Show cover of The Pediatric EMS Podcast

The Pediatric EMS Podcast

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.


Pediatric Prehospital Trauma Overview: Hitting the Highlights
This series is a collaboration with the EMS for Children Innovation and Improvement Center (EIIC) and will be part of the pre-hospital resources for its Pediatric Education and Advocacy Kit (PEAK) for multisystem trauma. Click on the link to learn more!  In this episode we kick off a multipart series on pediatric trauma just in time for summer and trauma season. Join your two hosts as they tackle the prehospital management of pediatric trauma. Everything from head to toe and the pathophysiology that makes pediatric trauma unique from the adult population. Below are the episode talking points you don't want to miss.  Objectives Assess the current landscape of pediatric trauma. Recognize the physiologic differences between adults and children in trauma. Evaluate how the mechanism of injury informs the management. Analyze how to approach a pediatric trauma patient. Summary and take-home points. Brought to you by The National Association of EMS Physicians (NAEMSP) and Missouri Emergency Medical Services for Children (MO-EMSC). Hosts: Dr. Joelle Donofrio-Odmann and Dr. Joseph Finney Website:  GET CEU CREDIT THROUGH PRODIGY EMS  Content Experts: Joelle Donofrio-Odmann, DO and Joseph Finney, MD Pediatric Assessment Triangle   The Changing Landscape of Traumatic Pediatric Death   Goldstick, 2022 Trimodal Distribution of Death From McLaughlin et al, 2017: 74% of pediatric deaths age 1-14y were in first 24 hours. Of children who die from traumatic injuries, most die within 24 hours of arriving to the hospital. When compared to adult trauma patients, children are more likely to die in the emergency department (ED) rather than surviving long enough for hospital admission or transfer to the operating room. Where you are treated matters Theodorou et al in 2021 reviewed over 7000 pediatric trauma admissions and found, of the 134 patients who died, Traumatic brain injury was the most common cause of death (66%), followed by anoxia (9.7%) and hemorrhage (8%).  54% died in the ED. More likely to die if suffered penetrating trauma.  Pediatric Trauma: ATC vs PTC The United States Government Accountability Office found 57 percent of the nation's 74 million children lived within 30 miles of a pediatric trauma center that can treat pediatric injuries, regardless of severity.  The presence of pediatric trauma centers was associated with lower rates of MVC death in children. Adult level 1/2 trauma centers appear to offer comparable risk reduction. Where population differences in pediatric trauma mortality are observed, addressing disparities in county-level access to pediatric trauma care may serve as a viable target for system-level improvement. Pediatric patients Large head on short weak neck with fulcrum out away from the center of gravityTraumatic brain injury likely present and must be investigated.80% of pediatric multisystem trauma involves the head.Remember TBI is a major cause of trauma mortality. Heavy head compared to body, often first impact point so affected by rapid acceleration deceleration forces. Also, higher risk of axonal injury from shearing forces given limited myelin development. Prehospital management focused on H bombs.Airway is crowded and easily obstructed.Use a shoulder roll anytime you are managing a pediatric airway under 8 years.Intubation is for your ego; SGA is for your patient Cuffed tubes are both safe and effective for pediatric patients.Overall uncommon, but devastating if they do occur.Primarily due to high-speed blunt trauma Associated with birth trauma (Forceps extraction)Higher cervical spine (C1-C2)Chance Fractures common in pediatricsHigh suspicion for internal organ injury with thoracolumbar injuryTo Collar or Not To CollarConsider in the following situations.AMSNeck painNeck stiffnessNeurologic deficitHigh speed MVCDiving injury (not drowning)Substantial torso injury presentHypotension occurs after 30% blood loss.Decompensated potentially irreversible shock.Tachycardia is the pediatric body screaming at you.Always investigate tachycardia.Do not assume pain.CompensationCompliant and cartilaginous skeletal structureForce is transferred internally. May be no broken ribs or external signs