2003Oklahoma EMSC Resource Center0 Pediatric Trauma And Triage Overview of the Problem and Necessary...

2003 Oklahoma EMSC Resource Center 1

Pediatric TraumaPediatric TraumaAnd TriageAnd Triage

Overview of the Overview of the Problem and Problem and

Necessary Care for Necessary Care for Positive Outcomes…Positive Outcomes…

Presented by: Jim Morehead, BS, NREMT-P


OBJECTIVESOBJECTIVES

• Increase awareness of issues Increase awareness of issues specific to children & trauma.specific to children & trauma.

• Improve pediatric trauma Improve pediatric trauma Assessment & Intervention skills.Assessment & Intervention skills.• Identify Mechanisms of Injury & key Identify Mechanisms of Injury & key

Assessment componentsAssessment components• Recognize differences btw adult & Recognize differences btw adult &

child priorities child priorities • Identify & avoid common errors in the Identify & avoid common errors in the

pediatric trauma carepediatric trauma care• Provide appropriate interventionsProvide appropriate interventions


NATURE OF NATURE OF “BEAST”“BEAST”

• Pediatrics account for Pediatrics account for 15-25%15-25% of of total emergent care patients.total emergent care patients.

• Trauma is approximately Trauma is approximately 50%50% of of all pediatric emergenciesall pediatric emergencies• Usually > 2 years oldUsually > 2 years old• More medical cases < 2 years oldMore medical cases < 2 years old

• InjuryInjury is the is the leading cause of leading cause of deathdeath in children in children• MVC = MVC = 50%50%


NATURE OF NATURE OF “BEAST”“BEAST” cont’dcont’d

• Almost Almost 70%70% of major pediatric of major pediatric trauma cases trauma cases die due to severity die due to severity of injuryof injury..• NOTNOT a a deficit in emergent caredeficit in emergent care

• When a child is injured, the whole When a child is injured, the whole family is injured too!family is injured too!• > 40%> 40% divorce ratedivorce rate within 1 year within 1 year

after a major traumaafter a major trauma


Clinical PearlsClinical Pearls


Consider Possibility ofConsider Possibility ofChild AbuseChild Abuse

When you see an injured childWhen you see an injured child• Common cause of injuries in Common cause of injuries in

children.children.• 50%50% of of second hospital visitssecond hospital visits for for

these children result in deaththese children result in death• Awareness of signs & symptoms Awareness of signs & symptoms

of abuse helps identify casesof abuse helps identify cases


General Principles ofGeneral Principles ofPediatric TraumaPediatric Trauma

• Priorities are similar to adultsPriorities are similar to adults• All roads lead to the A-B-C (D-E)’sAll roads lead to the A-B-C (D-E)’s• Start with “A”, not the most obviousStart with “A”, not the most obvious

• Children have certain key Children have certain key differencesdifferences• Different energy transfer due to sizeDifferent energy transfer due to size• MetabolismMetabolism• Ability to respond to words & give Ability to respond to words & give

historyhistory• History of accident may be critical in History of accident may be critical in

determining intervention plandetermining intervention plan


Physical DifferencesPhysical Differences

• HEADHEAD Is Larger Is Larger• Brain injury increased during impactsBrain injury increased during impacts• More leverage on neckMore leverage on neck• Occiput forces neck into flexion while Occiput forces neck into flexion while

lying flatlying flat• Airway tends to buckle & close on adult Airway tends to buckle & close on adult

spine board without proper shoulder spine board without proper shoulder supportsupport

• NECKNECK Is Shorter Is Shorter• Causes different injury patternsCauses different injury patterns• C2-C4 more common injuriesC2-C4 more common injuries


Physical DifferencesPhysical Differences cont’dcont’d

• CHESTCHEST More Pliable More Pliable• Pulmonary contusion more likelyPulmonary contusion more likely• Diaphragm motion essential for Diaphragm motion essential for

ventilationventilation• Energy transmitted to chest organsEnergy transmitted to chest organs

