Safe Pediatric Transport - umcemsce.org

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Educational Objectives:

• Explore the risks involved with the transport of pediatric patients and non-patients in an ambulance.

• Determine the best way to secure a pediatric patient in the ambulance and consider alternative transport

locations for non-patient children.

• Learn about the National Highway and Transportation Safety Administration’s (NHTSA) efforts to improve

child safety and their specific guidelines for ambulances.

• Understand what a LATCH system is and how that improves safety for restrained children.

• Explain how to secure a child safety restraint to a wheeled ambulance stretcher, including the Pedi-

Mate™ device.

• Learn which factors determine whether a child seat can be reused after a vehicle collision.

2021 Update: Safe Pediatric Transport Keeping our smallest patients safe

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Contents

Introduction .................................................................................................................................................................. 3

The numbers ................................................................................................................................................................. 3

How the NHTSA improved pediatric transport safety .................................................................................................. 4

UMC EMS’s expectations for pediatric transport ......................................................................................................... 5

Infographic: How a car seat protects the child ............................................................................................................. 6

All about car seats ......................................................................................................................................................... 7

Babies and young children in car seats ..................................................................................................................... 7

Rear facing car seats: ............................................................................................................................................ 7

Infant seat ............................................................................................................................................................. 7

Convertible seat: ................................................................................................................................................... 7

Older children in booster seats and seat belts ......................................................................................................... 8

Booster seat: ......................................................................................................................................................... 8

“All in one” seat: ................................................................................................................................................... 8

Seat belts only: ...................................................................................................................................................... 9

Ways to secure a pediatric patient in the ambulance .................................................................................................. 9

Stretcher only: Who fits? .......................................................................................................................................... 9

Captain’s seat .......................................................................................................................................................... 10

Pedi-Mate ............................................................................................................................................................... 10

How to use the Pedi-Mate™ ........................................................................................................................................ 10

Steps for using the Pedi-Mate™ device: ............................................................................................................. 11

Securing a car seat: The LATCH system ...................................................................................................................... 12

Securing the child in a car seat ................................................................................................................................. 13

Infographic: There’s really three injury events during a collision ............................................................................. 14

Infographic: Why use seatbelts and car seats? .......................................................................................................... 15

Frequently Asked Questions ....................................................................................................................................... 16

Can the car seat be reused after a collision? .......................................................................................................... 16

Do car seats expire? ................................................................................................................................................ 16

I know a pregnant patient who may not be able to afford a car seat. How can I help? ....................................... 17

References .................................................................................................................................................................. 18

Image credits .............................................................................................................................................................. 18

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Introduction

In EMS, pediatric transports catch us in one of two ways: We’re either transporting a pediatric patient, or

someone asks for help installing an infant or child car seat. It doesn’t matter if you’re a parent or not, the

public expects you’ll transport a child safely, and secondly, you’re somehow considered an expert with the

complex workings of a car seat.

Most importantly though: As healthcare professionals, we need to advocate for our youngest patients who

can’t speak for themselves. They need us to look out for their best interests and safety during EMS care.

Finally, safe transport of the pediatric patient is also a legal concern. Properly securing a child in an ambulance

is a requirement, and not doing so targets your EMT/paramedic certification with the state of Texas based on

negligent safety practices. According to the National Association of State EMS Officials (NASEMSO):1

“Safe ambulance transport should be considered as a standard of care for the EMS system equivalent to maintaining an open airway, adequate ventilation and the maintenance of cardiovascular circulation…”

In other words, it’s as important as the child’s airway and CPR. That’s big.

The numbers

Car crashes are a leading cause of death for children ages 1 to 13 years old.2

An ambulance is really no different than a car except that the risk for a collision may be higher with “lights and

sirens” transport to the hospital. In the latest data from 2018, over 22,600 people were killed in motor

vehicle traffic crashes on U.S. roadways --- this excludes

fatalities in car versus pedestrian, bicyclists, motorcycles,

and commercial trucks.3 Of these fatalities, 29% involved

an intoxicated driver with a blood alcohol concentration

(BAC) of 0.08 grams per deciliter (g/dL) or greater.3 And

for “distraction-affected crashes” like texting and driving,

this claimed 7.8 percent of total fatalities.3

You can’t control the other drivers --- if they’re going to

crash into your ambulance, they are going to crash. The

best you can do is to protect your pediatric patient before

the ambulance starts rolling towards the hospital.