of trauma.Maintain high suspicion for internal injury.Pulmonary contusion commonHorizontal ribs, exposed organsLow set pelvis, higher risk of hollow organ injuryShortened AP diameter meaning retroperitoneal structures closer to front of body and more exposed.Minimal peri-organ fat and subcutaneous tissueLethal Triad (hypothermia, acidosis, coagulopathy): Hypothermia is a modifiable prehospital factorLarge surface area to body mass ratioLarge headPrioritize warming the patient both prehospital and in the EDTurn on the heat in the ambulance.Resuscitation: On-scene PrioritiesC-ABCFailure to recognize/investigate/act on tachycardia.Fear and stress are diagnoses of exclusion in the tachycardic pediatric trauma.Failure to identify abnormal behavior for age.Sleeping or tired or quiet is NOT NORMALShould be assumed to be impaired cerebral perfusion.Failure to suspect/assume internal injury in the absence of external signs of trauma.Mechanism informs the injuries.Treat PainNumerous studies underscore the failures of EMS to adequately address and treat pediatric painWorse for minority populationsGet pain medication on board earlyDelayed pain treatment can have devastating psychologic effects long termPTSDChronic pain syndromeBehavioral abnormalitiesAlways consider NAT in your altered pediatric patientEven without a history to support it.Watch for red flags (TEN4FACES)History doesn’t match developmental level.Delayed presentationUnwitnessedVague storyWe are all mandated reporters if we suspect abuse.Take a stroke to a stroke center.Take a pediatric trauma to a pediatric trauma center whenever possible. This will decrease mortality and exposure to radiation and unnecessary procedures. 100% Agreement among expertsPractical applicationSevere cases--straight to bloodLess severe patients--one bolus of crystalloid with close monitoring and immediate transition to blood if worsens/fails to improve. •       Use Low Titer O Whole Blood if available. •       If LTWOWB not available, use 1:1:1 plasma to RBCs to platelets. •       MTP with balanced blood product administration •       Consider calcium when giving blood: Siegler's Lethal Diamond •       Prehospital Blood in Pediatric Hemorrhagic Shock: "Reasonable based on availability and clinical judgement" •       100% Expert Agreement •       Death due to bleeding most common early after injury •       Delays in transfusion associated with increased mortality and prolonged time to hemostasis. •       Current evidence supports both the safety and feasibility of prehospital pediatric blood product. Tranexamic Acid in Pediatric Hemorrhagic Shock •       Use within 3 hours might be considered. •       80% agreement among experts •       Strong evidence in adults: CRASH-2 •       No high-quality evidence in pediatrics Tourniquet Application in PHS •       88% Agreement •       Has shown benefit. •       Biggest issues •       Applied when unnecessary. •       Applied incorrectly. •       Inadequate training There is no such thing as permissive hypotension in pediatrics Resources and Sources: •       Khalil M, Alawwa G, Pinto F, O'Neill PA. Pediatric Mortality at Pediatric versus Adult Trauma Centers. J Emerg Trauma Shock. 2021 Jul-Sep;14(3):128-135. doi: 10.4103/JETS.JETS_11_20. Epub 2021 Sep 30. PMID: 34759630; PMCID: PMC8527062. •       McLaughlin C, Zagory JA, Fenlon M, Park C, Lane CJ, Meeker D, Burd RS, Ford HR, Upperman JS, Jensen AR. Timing of mortality in pediatric trauma patients: A National Trauma Data Bank analysis. J Pediatr Surg. 2018 Feb;53(2):344-351. doi: 10.1016/j.jpedsurg.2017.10.006. Epub 2017 Oct 8. PMID: 29111081; PMCID: PMC5828917. •       Theodorou CM, Galganski LA, Jurkovich GJ, Farmer DL, Hirose S, Stephenson JT, Trappey AF. Causes of early mortality in pediatric trauma patients. J Trauma Acute Care Surg. 2021 Mar 1;90(3):574-581. doi: 10.1097/TA.0000000000003045. PMID: 33492107; PMCID: PMC8008945. •       Mikrogianakis A, Grant V. The Kids Are Alright: Pediatric Trauma Pearls. Emerg Med Clin North Am. 2018 Feb;36(1):237-257. doi: 10.1016/j.emc.2017.08.015. PMID: 29132580. •       Andrade EG, Onufer EJ, Thornton M, Keller MS, Schuerer DJE, Punch LJ. Racial disparities in triage of adolescent patients after bullet injury. J Trauma Acute Care Surg. 2022 Feb 1;92(2):366-370. doi: 10.1097/TA.0000000000003407. PMID: 34538831. •       