision of analgesia (75%) showed a higher compliance rate. However, only 54% had pain reassessed after analgesia. There was a near 100% compliance rate for patients being managed without hydrogel dressings and topical medicines.

Conclusion:

The results indicate several areas for improvement within the ambulance trust. Of importance is the application of basic first aid, such as cooling. It is important not only to improve education among staff but also to understand non-compliance. It should be acknowledged that assessment of pain and provision of analgesia demonstrated far higher compliance compared to current pre-hospital evidence. Several points for education and research have been identified.

Outcomes of civilian pediatric craniocerebral gunshot wounds: A systematic review

BACKGROUND

Pediatric craniocerebral gunshot injuries (CGIs) occur both in the context of accidental and intentional trauma. The incidence and physiology of pediatric CGIs merit reexamination of prognostic factors and treatment priorities. This study characterizes the current understanding of mortality and prognostic factors in this patient population.

METHODS

A systematic search was conducted. Selection criteria included all studies published since 2000, which described civilian isolated CGIs in pediatric patients. Data were analyzed qualitatively and quantitatively to identify factors prognostic for the primary outcome of mortality. Secondary outcomes included functional outcome status, requirement for surgery, and injury complications. Study quality was assessed with the Newcastle-Ottawa Scale. This study was registered with PROSPERO (CRD42019134231).

RESULTS

Initial search revealed 349 unique studies. Forty underwent full text screening, and eight studies were included in the final synthesis. The overall mortality rate was 44.8%. Most CGIs occurred in older teenagers. Aggressive surgical treatment was recommended by one author, while remaining studies emphasized clinical judgment. Reported prognostic factors include initial Glasgow Coma Scale, pupil reactivity, involvement of multiple lobes or deep nuclei, and bihemispheric injuries. Reported complications from CGIs included seizure, meningitis, abscess, cerebrospinal fluid leak, bullet migration, focal neurological deficits, endocrine abnormalities, cognitive deficits, and neuropsychological deficits. The Glasgow Outcome Scale was the predominant measure of function and demonstrated a moderate recovery in 17.4% and a good recovery in 27.3% of patients.

CONCLUSION

This systematic review analyzed the existing evidence for prognostic factors in the context of pediatric CGIs. Significant long-term clinical improvement is possible with interventions including urgent surgical therapy. Fixed bilateral pupils and low initial Glasgow Coma Scale correlate with mortality but do not predict all patient outcomes. Patients younger than 15 years are underreported and may have differences in outcome. The literature on pediatric CGIs is limited and requires further characterization.

LEVEL OF EVIDENCE

Systematic Review, level IV.

Assessing Infrastructure to Care for Pediatric Patients in the Prehospital Setting

OBJECTIVES

Pediatric patients represent a small proportion of emergency medical services (EMS) calls, challenging providers in maintaining skills in treating children. Having structural capacity to appropriately diagnose and treat pediatric patients is critical. Our study measured the availability of off-line and on-line medical direction and recommended pediatric equipment at EMS agencies.

METHODS

A Web-based survey was sent to EMS agencies in 2010 and 2013, and results were analyzed to determine availability of medical direction and equipment.

RESULTS

Approximately 5000 agencies in 32 states responded, representing over 80% response. Availability of off-line medical direction increased between years (78% in 2010 to 85% in 2013), was lower for basic life support (BLS) (63% and 72%) than advanced life support (ALS) agencies (90% and 93%), and was generally higher in urban than rural or frontier locations. On-line medical direction was consistently available (90% both years) with slight increases for BLS agencies (87% to 90%) and slightly greater availability for urban and rural compared with frontier agencies. The majority of agencies carried most recommended equipment; however, less than one third of agencies reported carrying all equipment. Agencies with off-line medical direction, on-line medical direction, and with both off-line and on-line medical direction were respectively 1.69, 1.31, and 2.21 times more likely to report carrying all recommended equipment.

CONCLUSIONS

Basic structural capacity exists in EMS for treating children, with improvements seen over time. However, gaps remain, particularly for BLS and nonurban agencies. Continuous attention to infrastructure is necessary, and the recent development of national performance measures should further promote quality emergency care for all children.

The first national data of Turkish pre-hospital emergency care for children: Epidemiology, clinical characteristics, and outcomes

Background and Objectives:

The emergency medical service system is designed to ensure rapid identification and transport of patients from the field to emergency departments. This study aims to examine pediatric patients’ clinical characteristics and reasons for ambulance use in Turkey. Life-saving interventions and non-life-saving interventions performed during transport and patients’ outcomes following transport were also investigated.