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How the NHTSA improved pediatric transport safety

In 1998, the National Highway Traffic Safety Administration (NHTSA) and the Federal Health Resources and

Services (HRSA) Emergency Medical Services for Children program formed a committee to review EMS child

transportation safety practices. This group of representatives from EMS national organizations, Federal

agencies, and transportation safety engineers developed a document entitled, “The Dos and Don’ts of

Transporting Children in an Ambulance” (December 1999).4 This document provided general guidance for

EMS field personnel and administrators on how to safely transport children in a ground ambulance.

The document included the following recommendations for the safe transport of infants and children:4

• Do tightly secure all monitoring devices and

other equipment.

• Do ensure available restraint systems are used

by EMTs and other occupants, including the

patient.

• Do transport children who are not patients,

properly restrained, in an alternate passenger

vehicle whenever possible.

• Do not leave monitoring devices and other

equipment unsecured in moving EMS vehicles.

• Do not allow parents, caregivers, EMTs or other

passengers to be unrestrained during transport.

• Do not have the child/infant held in the parent,

caregiver, or EMT’s arms or lap during transport.

• Do not allow emergency vehicles to be operated

by persons who have not completed the DOT

NHTSA Emergency Vehicle Operating Course

(EVOC), National Standard Curriculum, or its

equivalent. Our CEVO course meets this need.

The goal of this committee and landmark document was to protect children, parents, and providers. In

addition, this group recommended that:

“… Generally speaking, when the number of patients exceeds the ability to provide adequate care with existing EMS personnel and emergency ground ambulances, or to secure child patients as described in the following recommendations, EMS personnel need to request additional transportation resources that can respond in a timely manner.” 4

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Injured or not, each child needs to be properly restrained. The working group recommended that child

restraints and car seats should never be attached to a side-facing bench seat. Those seat belts don’t secure a

car seat tightly enough if there’s a collision.4

UMC EMS’s expectations for pediatric transport

UMC EMS follows the recommendations of the National Highway Traffic and Safety Administration and has

specialized equipment on every ambulance to accommodate the needs of infant and pediatric transport. In

some instances, it may be better for the pediatric patient to remain in the car seat or and secure it to the

stretcher or captain’s chair.

For example, if an infant was restrained in her car seat during a minor collision and there’s no obvious damage

to the car seat, keeping her in the car seat would reduce spinal motion versus lifting her out. The entire seat

(with infant secured in it) could be carried and secured to the ambulance stretcher, then loaded into the

ambulance. Never step in or out of an ambulance carrying a car seat with a baby or child in it. Use the

stretcher. No one knows when they’ll trip and fall out of the ambulance with a loaded car seat in their arms.

Children with special needs may travel better in their own transport device. There are Federal Motor Vehicle

Safety Standards compliant transport vests and harnesses available that help these children sit upright,

prevent them from unbuckling latches, and may have other features to ensure their safety during travel. If

these devices do not interfere with your medical care, it may be best to keep them on the child during

ambulance transport.

The number one thing to

avoid is allowing a parent or

other caregiver to hold the

baby or child during

transport.

A person has about a half-

second reaction delay at best.

During an unanticipated

collision, our natural instinct

is to extend our extremities,

not hug ourselves. If mom is

holding her baby and the

ambulance gets hit, the baby

is no longer secured in her

arms but instead becomes

airborne.

Image: Vest used to help support and keep

the child upright during travel. Image: Entire seat for a special needs child

who requires extra lateral support.

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Infographic: How a car seat protects the child

Image: Gardiner (2020)

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All about car seats

There are four types of infant and child car seats designed specifically to protect groups of children based on

mostly on weight and height: Rear facing seats (includes infant seats), convertible seats, booster seats, and

all-in-one seats.