Calhoun A, Keller M, Shi J, Brancato C, Donovan K, Kraus D, Leonard JC. Do Pediatric Teams Affect Outcomes of Injured Children Requiring Inter-hospital Transport? Prehosp Emerg Care. 2017 Mar-Apr;21(2):192-200. doi: 10.1080/10903127.2016.1218983. Epub 2016 Sep 16. PMID: 27636186. •       Byrne JP, Nance ML, Scantling DR, Holena DN, Kaufman EJ, Nathens AB, Reilly PM, Seamon MJ. Association between access to pediatric trauma care and motor vehicle crash death in children: An ecologic analysis of United States counties. J Trauma Acute Care Surg. 2021 Jul 1;91(1):84-92. doi: 10.1097/TA.0000000000003110. PMID: 33605706. •       Träff H, Hagander L, Salö M. Association of transport time with adverse outcome in paediatric trauma. BJS Open. 2021 May 7;5(3):zrab036. doi: 10.1093/bjsopen/zrab036. PMID: 33963365; PMCID: PMC8105622. •       Frank Lodeserto MD, "Approach to the Critically Ill Child: Shock", REBEL EM blog, October 15, 2018. Available at: •       Dai LN, Chen CD, Lin XK, Wang YB, Xia LG, Liu P, Chen XM, Li ZR. Abdominal injuries involving bicycle handlebars in 219 children: results of 8-year follow-up. Eur J Trauma Emerg Surg. 2015 Oct;41(5):551-5. doi: 10.1007/s00068-014-0477-5. Epub 2014 Nov 26. PMID: 26038003. •       Ten-4 bruising rule. Face It website. Accessed January 20, 2023, •       Newgard, Craig D. MD, MPH, FACEP; Fischer, Peter E. MD; Gestring, Mark MD; Michaels, Holly N. MPH; Jurkovich, Gregory J. MD, FACS; Lerner, E. Brooke PhD, FAEMS; Fallat, Mary E. MD; Delbridge, Theodore R. MD, MPH; Brown, Joshua B. MD, MSc, FACS; Bulger, Eileen M. MD;  the Writing Group for the 2021 National Expert Panel on Field Triage. National guideline for the field triage of injured patients: Recommendations of the National Expert Panel on Field Triage, 2021. Journal of Trauma and Acute Care Surgery 93(2):p e49-e60, August 2022. | DOI: 10.1097/TA.0000000000003627 •       Russell RT, Bembea MM, Borgman MA, Burd RS, Gaines BA, Jafri M, Josephson CD, Leeper CM, Leonard JC, Muszynski JA, Nicol KK, Nishijima DK, Stricker PA, Vogel AM, Wong TE, Spinella PC. Pediatric traumatic hemorrhagic shock consensus conference research priorities. J Trauma Acute Care Surg. 2023 Jan 1;94(1S Suppl 1):S11-S18. doi: 10.1097/TA.0000000000003802. Epub 2022 Oct 7. PMID: 36203242; PMCID: PMC9805504.
53:01 6/22/24
Evidence Empowers Judgement: Evidence Based Guidance on the Management of Traumatic Brain Injury and Cervical Spine Injury
In this episode we discuss the future of pediatric head and cervical spine imagine with the very physicians who brought us the groundbreaking research that will forever change how we approach these pediatric injuries. This episode will have you rethinking the evidence behind your own protocols and making adjustments going forward.  Brought to you by The National Association of EMS Physicians (NAEMSP) and Missouri Emergency Medical Services for Children (MO-EMSC). Hosts: Dr. Joelle Donofrio-Odmann and Dr. Joseph Finney Website:  GET CEU CREDIT THROUGH PRODIGY EMS  Content Experts: Joelle Donofrio-Odmann, DO and Joseph Finney, MD Guest Experts: Dr. Nate Kuppermann Dr. Julie Leonard Emergency Medical Services for Children (EMSC) Innovation and Improvement Center (EIIC) Pediatric Emergency Care Applied Research Network (PECARN): Studies from the episode: Julie C Leonard, Monica Harding, Lawrence J Cook, Jeffrey R Leonard, Kathleen M Adelgais, Fahd A Ahmad, Lorin R Browne, Rebecca K Burger, Pradip P Chaudhari, Daniel J Corwin, Nicolaus W Glomb, Lois K Lee, Sylvia Owusu-Ansah, Lauren C Riney, Alexander J Rogers, Daniel M Rubalcava, Robert E Sapien, Matthew A Szadkowski, Leah Tzimenatos, Caleb E Ward, Kenneth Yen, Nathan Kuppermann, PECARN prediction rule for cervical spine imaging of children presenting to the emergency department with blunt trauma: a multicentre prospective observational study, The Lancet Child & Adolescent Health, 2024, ISSN 2352-4642, (   Holmes JF, Yen K, Ugalde IT, Ishimine P, Chaudhari PP, Atigapramoj N, Badawy M, McCarten-Gibbs KA, Nielsen D, Sage AC, Tatro G, Upperman JS, Adelson PD, Tancredi DJ, Kuppermann N. PECARN prediction rules for CT imaging of children presenting to the emergency department with blunt abdominal or minor head trauma: a multicentre prospective validation study. Lancet Child Adolesc Health. 2024 May;8(5):339-347. doi: 10.1016/S2352-4642(24)00029-4. PMID: 38609287.   