Methods:

This is a prospective-multicentric study conducted at four metropolitan cities and nine tertiary pediatric emergency departments. This survey-based study evaluated all children brought by ambulance to emergency departments. Patient demographics, clinical features, triage levels, procedures performed in the ambulance or emergency department, and final outcomes were sought.

Results:

A total of 2094 patients were transported during the study period. Only a minority of ambulances were physician staffed (16.5%), and 72% of the patients were delivered to pediatric emergency departments without notification calls. Although notification calls were more likely given for particularly critically ill children, for non-urgent conditions transfer calls were less common (60.8% vs 23.5%, respectively; p < 0.001). A majority of transports were performed for trauma patients (20.5%), neurological issues (20%), and toxicological emergencies (13.8%). While parents prefer using the ambulances for medical emergencies, physicians prefer it for mainly traumatic and toxicological emergencies. In total, 65% of the patients received at least one intervention, and 18 patients needed immediate life-saving interventions (intubation, cardiopulmonary resuscitation, etc.) but they did not receive it. Mortality occurred in nine patients. If the health care providers were paramedics, they were more likely avoided by performing any intervention in critically ill children ( p < 0.001). A majority of the procedures performed in children were older than 12 months ( p < 0.001).

Conclusion:

This study presents comprehensive epidemiological and outcome data for pediatric patients transported by the national emergency medical service system in Turkey. Non-urgent calls were more likely made by parents, physicians avoided making NCs, and paramedics also avoided performing any intervention when they were transporting children.

Patient at Risk: Emergency medical service providers' opinions on improving an electronic emergency information form database for the medical care of children with special health care needs

BACKGROUND

Patient at Risk (PAR) is an online database using an emergency information form (EIF) that parents of children with special health care needs (CSHCN) complete to store their child's medical information. Emergency medical service (EMS) providers can then access PAR during medical emergencies or for pre-planning. PAR was active for over 10 years but use by patients and EMS was limited.

OBJECTIVE

To determine EMS perspectives on why PAR was not used to its full potential and how to improve PAR for EMS.

METHODS

Seven questions regarding PAR were developed and presented in focus groups at 32 fire/ambulance houses in southeast and central Wisconsin from June to August 2017. Responses were transcribed and reviewed for themes.

RESULTS

146 EMS providers participated and 11% were aware of PAR. Many did not use PAR because of a lack of follow up or barriers such as limited internet access, inconvenience, other urgent responsibilities, and not knowing when to use PAR. Solutions to these issues include developing or purchasing new technology, involving the dispatch operator in PAR, and returning to a paper-based EIF. The EIF layout and content received very positive reviews with few changes suggested. Most providers felt PAR was important because it would help them provide better care and feel more comfortable treating CSHCN.

CONCLUSION

Despite technological and logistical barriers, EMS providers want online EIF databases for pre-planning and utilization during ambulance runs so they can practice more informed and focused care, especially for vulnerable and medically challenging CSHCN.

A Review on the Etiology and Management of Pediatric Traumatic Spinal Cord Injuries

CONTEXT

Pediatric traumatic spinal cord injury (SCI) is an uncommon presentation in the emergency department. Severe injuries are associated with devastating outcomes and complications, resulting in high costs to both the society and the economic system.

EVIDENCE ACQUISITION

The data on pediatric traumatic spinal cord injuries has been narratively reviewed.

RESULTS

Pediatric SCI is a life-threatening emergency leading to serious outcomes and high mortality in children if not managed promptly. Pediatric SCI can impose many challenges to neurosurgeons and caregivers because of the lack of large studies with high evidence level and specific guidelines in terms of diagnosis, initial management and of in-hospital treatment options. Several novel potential treatment options for SCI have been developed and are currently under investigation. However, research studies into this field have been limited by the ethical and methodological challenges.

CONCLUSION

Future research is needed to investigate the safety and efficacy of the recent uprising neurodegenerative techniques in SCI population. Owing to the current limitations, there is a need to develop novel trial methodologies that can overcome the current methodological and ethical limitations.

Incidence of Pediatric Cervical Spine Injuries in Iraq and Afghanistan

Cervical spine injuries in pediatric trauma patients are uncommon, and subsequently, proper diagnosis and the efficacy of spinal motion restriction in these patients remain a subject of contention. The aim of this study was to describe the incidence of cervical spine injuries in pediatric patients in Iraq and Afghanistan.