• ABDOMINAL ORGANSABDOMINAL ORGANS Less Less ProtectionProtection• Liver not covered by the rib cageLiver not covered by the rib cage• Less abdominal wall muscle massLess abdominal wall muscle mass• Less Sub-Q tissue to absorb energyLess Sub-Q tissue to absorb energy


Energy Transfer Effects of Energy Transfer Effects of SizeSize

• Children are SmallerChildren are Smaller • More force per square inch of bodyMore force per square inch of body• Organs are closer together=multi-Organs are closer together=multi-

system injury rulesystem injury rule• Children are Softer Children are Softer (More Flexible / (More Flexible /

Bouncy)Bouncy)• Bones don’t break but instead pass Bones don’t break but instead pass

on energy on energy • Internal organ damage without Internal organ damage without

fractures is more commonfractures is more common• Larger Surface Area to Size RatioLarger Surface Area to Size Ratio

• Lose heat more rapidlyLose heat more rapidly


Metabolic Differences in Metabolic Differences in KidsKids

• Have Higher Metabolic RatesHave Higher Metabolic Rates• Nearly Twice as Rapid ONearly Twice as Rapid O22

ConsumptionConsumption• Increased Blood FlowIncreased Blood Flow• More Frequent Feedings More Frequent Feedings • More Fluid Intake per Size RatioMore Fluid Intake per Size Ratio


Metabolic Differences Metabolic Differences cont’dcont’d

• Children “SHOCK OUT” DifferentlyChildren “SHOCK OUT” Differently• Children Compensate Better Children Compensate Better INITIALLYINITIALLY

• May show minimal signs & symptomsMay show minimal signs & symptoms

• Children have less reserves than adultsChildren have less reserves than adults• Platinum Half-HourPlatinum Half-Hour in Trauma Resuscitation in Trauma Resuscitation• Rapid Intervention CriticalRapid Intervention Critical• Once Reserves ExhaustedOnce Reserves Exhausted

BAD THINGS HAPPENBAD THINGS HAPPEN!!!!!!


THE BAD THINGSTHE BAD THINGS

• Decompensation can be rapidDecompensation can be rapid• A conscious, crying child can become A conscious, crying child can become

pulseless and apneic in less than 2 pulseless and apneic in less than 2 minutesminutes

• Once decompensated, may be too Once decompensated, may be too latelate• Limited Reserves are gone; whole Limited Reserves are gone; whole

system collapsessystem collapses

RAPID & EARLY RECOGNITION & RAPID & EARLY RECOGNITION & INTERVENTION ARE CRITICALINTERVENTION ARE CRITICAL!!!!!!


ASSESSMENTASSESSMENT

For SurvivalFor Survival


Safety FirstSafety First

• Bodily Substance IsolationBodily Substance Isolation• Potential Hazards on, around, or Potential Hazards on, around, or

with Patientwith Patient• Available ResourcesAvailable Resources


Prepare YourselfPrepare Yourself

• The first step in a cardiac arrest The first step in a cardiac arrest or other critical situation is to:or other critical situation is to:

Take your own pulseTake your own pulse!!!!!!• Assign roles ahead of timeAssign roles ahead of time

• Respiratory ManagementRespiratory Management• Spine ManagementSpine Management• Circulatory ManagementCirculatory Management• Hx, Equipment, etc.Hx, Equipment, etc.


Careful AttentionCareful Attention

• Initial AssessmentInitial Assessment CRUCIALCRUCIAL• Don’t be distracted by the Don’t be distracted by the

blood and screamsblood and screams

A QUIET KID SHOULD A QUIET KID SHOULD SCARE the @$% of SCARE the @$% of

YOU!!!YOU!!!• If practical, keep parents If practical, keep parents

with child to help reduce with child to help reduce child's fearchild's fear

Lots of Lots of bloodbloodCan’t Can’t

breathebreathecryincryingg

Fx’sFx’sEveryone Everyone scaredscared

QuietQuietUncon.Uncon.


Brilliance vs. BasicsBrilliance vs. Basics

For every “For every “BRILLIANT”BRILLIANT” maneuver/diagnosis maneuver/diagnosis

you make which saves you make which saves a life, you’ll save 10 a life, you’ll save 10 by just doing a good, by just doing a good,

solid job.solid job.