Gambacorta A, Moro M, Curatola A, Brancato F, Covino M, Chiaretti A, Gatto A. PECARN Rule in diagnostic process of pediatric patients with minor head trauma in emergency department. Eur J Pediatr. 2022 May;181(5):2147-2154. doi: 10.1007/s00431-022-04424-9. Epub 2022 Feb 22. PMID: 35194653; PMCID: PMC9056473.  Kuppermann N, Holmes JF, Dayan PS, Hoyle JD Jr, Atabaki SM, Holubkov R, Nadel FM, Monroe D, Stanley RM, Borgialli DA, Badawy MK, Schunk JE, Quayle KS, Mahajan P, Lichenstein R, Lillis KA, Tunik MG, Jacobs ES, Callahan JM, Gorelick MH, Glass TF, Lee LK, Bachman MC, Cooper A, Powell EC, Gerardi MJ, Melville KA, Muizelaar JP, Wisner DH, Zuspan SJ, Dean JM, Wootton-Gorges SL; Pediatric Emergency Care Applied Research Network (PECARN). Identification of children at very low risk of clinically-important brain injuries after head trauma: a prospective cohort study. Lancet. 2009 Oct 3;374(9696):1160-70. doi: 10.1016/S0140-6736(09)61558-0. Epub 2009 Sep 14. Erratum in: Lancet. 2014 Jan 25;383(9914):308. PMID: 19758692.   
73:27 6/5/24
Prehospital Pediatric Airway Management: The Past, Present, and Future
Brought to you by The National Association of EMS Physicians (NAEMSP) and Missouri Emergency Medical Services for Children (MO-EMSC) and The Emergency Medical Services for Children Innovation and Improvement Center (EIIC) Hosts: Dr. Joelle Donofrio-Odmann and Dr. Joseph Finney Website:  GET CEU CREDIT THROUGH PRODIGY EMS  Content Experts: Joelle Donofrio-Odmann, DO and Joseph Finney, MD Guest Experts: Welcome back for a special episode outside our normal schedule! This episode was recorded in collaboration with The EMSC Innovation and Improvement Center (EIIC) to provide expert review of prehospital pediatric airway management. With respiratory complaints being one of the most common prehospital pediatric emergencies, you definitely want to join us to ensure you and your agency are ready for the next pediatric airway emergency.  Description This recorded 60-minute webinar, originally presented for EMSC Day, will share the developments on prehospital pediatric airway management, followed by a 30-minute Q&A session. Hosted by experts in the field, this session will share the historical milestones, current practices, and future advancements shaping pediatric airway management in emergency medical services (EMS).   Objectives: - To review the seminal and early research in prehospital pediatric airway management -To provide updates on the current recommendations on best practices for prehospital pediatric airway management -To share information about the upcoming Pediatric Prehospital Airway Resuscitation Trial (Pedi-PART)   Presenters: Marianne Gausche-Hill, MD, FACEP, FAAP, FAEMS -Professor Clinical Emergency Medicine and Pediatrics, David -Geffen School of Medicine at UCLA -Harbor-UCLA Medical Center, Departments of Emergency Medicine and Pediatrics  -Interim CEO, The Lundquist Institute for Biomedical Innovation at Harbor-UCLA Medical Center Lorin R. Browne, DO -Professor, Pediatrics and Emergency Medicine Medical College of Wisconsin -Associate Medical Director (Pediatrics) -Milwaukee County Office of Emergency Management EMS   Joelle Donofrio-Odmann, DO FAAP FACEP FAEMS -Co-host of The Pediatric EMS Podcast -Deputy Chief Medical Officer, City of San Diego -Medical Director, SDFD Paramedic School -EMS Medical Director, Rady Children’s Hospital -Associate Professor of Clinical Pediatrics and Emergency Medicine  -University of California, San Diego   Henry E. Wang, MD, MS -Professor and Vice Chair for Research -Department of Emergency Medicine -Deputy Director, OSU Center for Clinical and Translational Science  -The Ohio State University   Kathleen Adelgais, MD MPH FAAP FAEMS Co-Lead, Prehospital Domain EMS for Children Innovation and Improvement Center University of Colorado School of Medicine Colorado EMS for Children     Resources: EMSC Innovation and Improvement Center Pediatric Emergency Applied Care Research Network (PECARN) PEDI-PART NAEMSP Airway Compendium Position Statement    
59:00 5/31/24
Resus Recess: Pediatric Cardiac Arrest Literature Review