Objective

Military providers frequently treat civilians, including pediatric patients. Cervical spine injuries in pediatric trauma patients occur infrequently, with limited data on the incidence. The aim of this study was to describe the incidence of cervical spine injuries in pediatric patients in Iraq and Afghanistan.

Methods

We queried the Department of Defense Trauma Registry for all pediatric encounters from January 2007 to January 2016. We searched within that dataset for all cervical spine fractures.

Results

From January 2007 through January 2016 there were 3439 pediatric encounters. There were 36 subjects identified (1.0%) with a cervical spine fracture. Of those with a cervical spine fracture, 6 (17%) had a prehospital cervical collar placed, which did not improve survival to hospital discharge (collar, 66.7% vs no collar, 83.3%, P = 0.573). Of those with a cervical spine fracture, 6 (17%) had a documented spinal cord injury. The median age of subjects with a cervical spine fracture was 9.5 years and the majority (63.9%) were male. Most were injured by explosion (41.7%). The median composite injury score was higher in subjects with a cervical spine fracture compared with those without one (16.5 vs 10, P < 0.001). Subjects with a cervical spine fracture had longer lengths of stay in the intensive care unit (median 3 days vs 1, P = 0.012) and a trend toward worse survival to hospital discharge (80.6%, n = 29, vs 90.3%, n = 3074, P = 0.079).

Conclusions

Cervical spine injuries occurred infrequently in pediatric patients in Iraq and Afghanistan. When a fracture was present, almost one in five patients had spinal cord involvement. The pediatric prehospital literature would benefit from the development of a clinical decision tool to guide prehospital personnel as to when a cervical collar is indicated. Moreover, appropriate size equipment should be available when caring for host national civilians.

Initial assessment, level of care and outcome among children who were seen by emergency medical services: a prospective observational study

Background

The assessment of children in the Emergency Medical Service (EMS) is infrequent representing 5.4% of the patients in an urban area in the western part of Sweden. In Sweden, patients are assessed on scene by an EMS nurse whom independently decides on interventions and level of care. To aid the EMS nurse in the assessment a triage instrument, Rapid Emergency Triage and Treatment System-paediatrics (RETTS-p) developed for Emergency Department (ED) purpose has been in use the last 5 years. The aim of this study was to evaluate the EMS nurse assessment, management, the utilisation of RETTS-p and patient outcome.

Methods

A prospective, observational study was performed on 651 children aged < 16 years from January to December 2016. Statistical tests used in the study were Mann-Whitney U test, Fisher’s exact test and Spearman’s rank statistics.

Results

The dispatch centre indexed life-threatening priority in 69% of the missions but, of all children, only 6.1% were given a life threatening RETTS-p red colour by the EMS nurse. A total of 69.7% of the children were transported to the ED and, of these, 31.7% were discharged without any interventions. Among the non-conveyed patients, 16 of 197 (8.1%) visited the ED within 72 h but only two were hospitalised. Full triage, including five out of five vital signs measurements and an emergency severity index, was conducted in 37.6% of all children. A triage colour was not present in 146 children (22.4%), of which the majority were non-conveyed. The overall 30-day mortality rate was 0.8% (n = 5) in children 0–15 years.

Conclusions

Despite the incomplete use of all vital signs according to the RETTS-p, the EMS nurse assessment of children appears to be adapted to the clinical situation in most cases and the patients appear to be assessed to the appropriate level of care but indicating an over triage. It seems that the RETTS-p with full triage is used selectively in the pre-hospital assessment of children with a risk of death during the first 30 days of less than 1%.

Nurses' experiences of prehospital care encounters with children in pain

BACKGROUND

Pain relief in children is a complex issue, partly an ethical dilemma and due to a lack of nursing competence. There are few studies regarding prehospital care encounters with children in pain.

AIM

The aim of this study was to describe nurses' experiences in prehospital care encounters with children in pain and the specific related challenges.

METHOD

This study has a qualitative design. Eighteen Swedish nurses participated in three focus group interviews analysed using qualitative content analysis.

FINDINGS

The findings consist of a theme, "A challenge to shift focus and adjust to the child", and three categories describing prehospital care encounters with children in pain: "Being receptive and focusing on care," "Developing a trusting relationship," and "Providing professional nursing care." Caring for children in pain was stressful for the nurses. The nurses described how they had to shift focus and used different methods to build trust, such as playfulness, making eye contact, attracting curiosity, and using the parents to create trust. The also had to adjust to the child regarding dosages and materials.