STAY FOCUSED ON STAY FOCUSED ON THETHE

BASICS IN THE HEAT BASICS IN THE HEAT OF THE MOMENTOF THE MOMENT!!!!!!


Consider Consider MOIMOI

MMechanism

echanism OOf f IInjurynjury


RememberRemember ‘‘ss

““Proper basic airway management Proper basic airway management is often is often performed inadequatelyperformed inadequately if if at all, apparently due to fear and at all, apparently due to fear and panic.”panic.”

Theodore M. Barnett, M.D. Children's Mercy Hospital, Kansas City, MO


Pediatric Assessment Pediatric Assessment TriangleTriangle

AppearanceAppearance Work of BreathingWork of

Breathing

Circulation to SkinCirculation to Skin


AppearanceAppearance

• Look at the patient from a slight Look at the patient from a slight distance - What do you see?distance - What do you see?

• Mental StatusMental Status

• ColorColor

• Interaction / MovementInteraction / Movement

• RecognitionRecognition

STOSTOPP


RememberRemember

A A Quiet KidQuiet Kid is oneis one that that

should,should, SCARE You!!!SCARE You!!!


RespiratoryRespiratory

• AIRWAYAIRWAY: Patent with Precautions: Patent with Precautions• BREATHINGBREATHING: Respiratory Rate; too fast : Respiratory Rate; too fast

vs too slow, Abnormal Soundsvs too slow, Abnormal Sounds• A slow or irregular respiratory rate in a A slow or irregular respiratory rate in a

child is an child is an OMINOUS SIGN. OMINOUS SIGN. (Bad JU JU)(Bad JU JU)• Watch for the Watch for the EFFORT NEEDED to BREATHEEFFORT NEEDED to BREATHE

• Chest, neck, or abdominal muscle Chest, neck, or abdominal muscle retractionsretractions

• Flaring of the nostrilsFlaring of the nostrils• Adventitious Sounds -Crackles, Crows, Adventitious Sounds -Crackles, Crows,

Grunts Grunts (Rice Krispies, Rosters, Pigs)(Rice Krispies, Rosters, Pigs)


A=Airway: Control C-SpineA=Airway: Control C-Spine• Unconscious kids can’t protect Unconscious kids can’t protect

their airwaytheir airway• Tongue most common obstructionTongue most common obstruction• Little airways are easily blockedLittle airways are easily blocked• JAW THRUST: JAW THRUST: Neutral AlignmentNeutral Alignment for for

kids includes Pad under the Shoulderskids includes Pad under the Shoulders• May need Oral/Nasal AirwayMay need Oral/Nasal Airway

• Infants in first 30 days of life are Infants in first 30 days of life are obligate nasal breathersobligate nasal breathers• May need to suction out blood/mucusMay need to suction out blood/mucus


B=BreathingB=Breathing

• All ChildrenAll Children get get OxygenOxygen & & LOTS OF ITLOTS OF IT• May need to assist with B-V-MMay need to assist with B-V-M

• Good mask seal is the Good mask seal is the KEY KEY to baggingto bagging• Two people should bag when possibleTwo people should bag when possible• Avoid distending the stomachAvoid distending the stomach

• Cricoid pressure / Easy does itCricoid pressure / Easy does it• Distended stomach = less room for air in Distended stomach = less room for air in

lungslungs

Blue BADBlue BAD - - OxygenOxygen GOODGOOD


C=Circulation: C=Circulation: Peripheral vs Peripheral vs CentralCentral

• PulsePulse• Color , Temperature, Texture of Color , Temperature, Texture of

SkinSkin• CAPILLARY REFILLCAPILLARY REFILL

• << 2 seconds 2 seconds GOOD NEWSGOOD NEWS• 2-4 seconds WATCH OUT2-4 seconds WATCH OUT• >> 4 seconds 4 seconds

DEEP DOODOO NOW!!!DEEP DOODOO NOW!!!


Pediatric Trauma Pediatric Trauma MessagesMessages

1. A 1. A little bleedinglittle bleeding is is a lota lot the smaller the smaller you are.you are.

2. 2. BP often maintained until very late in BP often maintained until very late in hemorrhagehemorrhage by young patients by young patients because of their overactive because of their overactive vasoconstrictive responses.vasoconstrictive responses.