Brought to you by The National Association of EMS Physicians (NAEMSP), Emergency Medical Services for Children (EMSC) and The Emergency Medical Services for Children Innovation and Improvement Center (EIIC) Hosts: Dr. Joelle Donofrio-Odmann and Dr. Joseph Finney Website: Direct Download:  GET CEU CREDIT THROUGH PRODIGY EMS  In this episode we bring you two experts in pediatric prehospital care who are working tirelessly to identify why caring for children in cardiac arrest is so unique and so challenging. Join us as we review two papers that shed light on this critical care scenario and offer opportunities to elevate care for you and your agency. Content Experts: Joelle Donofrio-Odmann, DO and Joseph Finney, MD Guest Experts: Matt Hansen, MD  Carl Errikson, MD Papers reviewed in this episode: Take home points: Caring for children is challenging, strive to find ways to offload the cognitive burden of pediatric resuscitation It isn't just about training, you have to go deeper into education, skill performance, and simplification of tasks Do the basic skills well! BVM and CPR are basic skills, but frequently performed incorrectly and unsafely.  Do your homework. Matt and Carl work to bring you the very best in evidence based pediatric care. Do your part in reading and understanding how this work can inform your own care of children. 
35:18 5/18/24
The Prehospital Pediatric Readiness Project
Brought to you by The National Association of EMS Physicians (NAEMSP) and Missouri Emergency Medical Services for Children (MO-EMSC) Hosts: Dr. Joelle Donofrio-Odmann and Dr. Joseph Finney Website:  Direct Download:  GET CEU CREDIT THROUGH PRODIGY EMS: Unfortunately, not this episode but check out episode 8 in a few weeks for CEU credits! Content Experts: Joelle Donofrio-Odmann, DO and Joseph Finney, MD Guest Experts: Kathleen Adelgais, MD, MPH/MSPH Project Director, Colorado EMS for Children Program Professor of Pediatrics - Children's Hospital Colorado  Kathryn Kothari, MD Medical Director, Emergency Medical Services Assistant Professor, Pediatrics - Emergency Medicine, Baylor College of Medicine Episode Details: Welcome back for a special episode outside our normal schedule! This episode was recorded in collaboration with Phil Moy of The Prehospital Emergency Care Journal Podcast. We came together to discuss The Prehospital Pediatric Readiness Project which is an amazing project focused on improving prehospital pediatric care.  Is your agency pediatric ready? Are you ready to care for that next critically ill or injured child? Do you have the right equipment, the necessary training, and the adequate knowledge to care for children?  We can get you there! Check out this episode as we discuss the upcoming release of the prehospital pediatric readiness assessment survey and find out where your agency ranks on pediatric readiness.  Survey opens on Tuesday, April 23rd, 2024 Our guests will give you all the how and why for this amazing program. If you want to get your agency up to speed or need resources for pediatric focused education, training, and protocols, listen up as we get you everything you need to know to complete the survey and get your agency on the road to pediatric readiness! Resources: Emergency Medical Services for Children (EMSC): Roadmap to pediatric readiness: Joint policy statement on pediatric readiness:    
33:57 1/13/24
Drowning Prevention is Everyone's Responsibility: Advocacy, Research, and Prevention
  Brought to you by The National Association of EMS Physicians (NAEMSP) and Missouri Emergency Medical Services for Children (MO-EMSC) Hosts: Dr. Joelle Donofrio-Odmann and Dr. Joseph Finney Website:  Direct Download: GET CEU CREDIT THROUGH PRODIGY EMS: Content Experts: Joelle Donofrio-Odmann, DO and Joseph Finney, MD Special Guests:  Molly A. Greenshields, MD: Assistant Professor of Pediatrics at Children's Minnesota  Caitlin Farrell, MD: Associate Physician in Pediatrics, Division of Emergency Medicine and Assistant Professor of Pediatrics and Emergency Medicine, Harvard Medical School.  