When responding to a motor vehicle collision, if you find a pediatric patient in a child restraint that’s not

appropriate for their physical development, be suspicious of other injuries. For example, a large child in a

smaller car seat may have injuries to the shoulders or neck from straps that are not positioned correctly for

their height. For any child, if the chest clip is too low and sits on the abdomen, consider injury to that area.

Let the receiving RN or physician know about any unusual findings with the car seat. If the seat itself is

damaged and grabbing it would not extend scene time, try to bring it with you just as you would for a helmet

damaged in a motorcycle collision. This gives the physician a better picture of the mechanism of injury.

Babies and young children in car seats

Rear facing car seats: Children under one year old should always be secured in a rear-facing seat. The

seat cradles and supports the entire body. By rear-facing in the back seat, this position also helps prevent

broken windshield glass from harming the baby. This seat should be secured in the back seat of a vehicle

whenever possible. Babies can ride in a rear-facing “all in one” car seat or an infant seat, but they should not

be secured in a forward-facing seat.

Infant seat. A rear-facing infant seat is designed for newborns

and small babies as it cradles and fully supports the length of the

spine and their heavy heads. Babies usually outgrow their infant car

seats by 8 or 9 months, but they still need a larger rear-facing seat

until at least two years old. When there’s less than an inch between

the baby’s head and the top rim of the infant seat, the baby has

outgrown it and needs to graduate to another seat style.

The next level of car seats includes a “convertible” seat or just

readjusting the “all in one” seat to better fit the child’s weight and

height. At this age, rear-facing remains important to better protect

the growing child’s spine from injury.

Convertible seat: As a child grows, this style of car seat can eventually convert from a rear-facing to a

forward-facing seat. Because it fits younger children of various sizes, it allows them to stay in a rear-facing

position longer.

A rear-facing infant car seat.

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The rear-facing position better protects the child from any shattered glass (most

collisions are to the front). The back of the seat will distribute the force from

impact across the entire backside of the baby or child, not just digging in at the

straps on the front. It’s like applying pressure to your arm: If someone digs

their thumb into your arm, it’s painful because all of that force is applied over a

small surface area. If the same amount of force is applied to a board set on top

of the broadest part of your arm, it doesn’t hurt at all. The back part of the

infant seat works like a board, while the straps in the front apply pressure more

like a person’s thumb over a smaller surface area.

There does come a time where the child’s legs are too long for the rear-facing

position, and this is why rear-facing eventually has to switch to a forward-facing

position. The convertible car seat can be used either in the rear or forward-facing positions based on the

child’s height and weight.

Older children in booster seats and seat belts

Booster seat: A child should stay in a

convertible or all-in-one seat for as long as their

weight and height allow. When the child’s ears

reach the top rim of the car seat or their

shoulders are above the top strap slots of the

seat, it’s time to move to a forward-facing

booster seat. The booster seat helps to elevate

the child’s body enough where the vehicle’s seat

belts will sit across the strong pelvic bone

correctly. Most children do not properly fit into a

regular adult seat belt until they are about 4 feet

9 inches tall.

Some booster seat styles have high-back supports

on them and others do not.

“All in one” seat: This seat can be used from newborn to booster seat weight. One seat fits all of the

child’s needs. If this car seat does everything, why do individual infant seats,

convertible seats, and booster seats exist? Why not just buy an “all in one” and be

done with it?

Convenience, mostly. An “all in one” seat is big, bulky, and weighs a lot more than

any of the other seats because it can be adjusted and modified to handle all of

those tasks. While that’s not a concern faced by some parents, others who rely on

city taxi cabs, ridesharing, or compact cars may find this a problem. Parents who

don’t have a lot of upper body strength or simply don’t want to wrestle a

A rear or front facing

convertible car seat.

Images: A high-backed booster seat (left) and one that has no

back to it (right).

Image: An all-In-one seat

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monstrous plastic seat throughout the child’s life may find using lighter-weight, job-specific seats as a better

option.

Seat belts only: When a child reaches 4 feet and 9 inches tall, they can finally use a regular seat belt

without booster seats or other devices. This is just over 11 years old for most boys and girls based on growth

chart estimates for American children.