Tom Terndrup, MDTom Terndrup, MD

Director of Pediatric Emergency MedicineDirector of Pediatric Emergency Medicine University Hospital / Syracuse, N.Y.University Hospital / Syracuse, N.Y.


D=Disability: Neuro EvalD=Disability: Neuro Eval

• Use the AVPU system firstUse the AVPU system first– Avoid "lethargic“, "semi-conscious“, Avoid "lethargic“, "semi-conscious“,

etc. because everyone has different etc. because everyone has different meanings with these terms.meanings with these terms.

• Use the Pediatric Glasgow Coma Use the Pediatric Glasgow Coma ScaleScale– If time and circumstance permitIf time and circumstance permit– Age and behavior adjustedAge and behavior adjusted

• TBI’s need adequate oxygen !TBI’s need adequate oxygen !• Hyperventilate only if they deteriorateHyperventilate only if they deteriorate• Otherwise High Flow OOtherwise High Flow O22


E=ExposureE=Exposure

• Kids lose heat quicklyKids lose heat quickly• Keep them Keep them COVERED UPCOVERED UP• Expose only as you needExpose only as you need• If If YOUYOU are are

COMFORTABLECOMFORTABLE, it’s , it’s probably probably TOO COLDTOO COLD for for themthem


S-A-M-P-L-E HxS-A-M-P-L-E Hx

• S=Signs and SymptomsS=Signs and Symptoms• A=AllergiesA=Allergies• M=Medications currently takenM=Medications currently taken• P=Pertinent Past/ Present P=Pertinent Past/ Present

IllnessesIllnesses• L=Last MealL=Last Meal• E=Events/environment related to E=Events/environment related to

the injurythe injury


Positive OutcomesPositive Outcomes

Resulting from early & Resulting from early & rapid recognition, rapid recognition,

assessment, & assessment, & management of shock…management of shock…


Pediatric Trauma Score Pediatric Trauma Score ((PTSPTS))

• All components are scored:All components are scored:• +2+2• +1+1• -1-1

• Total score can rangeTotal score can range• +12, the best+12, the best• - 6, the worst- 6, the worst• The The threshold score is 8threshold score is 8

• Anyone scoring Anyone scoring << 8 send to 8 send to Pediatric Trauma CenterPediatric Trauma Center


PTS ComponentsPTS Components

• SIZESIZE– The most obvious of all the The most obvious of all the

componentscomponents– Automatically weights the infant-Automatically weights the infant-

toddler due to increased mortality toddler due to increased mortality associated to their smaller sizeassociated to their smaller size

• AIRWAYAIRWAY– Assesses functionability and Assesses functionability and

management parametersmanagement parameters– The more toys it takes, the lower the The more toys it takes, the lower the

scorescore


PTS Components PTS Components cont’dcont’d

• SYSTOLIC B/PSYSTOLIC B/P: Weighted to find : Weighted to find the evolving shock patient the evolving shock patient (50-90 (50-90 mmHg).mmHg).

• New DOT EMT Basic uses capillary New DOT EMT Basic uses capillary refill as an indicator of refill as an indicator of cardiovascular status.cardiovascular status.

• < 2sec, 2-4 sec, < 2sec, 2-4 sec, >> 4 sec 4 sec• Central vs PeripheralCentral vs Peripheral

• PALS recommends use of peripheral PALS recommends use of peripheral and central pulses as an indicatorand central pulses as an indicator


PTS Components PTS Components cont’dcont’d

• MENTAL STATUSMENTAL STATUS– Any changeAny change inin Mental Status Mental Status warrants a warrants a

lower scorelower score• SOFT TISSUE INJURYSOFT TISSUE INJURY

– Surface Area / Volume IssueSurface Area / Volume Issue• MUSCULO-SKELETAL INJURY/FXMUSCULO-SKELETAL INJURY/FX