Director, Section on EMS and Prehospital Care at Boston Children's Hospital  Elise Zimmerman, M.D., SIM Program Director; Clinical Assistant Professor of Pediatrics, UC San Diego   Chris and Christina Martin: Founders of The Gunner Martin Foundation and advocates for drowning prevention  Jon Boisvert: City of San Diego Oceanfront Lifeguard, San Diego Junior Lifeguard instructor B-side Narrator: Joelle Donofrio-Odmann, DO and Joseph Finney, MD  Editing and Publication: Joseph Finney, MD  Episode Summary We have a terrific episode for you today for this part 2 of our pediatric drowning series. To recap, episode one focused on the experiences of ocean front lifeguards and Midwest paramedics where we laid out prehospital priorities for the management of pediatric drowning. If you haven’t listened already, check that episode out before this one. The foundation of episode one will inform the understanding of this episode so go check that one out now. Ok, now for part 2 of our series. Today we are focusing on the story of two very special individuals who have made it their mission to ensure no more children die from drowning. They will take us on a personal journey that changed the trajectory of their lives forever leading to a career as a firefighter and a vocation of advocacy to help them heal after a tragic event. And it is in that advocacy that today’s episode really originates from because, as we will learn, the key to successful prehospital pediatric drowning management is ensuring the event never happens in the first place. And it’s there that we meet 3 experts in quality improvement and injury prevention as well as research. We will discuss some amazing work focused on drowning prevention and exploring the factors associated with disparities in pediatric drowning.   A word of caution, this episode recounts a real-life emergency that may be difficult for some listeners. And one last thing, although we normally guide the discussion for you the listener with pauses and summaries, this first part of the episode is so powerful and so real, it needs no guidance. On the back half of the episode, we will be there to highlight and reinforce but for this first part, just try and follow our guests. This is worth your full attention. Ok, let’s get to it! EMS Professionals are the frontline of drowning prevention and advocacy!! You can be the difference.  Key Tips for EMS Medical Directors and Agencies: Any drowning or water training should include a pediatric resuscitation scenario Know your pediatric destinations for a drowning victim. They may require ECMO! Work with community partners to advocate for water safety and encourage swim lessons Collaborate with CPR programs in your area to teach bystander CPR 5 keys to water safety: Adult supervision: Sober designated water watcher Avoid water wings or floaties Set up barriers to water access (door alarm, 4-sided fence, pool alarm, self latching gait) Multiple layers of barriers Swim lessons (As early as 1 year if developmentally appropriate, all kids by age 4 years) Critical Factors in an effective water barriers: Isolation fences (enclosed on all 4 sides, can’t enter the pool directly from the house​ Fence height >4ft, bottom of fence
63:51 12/22/23
A Silent Epidemic: Prehospital Priorities in the Management of Pediatric Drowning
  Brought to you by The National Association of EMS Physicians (NAEMSP) Hosts: Dr. Joelle Donofrio-Odmann and Dr. Joseph Finney Website: Direct Download: GET CEU CREDIT THROUGH PRODIGY EMS: Content Experts: Joelle Donofrio-Odmann, DO and Joseph Finney, MD Special Guests:  Bryan Clark: Marine Safety Lieutenant at San Diego Fire-Rescue Lifeguard and Paramedic  Gina Pellerito: Critical Care Paramedic with Mehlville Fire Protection District, Research Analyst/MOEMSC Chair at MU school of Medicine    Jon Boisvert: City of San Diego Oceanfront Lifeguard, San Diego Junior Lifeguard instructor B-side Narrator: Joelle Donofrio-Odmann, DO Editing and Publication: Joseph Finney, MD  Episode Summary Welcome back to the Pediatric EMS podcast. Where I (Joe) live, summer is winding down, but this episode topic knows no seasonality. It affects everyone and it can happen at any moment. Today, on episode 5 of the pediatric EMS podcast, Joelle and I bring you a two-part episode focused on the silent epidemic of pediatric drowning. Today, in part one, we hear from two San Diego lifeguards who break down how experts in drowning prevention approach water safety, drowning prevention, rescue, and resuscitation. But we will also have a guest from one of our first episodes, Gina Pellerito who will take us through a call she will never forget, one that put her on a career path focused on improving prehospital pediatric care. In part two, we will hear from a whole new group of experts in advocacy, prevention, and expert research including a story you won’t