CONCLUSION

Nurses has to be practically, mentally, and theoretically prepared to care for children with prehospital pain. It is essential to evaluate the administration of adequate pain relief to children, and more evidence-based knowledge is necessary concerning the different modes of administering pain-relieving drugs to prehospital children.

The Preschool-Aged and School-Aged Children Present Different Odds of Mortality than Adults in Southern Taiwan: A Cross-Sectional Retrospective Analysis

Background: This study aimed to profile the epidemiology of injury among preschool-aged and school-aged children in comparison to those in adults. Methods: According to the Trauma Registry System of a level I trauma center, the medical data were retrieved from 938 preschool-aged children (aged less than seven years), 670 school-aged children (aged 7⁻12 years), and 16,800 adults (aged 20⁻64 years) between 1 January 2009 and 31 December 2016. Two-sided Pearson’s, chi-squared, and Fisher’s exact tests were used to compare categorical data. A one-way analysis of variance (ANOVA) with the Games-Howell post-hoc test was used to assess the differences in continuous variables among different groups of patients. The mortality outcomes of different subgroups were assessed by a multivariable regression model under the adjustment of sex, injury mechanisms, and injury severity. Results: InFsupppjury mechanisms in preschool-aged and school-aged children were remarkably different from that in adults; in preschool-aged children, burns were the most common cause of injury requiring hospitalization (37.4%), followed by falls (35.1%) and being struck by/against objects (11.6%). In school-aged children, injuries were most commonly sustained from falls (47.8%), followed by bicycle accidents (14%) and being struck by/against objects (12.5%). Compared to adults, there was no significant difference of the adjusted mortality of the preschool-aged children (AOR = 0.9; 95% CI 0.38⁻2.12; p = 0.792) but there were lower adjusted odds of mortality of the school-aged children (AOR = 0.4; 95% CI 0.10⁻0.85; p = 0.039). The school-aged children had lower odds of mortality than adults (OR, 0.2; 95% CI, 0.06⁻0.74; p = 0.012), but such lower odds of risk of mortality were not found in preschool-aged children (OR, 0.7; 95% CI, 0.29⁻1.81; p = 0.646). Conclusions: This study suggests that specific types of injuries from different injury mechanisms are predominant among preschool-aged and school-aged children. The school-aged children had lower odds of mortality than adults; nonetheless there was no difference in mortality rates of preschool-aged children than adults, with or without controlling for sex, injury mechanisms and ISS. These results highlight the importance of injury prevention, particularly for preschool-aged children in Southern Taiwan.

Timing of mortality in pediatric trauma patients: A National Trauma Data Bank analysis

BACKGROUND/PURPOSE

The classic "trimodal" distribution of death has been described in adult patients, but the timing of mortality in injured children is not well understood. The purpose of this study was to define the temporal distribution of mortality in pediatric trauma patients.

METHODS

A retrospective cohort of patients with mortality from the National Trauma Data Bank (2007-2014) was analyzed. Categorical comparison of 'dead on arrival', 'death in the emergency department', and early (≤24h) or late (>24h) inpatient death was performed. Secondary analyses included mortality by pediatric age, predictors of early mortality, and late complication rates.

RESULTS

Children (N=5463 deaths) had earlier temporal distribution of death compared to adults (n=104,225 deaths), with 51% of children dead on arrival or in ED compared to 44% of adults (p<0.001). For patients surviving ED resuscitation, children and adolescents had a shorter median time to death than adults (1.2 d and 0.8 days versus 1.6 days, p<0.001). Older age, penetrating mechanism, bradycardia, hypotension, tube thoracostomy, and thoracotomy were associated with early mortality in children.

CONCLUSIONS

Injured children have higher incidence of early mortality compared to adults. This suggests that injury prevention efforts and strategies for improving early resuscitation have potential to improve mortality after pediatric injury.

LEVEL OF EVIDENCE

Level III: Retrospective cohort study.

Helicopters and injured kids: Improved survival with scene air medical transport in the pediatric trauma population

BACKGROUND

Helicopter emergency medical services (HEMS) are frequently used to transport injured children, despite unclear evidence of benefit. The study objective was to evaluate the association of HEMS compared with ground emergency medical services (GEMS) transport with outcomes in a national sample of pediatric trauma patients.