– High incidence in kidsHigh incidence in kids– Energy transmission instead of localized Energy transmission instead of localized

fracturefracture

MULTI-SYSTEMS TRAUMA IS MULTI-SYSTEMS TRAUMA IS RULERULE


Recognizing Signs of Recognizing Signs of ShockShock

• Early signs can be subtleEarly signs can be subtle• May be minimal signs with under May be minimal signs with under

20% blood loss20% blood loss• 50% and over blood loss usually 50% and over blood loss usually

pulseless and unconscious pulseless and unconscious (Read as (Read as DEAD)DEAD)

• Any injured kid who is Any injured kid who is CoolCool & & TachycardicTachycardic is in is in SHOCKSHOCK until until proven otherwise!!!proven otherwise!!!


Shock Recognition Shock Recognition cont’dcont’d

• Altered mental status may be first sign Altered mental status may be first sign of shockof shock

• Another early sign is Another early sign is DELAYED DELAYED CAPILLARY REFILLCAPILLARY REFILL

• Next comes a decrease in pulse Next comes a decrease in pulse pressurepressure• Systolic minus DiastolicSystolic minus Diastolic

• Drop in Blood Pressure is a Drop in Blood Pressure is a LATE SIGNLATE SIGN• Systolic should be > [ 70 + 2(age in years)] Systolic should be > [ 70 + 2(age in years)]

but it rarely falls below this until 25-30% but it rarely falls below this until 25-30% blood lossblood loss


Shock Recognition Shock Recognition cont’dcont’d

• Anxiety, fear, and cold weather Anxiety, fear, and cold weather can all mimic early shockcan all mimic early shock• Increased heart rateIncreased heart rate• Decreased capillary refillDecreased capillary refill• Pale, cool extremitiesPale, cool extremities• Weak peripheral pulsesWeak peripheral pulses

• History alone can be a good History alone can be a good enough reasonenough reason• Remember the Remember the MOIMOI


Shock InterventionShock Intervention

• OO22 (shoot the juice)(shoot the juice)• ProtectionProtection

• Spinal Stabilization/ImmobilizationSpinal Stabilization/Immobilization• Preserve Body TemperaturePreserve Body Temperature

• Hemorrhage ControlHemorrhage Control• Volume ReplacementVolume Replacement

• Crystalloids (NS/LR) 20 mL/kgCrystalloids (NS/LR) 20 mL/kg• Length-Based Resuscitation TapeLength-Based Resuscitation Tape


Infant Transport by EMSInfant Transport by EMS

• ““Keep infants in car seats unless Keep infants in car seats unless treatment of injuries requires removal treatment of injuries requires removal (IV, ETT, BVM, control of hemorrhage). (IV, ETT, BVM, control of hemorrhage). If they survived the crash in an intact If they survived the crash in an intact car seat, they are usually better off to car seat, they are usually better off to stay in it for the ride to the hospital.”stay in it for the ride to the hospital.”

William E. Hauda, II, MDWilliam E. Hauda, II, MDPediatric Emergency Medicine FellowPediatric Emergency Medicine Fellow

Attending Emergency Medicine PhysicianAttending Emergency Medicine PhysicianFairfax Hospital, Falls Church, VAFairfax Hospital, Falls Church, VA


Trauma ManagementTrauma Management

• Kids are large headed and may Kids are large headed and may have cervical spine injury without have cervical spine injury without evidenceevidence

• Ideal immobilization is a hard Ideal immobilization is a hard collar, spine board with pads & collar, spine board with pads & head-straps.head-straps.

• TBI’s need adequate oxygen!TBI’s need adequate oxygen!• Hyperventilate only if they deteriorateHyperventilate only if they deteriorate• Otherwise High Flow OOtherwise High Flow O22


Pediatric Trauma Pediatric Trauma TriageTriage

Identifying a possible Identifying a possible tool to accomplish tool to accomplish

task…task…


Pediatric Problems in Pediatric Problems in TriageTriage

• Children often not Children often not triaged as well as triaged as well as adults in traumatic adults in traumatic MCI’sMCI’s

• Currently no published Currently no published or widely utilized Multi-or widely utilized Multi-Casualty Triage Tools Casualty Triage Tools that take into account that take into account physiology differences physiology differences between children & between children & adultsadults


