This is the Pediatric EMS Podcast with the mission to provide case-based discussion with evidence-based recommendations by content experts in prehospital pediatric medicine with the goal of advancing the care of children outside the hospital and in your community.
Your Hand is Their Heart
Your Hand is Their Heart Brought to you by: Dr. Joelle Donofrio-Odmann and Dr. Joseph Finney We are excited to be back with our second episode. In this episode, we tackle a really powerful topic in prehospital medicine, pediatric out of hospital cardiac arrest. Every paramedic will tell you that this is one of the toughest calls they’ll ever go on. But it doesn't have to be. Join us as we will breakdown all the important steps necessary to give your patient the best chance of survival. Our guests are experts in prehospital medicine, resuscitation, and critical care. Together, we will guide you through this anxiety provoking topic and ensure that you have all the tools you need to successfully manage the next pediatric out of hospital cardiac arrest. But we wont stop there! We will take you into the ICU for post-cardiac arrest care and even discuss what the future holds for out of hospital cardiac arrest. You won't hear me say this often but when it comes to pediatric out of hospital cardiac arrest, it's time to start treating children like little adults. Website: https://sites.libsyn.com/414020/your-hand-is-their-heart Direct Download: https://traffic.libsyn.com/34eda738-c0e3-471c-94e6-5d7bb718e70f/Episode_2_FINAL-_POHCA.mp3 Content Experts: Paul Banerjee, Katherine Remick, Steve Laffey, Gina Pellerito, Matt Murray, Helen Harvey B-side Narrator: Joseph Finney Editing and Publication: Phil Moy and Joseph Finney Current Landscape of Pediatric Out of Hospital Cardiac Arrest: 5% bystander CPR (Atkins et al, 2009) Overall, >5,000/year (Atkins et al, 2009) Survival (Atkins et al, 2009) Older children ~10% Infant ~3% Marked regional variation and associated with frequency of bystander CPR PEA/Asystole is initial rhythm 80% of the time (Atkins et al, 2009) No improvement in survival in last decade (Jayaram et al 2015) 1 in 12 survive to hospital discharge (Jayaram et al 2015) Resources The Pediatric Readiness Project https://emscimprovement.center/domains/pediatric-readiness-project/readiness-toolkit/ Check out this link for all the information your emergency department will need to ensure they are pediatric ready. We all need to make sure our hospital is ready for any patient and this means preparing for the next pediatric cardiac arrest. American Heart Association https://www.heart.org/?s_src=22U5W1AEMG&s_subsrc=evg_sem&gclid=Cj0KCQjwuO6WBhDLARIsAIdeyDIcTX32jP4p9AfuoAzx-GL5li7mtInhOxkeeopw1t-ahn4tqjG40acaAl0tEALw_wcB&gclsrc=aw.ds Here you can find information for training and education to make sure your agency has the knowledge and skills to manage a pediatric patient in cardiac arrest. We strongly encourage every agency to maintain certification in PALS. Literature Breakdown: Early Epi is Key!! Andersen LW, Berg KM, Saindon BZ, Massaro JM, Raymond TT, Berg RA, Nadkarni VM, Donnino MW; American Heart Association Get With the Guidelines–Resuscitation Investigators. Time to Epinephrine and Survival After Pediatric In-Hospital Cardiac Arrest. JAMA. 2015 Aug 25;314(8):802-10. doi: 10.1001/jama.2015.9678. PMID: 26305650; PMCID: PMC6191294. Data analysis of AHA sponsored database 2000-2014 US pediatric patients (5min leads to decrease ROSC and decrease survival with favorable neurologic outcome Thoughts: Get the epi in right away! Get on scene and get to work: Banerjee PR, Ganti L, Pepe PE, Singh A, Roka A, Vittone RA. Early On-Scene Management of Pediatric Out-of-Hospital Cardiac Arrest Can Result in Improved Likelihood for Neurologically-Intact Survival. Resuscitation. 2019 Feb;135:162-167. doi: 10.1016/j.resuscitation.2018.11.002. Epub 2018 Nov 6. PMID: 30412719. This is a study of Polk County Fire and Rescue EMS database pre and post intervention. Polk County is a huge EMS agency in Florida with robust QI and data collection that has prompted several high profile publications. In the study, the first group of data was collected between 2012-2013 when standard practice was for ALS interventions to occur enroute to ED and the second group was between 2014-2015 when there was a change for this agency to perform ALS interventions on scene after specialized training There were 4 targeted Interventions instituted in 2014 Rapid insertion of advanced airway (ETT or Igel) Immediate intra-osseous vascular access (deferring intravenous attempts) Early epinephrine Tight ventilation parameters (one breath every 10 seconds) Study Details Primary outcome: Neuro intact survival 94 P-OHCA with median age 12mo 80% asystole initially Arrest etiology was 85% respiratory, 8% trauma, 3% seizures, 2% choking and no significant difference between groups They found that Neuro intact survival increased from 0% to 23.2% between the two groups Time on Scene: Tijssen, Janice A et al. “Time on the scene and interventions are associated with improved survival in pediatric out-of-hospital cardiac arrest.” Resuscitation vol. 94 (2015): 1-7. doi:10.1016/j.resuscitation.2015.06.012 Observational study ROC database 2005-2012 Age 3 days to 19 years 2244 patients Study Aim: Identify which times on scene and which interventions were associated with improved survival They found: Time on