Ways to secure a pediatric patient in the ambulance

We know that a parent shouldn’t hold a child on the stretcher during transport, and it’s not safe to just strap a

baby to the cot with a single set of straps. What are our alternatives?

If the child is already in a car seat or there’s one we can use, we can secure that to the stretcher using the

existing cot straps. If the patient’s care is affected by a bulky car seat, we have the Pedi-Mate™ securement

device or if they are older, the captain’s chair by the head of the stretcher.

Stretcher only: Who fits?

The captain’s seat has a built-in child seat that is narrowly rated for

children weighing between 20 to 50 lbs (9 to 23 kg). The ambulance

stretcher can be used for children too heavy for the captain’s seat child

restraint system. Or, the stretcher can be used as the foundation to

secure a car seat or instead, for the Pedi-Mate™ child restraint device.

The stretcher should not be used on its own for babies or smaller

children when their weight and height measurement fall within range

of the Pedi-Mate™ or an infant car seat. One stretcher strap set is not

going to secure a baby or child safely.

Image: An example of an “all-in-one” car seat and the various styles one seat can be modified into

over time.

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Captain’s seat

The ambulance’s captain seat can be used for pediatric patients

weighing between 20 to 50 lbs (9 to 23 kg), who can sit upright

unassisted, and can reliably maintain head control during the

entire transport. This rules out infants since they are able to sit up

unassisted for only a few minutes after about 8 months old.

So as a general rule of thumb, use the captain’s chair only if the

child is one year of age or older with normal physiological

development. There is very little lateral support in this seat.

Pedi-Mate

The Pedi-Mate™ device can accommodate infants and children weighing

between 10 to 40 lbs (4.5 kg to 18 kg), with the upper limit close to a 5

year old boy’s weight. Assess your patient’s needs as an individual, but

don’t exceed the upper weight or height limit for the device.

The Pedi-Mate is used in place of an infant or small child car seat, but it

must be secured on the ambulance stretcher. It cannot be secured to any

seat inside the cab of the ambulance, on the captain’s chair, or even the

bench seat.

How to use the Pedi-Mate™

The Pedi-Mate™ device may be used where spinal precautions are advised in our protocols. It is not an

“immobilization device” like a rigid spineboard, but it does meet our own Spinal Precautions protocol

requirement for both lateral and shoulder strap use.

Every ambulance at UMC EMS, Idalou EMS, and Shallowater EMS is required to carry a Pedi-Mate™ device. It

is reusable and easily cleaned with disinfecting wipes. Replace the Pedi-Mate™ if there’s signs of fraying or

other structural concerns.

The Pedi-Mate™ is secured to the stretcher using the steps outlined on the next page.

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Steps for using the Pedi-Mate™ device:

1. Unroll the device on the stretcher and inspect for any damage

that would contradict its use. If damaged, be sure to report

this finding to the Chief on duty.

2. Secure the black straps on the device to the stretcher, as

shown to the right. The upper strap should be secured

around the torso/head portion of the stretcher, and each

lower strap to the main lateral frame. Some things that

shouldn’t be done:

• Do not secure the Pedi-Mate’s black straps to the

handrails or legs of the stretcher. You risk injuring

the child when the legs/rails are raised or lowered.

• Do not use the stretcher’s straps to secure the Pedi-

Mate device. They need to be secured to the frame.

• Do not secure the mother or another person on the

stretcher and then secure the Pedi-Mate™ over her

so she can still hold her child. This is unsafe for both

the family member and infant/child.

3. Check that the Pedi-Mate™ is snug on the stretcher before placing the patient on it.

4. The patient should be carefully placed on the Pedi-Mate™ and secured using the device’s gray straps and

plastic chest clip, as shown in the image to the lower right. Start with the crotch strap and then proceed

to each upper extremity strap. Be sure that the patient is not wearing a thick puffy coat or other clothing

that would prevent the straps from tightening properly.

a. The straps should be snug enough where you

can’t pinch any slack out of them, but not so

tight that they cause discomfort or injury to the

child.

b. The plastic, movable chest clip should be

aligned horizontally with the child’s armpits.

c. Double-check that the patient’s skin is not

being pinched or constricted in any way.