METHODS

Patients 15 years or younger undergoing scene transport by HEMS or GEMS in the National Trauma Data Bank from 2007 to 2012 were included. Propensity score matching was used to match HEMS and GEMS patients for likelihood of HEMS transport based on demographics, prehospital physiology and time, injury severity, and geographic region. Absolute standardized differences of less than 0.1 indicated adequate covariate balance between groups after matching. The primary outcome was in-hospital survival, while the secondary outcome was discharge disposition in survivors. Conditional logistic regression determined the association between HEMS versus GEMS transport with outcomes while controlling for demographics, admission physiology, injury severity, nonaccidental trauma, and in-hospital complications not accounted for in the propensity score. Subgroup analysis was performed in patients with a transport time of greater than 15 minutes to capture patients with the potential for HEMS transport.

RESULTS

A total of 25,700 HEMS/GEMS pairs were matched from 166,594 patients. Groups were well matched, with all propensity score variables having absolute standardized differences of less than 0.1. In matched patients, HEMS was associated with a 72% increase in odds of survival compared with GEMS (adjusted odds ratio, 1.72; 95% confidence interval, 1.26-2.36; p < 0.01). Transport mode was not associated with discharge disposition (p = 0.47). Subgroup analysis included 17,657 HEMS/GEMS pairs. HEMS was again associated with a significant increase in odds of survival (adjusted odds ratio, 1.81; 95% confidence interval, 1.24-2.65; p < 0.01), while transport mode was not associated with discharge disposition (p = 0.58).

CONCLUSION

Scene transport by HEMS was associated with improved odds of survival compared with GEMS in pediatric trauma patients. Further study is warranted to understand the underlying mechanisms and develop specific triage criteria for HEMS transport in this population.

LEVEL OF EVIDENCE

Therapeutic study, level III.

Paediatric Blunt Torso Trauma: Injury mechanisms, patterns and outcomes among children requiring hospitalisation at the Sultan Qaboos University Hospital, Oman

OBJECTIVES

Trauma is the greatest cause of morbidity and mortality in paediatric/adolescent populations worldwide. This study aimed to describe trauma mechanisms, patterns and outcomes among children with blunt torso trauma admitted to the Sultan Qaboos University Hospital (SQUH) in Muscat, Oman.

METHODS

This retrospective single-centre study involved all children ≤12 years old with blunt torso trauma admitted for paediatric surgical care at SQUH between January 2009 and December 2013. Medical records were analysed to collect demographic and clinical data.

RESULTS

A total of 70 children were admitted with blunt torso trauma during the study period, including 39 (55.7%) male patients. The mean age was 5.19 ± 2.66 years. Of the cohort, 35 children (50.0%) received their injuries after having been hit by cars as pedestrians, while 19 (27.1%) were injured by falls, 12 (17.1%) during car accidents as passengers and four (5.7%) by falling heavy objects. According to computed tomography scans, thoracic injuries were most common (65.7%), followed by abdominal injuries (42.9%). The most commonly involved solid organs were the liver (15.7%) and spleen (11.4%). The majority of the patients were managed conservatively (92.9%) with a good outcome (74.3%). The mortality rate was 7.1%. Most deaths were due to multisystem involvement.

CONCLUSION

Among children with blunt torso trauma admitted to SQUH, the main mechanism of injury was motor vehicle accidents. As a result, parental education and enforcement of infant car seat/child seat belt laws are recommended. Conservative management was the most successful approach.

Impact of pre-hospital care on the outcome of children arriving with agonal breathing to a pediatric emergency service in South India

BACKGROUND

Data on the prehospital interventions received by critically ill children at arrival to Paediatric Emergency Services (PES) is limited in developing countries. This study aims to describe the pre-hospital care scenario, transport and their impact on outcome in non-traumatic, acutely ill children presenting in PES with agonal breathing.

METHODS

Prospective observational study done on children aged below 15 years arriving in PES with agonal breathing due to non-trauma related causes.

RESULTS

Out of 75 children studied, 69% were infants. The duration of illness among 65% of them (75) was less than 3 days. Majority of them (81%) had received treatment prior to arrival. Government sector physicians (72%), half of them (51%) being pediatricians were the major treating doctors. 37% of the children had arrived to the Emergency in an ambulance. Cardiopulmonary Resuscitation (CPR) was given to 27% on arrival in PES. Other interventions included fluid boluses to correct shock (92%) and inotrope infusion (56%). Sepsis (24%) and pneumonia (24%) were the most common diagnoses. Out of 75, 57 (76%) children who were stabilized and shifted to PICU and among them 27 (47%) survived to discharge. Normal blood pressure (p=0.0410) and non-requirement of CPR (0.0047) and inotropic infusion (0.0459) in PES were associated with a higher chance of survival.