Triage Problems Triage Problems cont’dcont’d

• Pediatric Multi-Casualty triage Pediatric Multi-Casualty triage may be affected by the emotional may be affected by the emotional states of providersstates of providers

• May be tendencies to upgrade May be tendencies to upgrade triage categories out of triage categories out of compassion or lack of confidence compassion or lack of confidence in pediatric assessment & in pediatric assessment & intervention skillsintervention skills


May 3, 1999May 3, 1999


May 3, 1999 May 3, 1999 cont’dcont’d


Multi-Casualty Triage GoalMulti-Casualty Triage Goal

““To do the To do the BESTBEST for the for the MOSTMOST with with the the LEASTLEAST.”.”


SSimple imple TTriage riage AAnd nd RRapid apid TTxx

• Triage categoriesTriage categories• GreenGreen (ambulatory) (ambulatory)• RedRed (immediate) (immediate)• YellowYellow (delayed) (delayed)• BlackBlack (dead or non-salvageable) (dead or non-salvageable)

• Components of AssessmentComponents of Assessment• AmbulationAmbulation• RespirationsRespirations• PerfusionPerfusion• Mental statusMental status


START TriageSTART Triage

RESPIRATIONS

NO

YES

Non-salvageable

Immediate

Position Airway

NO YES

Over 30/min

Immediate

Under 30/min

PERFUSION

Radial PulseAbsent

ControlBleeding

Immediate

Radial Pulse Present

MENTALSTATUS

Failure to followsimple commands

Can followsimple commands

Immediate Delayed


Pediatric Problems with Pediatric Problems with STARTSTART

• Apneic child more likely to have a Apneic child more likely to have a primary respiratory problem than primary respiratory problem than adultadult

• Perfusion may be maintained for Perfusion may be maintained for a short time & child may be a short time & child may be salvageablesalvageable

• RR +/- 30 may either over-triage RR +/- 30 may either over-triage or under-triage a child, or under-triage a child, depending on agedepending on age


Problems with START Problems with START cont’dcont’d

• Capillary refill may not adequately Capillary refill may not adequately reflect peripheral hemodynamic reflect peripheral hemodynamic status in a cool environmentstatus in a cool environment• In fact START has changed to reflect In fact START has changed to reflect

peripheral pulse checks instead of peripheral pulse checks instead of cap refillcap refill

• Obeying commands may not be Obeying commands may not be an appropriate gauge of mental an appropriate gauge of mental status for younger childrenstatus for younger children


JUMPSTART GoalsJUMPSTART Goals

• Modify an existing tool for use Modify an existing tool for use with childrenwith children

• Utilize decision points that are Utilize decision points that are flexible enough to serve children flexible enough to serve children of all ages & reflective of the of all ages & reflective of the unique points of pediatric unique points of pediatric physiologyphysiology

• Reduce over- and under-triageReduce over- and under-triage• Accomplish triage for most Accomplish triage for most

patients within 15 second/pt goalpatients within 15 second/pt goal


The JumpSTART Field Pediatric Multi-Casualty Triage System ©(Patients aged 1- 8 years)

Black = Deceased/expectantRed = ImmediateYellow = DelayedGreen = Minor/Ambulatory

Identify and direct all ambulatory patients to designatedGreen area for secondary triage and treatment. Begin assessment of nonambulatory patients as you come to them.Proceed as below:

Spontaneous respirations?

NO

Open airway


YES

IMMEDIATE

NO

DECEASED

YES

Peripheral pulse?

YES

Perform 15 sec.Mouth to MaskVentilations


YES

IMMEDIATE

NO

DECEASED

NO

Check resp. rate

< 15/min or

> 40/minor irregular

IMMEDIATE

15 - 40/ min,regular

Peripheral pulse?