5. Keep the head of the stretcher between 15 to 45

degrees to maintain optimal center of gravity.

6. Make sure the child is centered horizontally on the stretcher, and then retighten the black straps that

secure the device to the stretcher.

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Securing a car seat: The LATCH system

If the child is being transported by Fox truck (not a patient) or even by a family member’s vehicle, you may

need to secure the car seat using the LATCH system. Many of the older car seats were secured to older

vehicles by threading the seat belt through a narrow channel in the back. This was a painful process if you

had larger hands or struggled trying to tighten the car seat down into place. Inevitably, many infant and child

car seats were not secured properly to the vehicle seat or even secured at all --- one estimate suggests 3 out

of 4 car seats were not installed correctly.5 A new, more parent-friendly system was needed.

A new securement system (“LATCH”) was required by federal law to be integrated in infant, convertible and

forward-facing child safety seats.4 LATCH stands for "Lower Anchors and Tethers for Children". The car seat

is attached using easily-accessible anchor points and straps on the car seat itself and built in anchors in the

passenger vehicle. While many of the old vehicles don’t have the anchor points for a LATCH system, it

became a federal requirement for most passenger vehicles after September 1, 2002.

Depending on the type of vehicle, anchor points can be found at

the junction of the seat and backrest (the seat “crack”) or mounted

directly to the floorboard. There may be other anchor points

depending on the type of vehicle. The anchor points are metal and

shaped like a square “U”, unlike the weaker plastic cargo tiedown

points found in some vehicles.

Those dangling nylon straps hanging off your patient's child seat...

those are the LATCH straps and hardware used to hook onto these

special anchor points.

The newer forward-facing car seats for children have a lower anchor strap that secures it to the vehicle’s seat

anchor point (or floorboard) and then uses a second

anchor point for additional stability called a “tether”

(illustration above). The tether strap secures the upper

part of the car seat to a tether point on the vehicle and

prevents the top of the car seat from throwing forward

or backward in a collision. It can reduce the amount of

forward travel at the level of the child's head by about 6

to 8 inches.

Like lower anchors, tether anchor points are also made

of metal but can be a bar or U shape, or even concealed

under a removable plastic cover. Every recent forward-

facing child car seat is required to have a tether strap

integrated in its design and manufacture. Image: Possible tether point locations in a vehicle.

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What to use and when to use them? If they exist, the lower anchors are used INSTEAD of the seat belt

passageways integrated into the car seat. The upper tethers should always be used, no matter if you’re

securing the cat seat with lower anchors or a regular seat belt.

Becoming familiar with the LATCH system not only helps with car seat removal from a vehicle, but also helps

when securing the child seat in the cab of the ambulance, a first responder vehicle, or another family

member’s vehicle who may not be familiar with the technology.

Securing the child in a car seat

Securing the child with the correct straps at the right place is just as important as properly positioning a seat

belt on an adult. A child could be seriously injured or even ejected from his seat if the straps are left too loose

or not positioned correctly. The image to the right shows key points to remember when adjusting the straps

and clips in a child seat. And finally, make sure the seat’s airbag is turned off!

Are the harness straps snug enough? Use the “pinch test”

to determine if the harness straps

are snug enough or too tight. If

you can pinch out the slack with

your finger and thumb on the

strap, then the harness is too loose.

If you can slip a couple of fingers

under the strap at the chest, it’s

probably tight enough.

What if it’s cold out there and the child is all bundled up

in a puffy jacket? The jacket needs to be removed before

placing the child in a car seat. The extra fluff in the jacket

will prevent the car seat harness from securing tight

enough against the child to keep her in place during a

collision. Keep the ambulance warm and use blankets or

cover her with the same jacket after she’s secured in the

car seat.

Source for illustrations of the LATCH system: The Car Seat Lady at http://thecarseatlady.com/

A lower anchor point A tether anchor point A tether used with a ceiling tether anchor

“Pinch test”: Too loose

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Infographic: There’s really three injury events during a collision



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Infographic: Why use seatbelts and car seats?