scene of 10-35min had highest survival to hospital discharge (10.2%) Adolescents had longest scene times and best outcomes Infants had the shortest scene time, fewest interventions, and worst outcomes Survival improved for all groups over the course of the study but the least for infants Nuero outcome was unfortunately not reported Other interesting findings: IV/IO access and fluid administration associated with improved survival (OR 2.4) Advanced airway had no association with survival (OR 0.69) Resuscitation meds (epi) associated with worse outcomes (OR 0.24) ****Important to note, patients were included if ANY EMS resuscitation was undertaken even if they were subsequently discontinued****, this matters because scene time less than 10 min had poor outcomes and it's unclear if this is because the resuscitation was deemed futile and terminated. Further, scene time
Ouch-less Pediatrics Safely and effectively managing pain in our pediatric patients is a primary responsibility for our EMS clinicians. Medical directors must be able to identify gaps in pediatric pain management and provide the necessary QA/QI to close those gaps. In this episode we focus on exactly that, with several experts in EMS joining us to offer their knowledge and critical appraisal of the evidence in order to identify and close the gaps in the management of pain in children. Brought to you by: Dr. Joelle Donofrio-Odmann and Dr. Joseph Finney Take Home Points Medical Directors can utilize QA/QI to improve management of pediatric pain within their EMS systems. Protocols for managing pediatric pain benefit from mirroring the most current evidence. This podcast provides information on how to develop protocols, what QA/QI to consider, the current evidence to optimize your ouch-less EMS agency, and how to use your tertiary Children’s hospital to help. Below are all the tools you need to make your agency “ouch-less”. The NASEMSO Model Guidelines are also a great option to help guide protocol development (link below). DON’T WAIT TO TREAT PAIN! https://nasemso.org/projects/model-ems-clinical-guidelines/ We also recommend utilizing the EIIC Pain management resources available at the link below. The EIIC has educational resources, tools, and recommendations for improving pediatric pain management. https://emscimprovement.center/education-and-resources/toolkits/pediatric-pain-management-toolkit/ Literature Review Recap Analgesia Use in Children with Acute Long Bone Fractures in the Pediatric Emergency Department. Published in The Journal of Emergency Medicine in 2020 Where: Assessment of the management of pediatric pain in a tertiary children’s hospital emergency department in the setting of long bone fractures. What: Retrospective single center study Who: Age 18yo and younger with ED diagnosis of long bone fracture, 2005-2016 905 patients included 63% male 48% African American Median age 6yo 72% fracture in upper arm, 77% sent home Outcome: 28% received no pain medication Median time to document a pain score was 6 minutes Pain medication order time was 63 minutes 87 minutes to time of administration of pain medications Factors related to undertreatment African American children Public insurance Single fracture POV arrival to ED Factors related to faster treatment Arriving when ED is busier Private insurance Lower extremity fracture EMS arrival to ED Implications: Even in the ED, we don’t do a very good job of quickly treating pain or even treating it at all. Consider standing orders for managing pain in certain situations such as long bone fractures. Prehospital Pain Management: Disparity By Age and Race published in Prehospital Emergency Care in 2018 Where: Research data set What: Retrospective descriptive study from 2012-2014 Who: Patients 69 million EMS activations, 276,925 were for patients transported with primary impression of fracture, burn or penetrating injury. 6% of EMS activations with these potentially painful medical impressions received any pain meds and this was lowest in amongst infants and toddlers where it was only 6.4%. The most administered meds were Morphine and fentanyl. < 7% of children age < 11 received either med. Only 29.5% had pain documented as a symptom Significantly lower amongst infants and toddlers at 14.6%. When pain was documented as a symptom, only 19.9% received pain medication (only 68% of infants and toddlers vs. 26.4% of children aged 11-14) To examine racial disparities, patients were grouped by age < 15 and > 15yrs of age. Administration of pain medications varied significantly amongst racial groups. Black patients were the least likely to be administered pain medication (8.7%) while white patients were the most like (22.4%). This disparity held for both age groups. Implications: There is likely bias leading to disparities in the management of pain prehospital both by age and race. Consider establishing protocols for pain management especially in our youngest patients. QA and QI focused on bias in prehospital medicine is critical for medical directors. Multicenter Evaluation of Prehospital Opioid Pain Management in Injured Children published in Prehospital Emergency Care in 2016 Objective: Assess the change in frequency of pain documentation and the change in frequency of opioid administration in kids with injuries after applying evidence-based guidelines Where: 3 separate EMS agencies, part of CHAMP research node of PECARN Who: