Kids, Cars, Falls and Brawls The Pediatric Golden Hour. Kids, Cars, Falls and Brawls The Pediatric Golden Hour. The Pediatric Golden Hour
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1 Kids, Cars, Falls and Brawls Kids, Cars, Falls and Brawls M. Jeffrey Fein RN, CFRN Educator Critical Care Transport Team The Golden Hour The idea has been propagated from intuition and the writings of R. Adams Crowley. Our search into the background of this term yielded little scientific evidence to support it. E. B. Lerner and R. Moscati Acad Emergency Med 2001 Jul:8 (7):
2 You live or die depending on where you have your accident because they take you to the nearest hospital! R. Adams Cowley, MD In the Blink of an Eye The 3 Rights of Trauma Care The right patient to the right place at the right time Donald Trunkey, MD Development 0-6 months Roll over, Sleep, Eat, The Other Thing Falls, Drowning, Burns 6-12 months Crawls, Sits up, Pulls Up To Stand Falls, Drowning, Burns, Crush 1 2 years Runs, Climbs, Curiosity and Exploring Falls, Drowing,, Burns, Crush, Cars 2
3 Development 3 5 years Runs, Climbs, Exploring, Resists Constraints Falls, Drowing,, Burns, Crush, Cars 6 12 years Team Sports, Wheeled Stuff, Unsupervised Play, Independence Over 12 years More Independence, Invulnerability, Increased Risk Taking The Clock Starts Now 3
4 Zero minutes minutes The Clock Starts Now The accident occurs Call for help 5 minutes Call for help minutes Ambulance arrives minutes Ambulance leaves the scene minutes Ambulance arrives at the Hospital IF the EMS GODS are smiling! The Clock Starts Now Delays No Cell Phone Entrapped Airway Control Spinal Immobilization No Ambulance Isolated 4
5 Epidemiology 22 million children/year 1 in 4 suffer serious injury/year More children die from trauma or its effects than all other causes combined! For each injury related death 42 hospitalizations 1120 ED visits Emergency Medical Services Dark Territory - Scary 10% of EMS calls are for pediatrics 10-20% of ED visits are for pediatrics Equipment 4 55% offered pediatric training 24% did not have pediatric BP cuffs 79% did not have pediatric ventilation masks 5
6 Emergency Medical Services Skills - 60 active EMS providers 5 One Pediatric BVM every 1.7 years One Pediatric Intubation every 3.3 years One I/O access every 6.7 years Anatomy and Physiology Body Surface Area infants and children hypothermia use heat lamps, radiant warmers, blankets, or warmed IV fluids 6
7 Anatomy and Physiology Big Heads deceleration - falls and MVA 9.8 meter/sec 2 KE=mv 2 /2 thinner / softer craniums break / don t t break not completely myelinated - shearing open sutures and fontanelles (hooray/boo) Anatomy and Physiology Airway Failure to manage the airway properly is the leading cause of preventable death due to trauma 7
8 Anatomy and Physiology Airway glottis anterior and superior trachea shorter cricoid cartilage narrowest (8 years) thorax more compliant (50/50) lung contusion pneumothorax more dependant on diaphragmatic breathing Anatomy and Physiology Airway and SPINE Management of the Airway MUST include CONTROL of the CEVICAL SPINE Treatment Airway and SPINE Manual stabilization of the spine Appropriate Cervical Collar Towel Roll Long Board / PediBoard OXYGEN Control of the Airway 8
9 Anatomy and Physiology Circulation Blood Volume 7-88 % of body weight 20% greater than adults Compensate well Strong heart Mickey D s D s / CAD Age Group Infant Vital Signs Heart Rate Respiratory Rate BP Systolic BP Diastolic Toddler Preschooler School-age Adolescent Treatment Circulation IV access IO Sugar Fluids NO DEXTROSE SOLUTIONS for resuscitation 10 ml/kg neonates 20 ml/kg everyone else FILL THE TANK 9
10 Treatment Circulation Blood Vasopressors FILL HER UP AND CHECK THE OIL Anatomy and Physiology Burns Approximately 700,000 burns yearly 40,000 treated in burn centers 30-40% pediatric burn injuries 70,000 hospitalized 12,000 deaths annually 10
11 Anatomy and Physiology Burns Highest incidence in year age group 2 nd peak in adolescence 3 rd leading cause of death in ages Treatment Burns AIRWAY, AIRWAY, AIRWAY Burns BSA Treatment Palmar Method Rule of Nines Lund and Browder 11
12 Treatment Burns Fluid Management Lactated Ringers or Normal Saline Parkland Formula 4 ml s s X wt. / kgs.. X %TBSA= Over 1 st 24 hrs. ½ in 1 st 8 hrs. Parkland + Maintenance Treatment Burns Pain Control Dressings check with the Burn Center or Specialist 12
13 Abuse High Index of Suspicion Story does not match the injury Delay in care Pre Hospital / Pre Specialty Care ABC s Monitor, Monitor, Monitor Early intervention with airway a maintainable airway Aggressive fluid management different from adults Care in managing C spine injuries SCIWORA Think out of the box The Team Specialties rarely thought of Pediatric Psychologist Pediatric Pharmacist Pediatric Social Worker Pediatric Discharge Planning Coordinator Child Life 13
14 Transfer American Academy of Pediatrics Because of their special needs, children require health professionals with special training and expertise in assessment and appropriate treatment of their illness and injuries. Transfer Provide intensive care in a moving environment Critical care transport doesn t t preclude the necessity of critical care intervention at referring hospital Most stabilization procedures should be done prior to transport if possible 14
15 Transfer Only those clinicians who have experience working in the unique setting of critical transports will be truly effective in this type of environment In pediatric trauma, you don t t just have an injured child, you have an injured family M. Eichelberger,, MD In the Blink of an Eye M. Jeffrey Fein St. Christopher s s Hospital for Children Critical Care Transport Team Nurse Educator jeffrey.fein@tenethealth.com 15
16 References 1. Lerner, E.B., Moscati,, R.M. The Golden Hour: Scientific Fact or Medical Urban Legend? Acad Emergen Med 2001 Jul;8 (7): Bledsoe, B.E. The Golden Hour: Fact or Fiction? Emerg Med Serv Jun;31 (6): Little, W.K., Golden Hour of Golden Opportunity: Early Management t of Pediatric Trauma Clinical Pediatric Emergency Medicine (March 2010) Volume 11 Issue Seidel Pediatrics 1984;73:769/1986;79: Babl PEC 2000;17: Flavin,, M, Dostaler,, S.M., Simpson, K., Brison,, R.J., and Pickett, W. Stages of development and injury patterns in the early years: a population-based analysis Retrieved 8/15/10 from 7. National Vital Statistics Report Vol 50, No. 15 September 16,
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