CONCLUSION

36% (27/75) of children who arrived to our PES with agonal breathing survived to hospital discharge. Survival was significantly better among those who did not need CPR.

Paediatric trauma resuscitation: an update

Purpose

Paediatric trauma is the leading cause of mortality in children. Paediatric trauma resuscitation is the first and foremost step towards a successful treatment and subsequent recovery. Significant advances have taken place in the last years in relation to this field of trauma care.

Methods

In this narrative review, we attempt to summarise the recent development in the concepts of fluid resuscitation, massive transfusion, permissive resuscitation, management of coagulopathy and use of tranexamic acid, literature pertaining to implementation of transfusion protocols in the paediatric population and education related to the paediatric trauma resuscitation.

Results/Conclusions

The current evidence although emerging is still sparse and high-quality studies are needed to shed more light on most of the above domains of resuscitation.

[Typical problems in pediatric emergencies: Possible solutions]

BACKGROUND

Pediatric emergencies are rare and challenging for health care providers, parents, and patients. The purpose of this article is to highlight typical difficulties in the treatment of pediatric patients and to discuss potential solutions.

MATERIALS AND METHODS

This article is based on a selective literature search using PubMed and the experience of the authors in the field of simulation and pediatric emergencies.

RESULTS

Inexperience with pediatric emergencies, uncertainty in technical skills, in the usage of pediatric equipment and in medication dosage as well as parental presence foster the perception of stress and potentially compromise the success of patient care. Beside implementation of simplified technical skill devices (e.g., intraosseous vascular access system, supraglottic airway devices, and alternative approaches for drug administration), there have been many efforts in recent years to improve patient safety. Tools for estimating body weight and precalculated drug-dosing charts have been implemented as well as standardized courses for guidelines, technical skills, and team-related skills have been established.

CONCLUSION

To improve patient safety, regular training and implementation of a sustainable safety culture are mandatory.

An evaluation of the professional, social and demographic profile and quality of life of physicians working at the Prehospital Emergency Medical System (SAMU) in Brazil

OBJECTIVE

To describe the profile of physicians working at the Prehospital Emergency Medical System (SAMU) in Brazil and to evaluate their quality of life.

METHODS

Both a semi-structured questionnaire with 57 questions and the SF-36 questionnaire were sent to research departments within SAMU in the Brazilian state capitals, the Federal District and inland towns in Brazil.

RESULTS

Of a total of 902 physicians, including 644 (71.4%) males, 533 (59.1%) were between 30 and 45 years of age and 562 (62.4%) worked in a state capital. Regarding education level, 45.1% had graduated less than five years before and only 43% were specialists recognized by the Brazilian Medical Association. Regarding training, 95% did not report any specific training for their work at SAMU. The main weaknesses identified were psychiatric care and surgical emergencies in 57.2 and 42.9% of cases, respectively; traumatic pediatric emergencies, 48.9%; and medical emergencies, 42.9%. As for procedure-related skills, the physicians reported difficulties in pediatric advanced support (62.4%), airway surgical access (45.6%), pericardiocentesis (64.4%) and thoracentesis (29.9%). Difficulties in using an artificial ventilator (43.3%) and in transcutaneous pacing (42.2%) were also reported. Higher percentages of young physicians, aged 25-30 years (26.7 vs 19.0%; p<0.01), worked exclusively in prehospital care (18.0 vs 7.7%; p<0.001), with workloads >48 h per week (12.8 vs 8.6%; p<0.001), and were non-specialists with the shortest length of service (<1 year) at SAMU (30.1 vs 18.2%; p<0.001) who were hired without having to pass public service exams (i.e., for a temporary job) (61.8 vs 46.2%; p<0.001). Regarding quality of life, the pain domain yielded the worst result among physicians at SAMU.

CONCLUSIONS

The doctors in this sample were young and within a few years of graduation, and they had no specific training in prehospital emergencies. Deficiencies were mostly found in pediatrics and psychiatry, with specific deficiencies in the handling of essential equipment and in the skills necessary to adequately attend to prehospital emergencies. A disrespectful labor scenario was also found; the evaluation of quality of life showed a notable presence of pain on the SF-36 among physicians at SAMU and especially among doctors who had worked for a longer length of time at SAMU.