NO

IMMEDIATE

YES

Check mental status(AVPU)

AVP (appropriate)

DELAYED

P (inappropriate)U

IMMEDIATE

MINOR

© Lou Romig 1995


JUMPSTART AgeJUMPSTART Age

• Ages 1-8 years chosenAges 1-8 years chosen• <1 year of age is less likely to be <1 year of age is less likely to be

ambulatoryambulatory– These children can be triaged using These children can be triaged using

JUMPSTART but should be fully screenedJUMPSTART but should be fully screened– If all “If all “DELAYEDDELAYED” criteria satisfied & without ” criteria satisfied & without

significant external injuries, the child may significant external injuries, the child may be classified as “be classified as “AMBULATORYAMBULATORY””

• Pertinent pediatric physiology Pertinent pediatric physiology (specifically airway) approaches that of (specifically airway) approaches that of adults by approximately eight years of adults by approximately eight years of ageage


JUMPSTART JUMPSTART AmbulatoryAmbulatory

• Identify & direct all ambulatory Identify & direct all ambulatory patients to designated patients to designated GREENGREEN area area for secondary triage & treatmentfor secondary triage & treatment

• Begin assessment of non-ambulatory Begin assessment of non-ambulatory patients as you come to thempatients as you come to them


JUMPSTART BreathingJUMPSTART Breathing

• If breathing spontaneously, go on If breathing spontaneously, go on to the next step, assessing to the next step, assessing respiratory raterespiratory rate

• If apneic or with very irregular If apneic or with very irregular breathing, open the airway using breathing, open the airway using standard positioning techniquesstandard positioning techniques

• If positioning results in resumption If positioning results in resumption of spontaneous respirations, tag of spontaneous respirations, tag the patient the patient IMMEDIATEIMMEDIATE & move on & move on


JUMPSTART PartJUMPSTART Part

• If no breathing after airway open, If no breathing after airway open, check peripheral pulsecheck peripheral pulse– If no pulse, move on after tagging patient If no pulse, move on after tagging patient

DECEASED/NONSALVAGEABLE

• If peripheral pulse present, give 15 If peripheral pulse present, give 15 sec of Mouth-to-Mask ventilations sec of Mouth-to-Mask ventilations (about 5 breaths)(about 5 breaths)– If apnea persists, move on after tagging If apnea persists, move on after tagging

patient patient DECEASED/NONSALVAGEABLE

• If breathing resumes after If breathing resumes after “JUMPSTART”, tag patient “JUMPSTART”, tag patient IMMEDIATEIMMEDIATE & move on& move on


JUMPSTART Respiratory JUMPSTART Respiratory RateRate

• If respiratory rate is 15-40/min (1 If respiratory rate is 15-40/min (1 breath every 2-4 sec) assess breath every 2-4 sec) assess perfusionperfusion

• If respiratory rate is <15 or If respiratory rate is <15 or >40/min (<1 breath every 4 sec >40/min (<1 breath every 4 sec or >1 breath every 2 sec) or or >1 breath every 2 sec) or irregular, tag patient as irregular, tag patient as IMMEDIATEIMMEDIATE & move on & move on


JUMPSTART PerfusionJUMPSTART Perfusion

• If palpable peripheral pulse, If palpable peripheral pulse, proceed to assess mental statusproceed to assess mental status

• If no peripheral pulse present (in If no peripheral pulse present (in the least injured limb), tag the least injured limb), tag patient patient IMMEDIATEIMMEDIATE & move on& move on


JUMPSTART Mental StatusJUMPSTART Mental Status

• Use AVPU scale to assessUse AVPU scale to assess• If Alert, responsive to Verbal, or If Alert, responsive to Verbal, or

appropriately responsive to Pain, appropriately responsive to Pain, tag as tag as DELAYEDDELAYED and move on and move on

• If inappropriately responsive to If inappropriately responsive to Pain or Unresponsive, tag as Pain or Unresponsive, tag as IMMEDIATEIMMEDIATE & move on& move on


START/JUMPSTART START/JUMPSTART SimilaritiesSimilarities

• As soon as a definitive triage As soon as a definitive triage category determined further category determined further assessment STOPSassessment STOPS

• Ambulatory patients are Ambulatory patients are immediately moved away for immediately moved away for secondary triagesecondary triage

• To be in the To be in the DELAYEDDELAYED category pt’s category pt’s must have adequate respirations & must have adequate respirations & perfusion & mental status that is perfusion & mental status that is unlikely to compromise the airwayunlikely to compromise the airway