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Frequently Asked Questions

A few of the more frequently asked questions about car seat use are listed below.

Can the car seat be reused after a collision?

This is one of the most frequent questions parents ask EMS about car seats.

The NHTSA recommends that car seats be replaced following a moderate or severe crash to ensure a

continued high level of crash protection for child passengers. Car seats do not automatically need to be

replaced following a minor crash.

But what defines a minor crash? A minor crash is one in which ALL of the following apply:

• The vehicle was able to be driven away from the crash site.

• The vehicle door nearest the car seat was not damaged.

• None of the passengers in the vehicle sustained any injuries in the crash.

• If the vehicle has air bags, the air bags did not deploy during the crash; and

• There is no visible damage to the car seat.

The parent should NEVER continue to use a car seat that has been involved in a moderate to severe crash.

Do car seats expire?

The carton of milk in the station refrigerator has probably expired and is a rich medium for new forms of life

right now. But did you know that car seats expire? The standard is 6

years after their manufacture date. You’ll find the expiration date on

a label or imprinted in the plastic itself.

Some reasons for the limited time use: The plastic will degrade and

weaken after years of varying temperatures and UV light exposure in

the vehicle. There’s little protection for the child if the car seat

degrades.

Image: Expiration date label on the

side of a child’s car seat.

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I know a pregnant patient who may not be able to afford a car seat. How

can I help?

To reduce the number of motor vehicle crash (MVC) injuries and fatalities to children in Texas who are

unrestrained due to family low-income status, the “Safe Riders” program manages a child safety seat

distribution and education program. The program is available in most, but not all areas of Texas and is

operated through the Texas Department of State Health Services. The web site is:

https://dshs.texas.gov/saferiders/default.shtm

Eligibility requirements for receiving a seat:

• Family must be low-income.

• One of the child's primary caregivers must attend a 1-hour class about child passenger safety.

• Someone in the household must have a vehicle.

Pregnant women in their last trimester are encouraged to participate. Safe Riders does not provide infant

carriers, but does offer convertible seats that can be used rear-facing for young children and then converted

to forward-facing use when appropriate. Booster seats for older children are also available. Assistance is

designed to be one-time only.

Be sure to log into your continuing education account to take the quiz and earn CE credit for this course. If you have any

questions, please contact a member of the training staff. Thank you!

https://dshs.texas.gov/saferiders/default.shtm

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References

1 Safe Transport of Children by EMS: Interim Guidance. Safe Transport of Children Ad Hoc Committee.

National Association of State EMS Officials. March 8, 2017. Available at: https://nasemso.org/wp-

content/uploads/Safe-Transport-of-Children-by-EMS-InterimGuidance-08Mar2017-FINAL.pdf. Accessed

March 2, 2021.

2 Car Seats and Booster Seats. National Highway Traffic Safety Administration - U.S. Department of

Transportation. Available at: https://www.nhtsa.gov/equipment/car-seats-and-booster-seats. Accessed

March 1, 2021.

3 2018 Fatal Motor Vehicle Crashes: Overview. Traffic Safety Facts - Research Note. National Highway

Traffic Safety Administration. October 2019. Available at:

https://crashstats.nhtsa.dot.gov/Api/Public/ViewPublication/812826. Accessed on March 2, 2021

4 Working Group Best-Practice Recommendations for the Safe Transportation of Children in Emergency

Ground Ambulances. DOT HS 811 677; September 2012. National Highway Traffic Safety Administration -

U.S. Department of Transportation. Available at: https://www.nhtsa.gov/staticfiles/nti/pdf/811677.pdf.

Accessed March 1, 2021.

5 What is LATCH? Children's Hospital of Philadelphia. Web page: https://www.chop.edu/pages/what-latch.

Accessed on March 1, 2021.

Image credits

Gardiner K, Fink R, Wilkinson S. Pictures Explain: Why You MUST Keep Your Child Rear-Facing as Long As

Possible. Parenting Pod. 2017 (updated November 2020). Available at https://parentingpod.com/car-seat-

infographic/. Accessed March 3, 2021.

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