START/JUMPSTART START/JUMPSTART DifferencesDifferences

• Apneic children are rapidly assessed Apneic children are rapidly assessed for sustained circulationfor sustained circulation• Apneic children with circulation receive a Apneic children with circulation receive a

brief ventilatory trial as an additional brief ventilatory trial as an additional airway opening & stimulating maneuverairway opening & stimulating maneuver

• Respiratory rates are adjustedRespiratory rates are adjusted• Peripheral pulse is substituted for Cap Peripheral pulse is substituted for Cap

RefillRefill• This is now done in START tooThis is now done in START too

• AVPU is used to assess mental statusAVPU is used to assess mental status


POTENTIALPOTENTIAL

JUMPSTARTJUMPSTART

DISADVANTAGESDISADVANTAGES


DisadvantagesDisadvantages

• Extra steps for apneic children Extra steps for apneic children add time to the triage processadd time to the triage process

• Mouth-to-Mask ventilation Mouth-to-Mask ventilation increases the risk of cross-increases the risk of cross-contamination between patientscontamination between patients

• Additional equipment must be Additional equipment must be carried by triage personnelcarried by triage personnel

• TOO COMPLICATEDTOO COMPLICATED• NO PROOF IT WILL WORKNO PROOF IT WILL WORK


POTENTIALPOTENTIAL

JUMPSTARTJUMPSTART

ADVANTAGESADVANTAGES


AdvantagesAdvantages

• Provides rapid triage system Provides rapid triage system specifically designed for children, specifically designed for children, taking into consideration their taking into consideration their unique physiologyunique physiology

• Algorithm modified from an Algorithm modified from an existing system widely accepted existing system widely accepted for adult triagefor adult triage

• For most patients, triage can be For most patients, triage can be accomplished within the 15 sec accomplished within the 15 sec goalgoal


Advantages Advantages cont’dcont’d

• Objective criteria for children will Objective criteria for children will help eliminate role of emotions in help eliminate role of emotions in triage processtriage process

• Objective criteria will provide Objective criteria will provide emotional support for personnel emotional support for personnel forced to make life or death forced to make life or death decisions for children in the MCI decisions for children in the MCI settingsetting


Transport DecisionsTransport Decisions

Oklahoma ‘s Trauma Oklahoma ‘s Trauma Triage and Transport Triage and Transport

GuidelinesGuidelines


Air Medical ServicesAir Medical Services

MEDIFLIGHT OF OKLAHOMA MEDIFLIGHT OF OKLAHOMA • 1-800-522-02121-800-522-0212

AIR EVAC LIFE TEAMAIR EVAC LIFE TEAM• 1-918-426-40811-918-426-4081

TULSA LIFE FLIGHT TULSA LIFE FLIGHT • 1-888-4TRAUMA1-888-4TRAUMA

EAGLEMED EAGLEMED • 1-800-525-52201-800-525-5220


Pediatric Special Care Pediatric Special Care FacilitiesFacilities

Children’s Hospital at OU Med Center, Children’s Hospital at OU Med Center, OKCOKC

(405) 271- 4876(405) 271- 4876

University Hospital at OU Med Center, University Hospital at OU Med Center, OKCOKC

(405) 271- 4363(405) 271- 4363

Children’s Center of St. Francis Children’s Center of St. Francis Hospital, TulsaHospital, Tulsa

(918) 584-5433(918) 584-5433


SummarySummary

• The more critical the patient, the The more critical the patient, the more important it is to focus on more important it is to focus on the basicsthe basics

IN ORDERIN ORDER• Rapid Recognition & Intervention for Rapid Recognition & Intervention for

ShockShock• AirwayAirway• OxygenOxygen• Proper ImmobilizationProper Immobilization• Keep WarmKeep Warm

• Assign roles ahead of timeAssign roles ahead of time


OK-EMSC Resource CenterOK-EMSC Resource Center

To Contact Us:To Contact Us:

Phone: 405-271-3307Phone: 405-271-3307

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2003Oklahoma EMSC Resource Center0 Pediatric Trauma And Triage Overview of the Problem and Necessary...

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