want to miss. You have waited long enough, let’s get into part one and learn how to manage a drowning event. Disposition: “The decision to admit to an ICU or hospital bed vs observation in the ED or discharge home should consider the severity of the patient’s drowning as well as any co-morbid or premorbid conditions” (Szpilman et al 2020)  The majority of drowning victims are well and without symptoms. Historically, despite well-appearance, all victims of drowning were admitted for observation given concern for sudden clinical deterioration (Noonan et al 1996). This thinking has changed over time, luckily. Now, only a certain group of symptomatic drowning victims will require admission.  Except for our most severe patients, if there are symptoms, they will primarily be respiratory in nature. I find it easiest to divide patients into three broad potential categories; well appearing and asymptomatic, symptomatic with respiratory distress, and those who are unresponsive with cardiorespiratory collapse. This can feel like an oversimplification but it is important to help triage patients and determine who can go home, who should be observed, and who needs to be admitted.  Noonan et al in 1996 performed a retrospective chart review of 72 drowning victims. They found that 98% of patients who developed any symptoms did so in the first 4.5 hours. Based on their findings, they recommended the following: Asymptomatic, well appearing in the ED→ Observation for 6-8 hours and discharge if no symptoms develop Stable mildly symptomatic patients should be observed for 6-8 hours and admitted if they deteriorate or fail to improve, supportive care with supplemental oxygen and evaluation for aspiration/edema with CXR should be performed Ill, symptomatic patients should be stabilized in the ED and subsequently admitted to the ICU or general inpatient unit Consider ECG in all patients to screen for arrhythmia if history concerning Ultimately, most patients can be observed and discharged. Management of the more critically ill patients will require a thoughtful, multidisciplinary approach with the goal of “maintaining adequate oxygenation, preventing aspiration and stabilising body temperature.” (Royal Children’s Hospital Melbourne CPG)  In this episode: 3 prehospital experts take us through their experience with pediatric drowning from the perspective of two San Diego Lifeguards and 1 Paramedic Highlights from Joe and Joelle on exactly how to approach pediatric drowning management Advice for medics and medical directors on training for this low frequency high risk event Back to the basics with review of the fundamentals in resuscitation  Resources Amazing course on pediatric drowning for EMS and bystanders: Clarifying terms for drowning:'re%20struggling%20underwater,Milk. Prehospital Readiness: Key Take-Aways: Training is critical, drill in your agency and with community partners to make sure you are ready Focus on the basics: ventilation and high quality CPR C-collars are for trauma Arrhythmias are uncommon Survival requires rapid rescue and bystander resuscitation. Teach your community and your family Scene safe! Don't become a second victim check out the NASEMSO model guidelines for drowning protocol recommendations and other protocol guidance  Come back for part 2 where we focus on prevention and advocacy in pediatric drowning. Plus, we will have a story you DO NOT WANT TO MISS! Stay safe and stay sharp. Joe and Joelle
56:33 11/20/23
Expedite The Route, Simplify The Dose: Managing Pediatric Prehospital Seizures
Expedite The Route, Simplify The Dose: Managing Pediatric Prehospital Seizures Brought to you by The National Association of EMS Physicians (NAEMSP) Hosts: Dr. Joelle Donofrio-Odmann and Dr. Joseph Finney Website: Direct Download: Content Experts: Manish Shah, MD, Denise Whitfield, MD, Rejean Guerriero, DO B-side Narrator: Joelle Donofrio-Odmann, DO Editing and Publication: Joseph Finney, MD  Episode Summary I know it’s been a minute, but we are glad to be back to bring you an extremely important episode focused on the prehospital management of pediatric seizures. Seizures are one of the most common reasons EMS is called for a pediatric patient and prompt termination of that seizure can be lifesaving. A prehospital pediatric seizure is not only one of the scariest events for a parent, but it is also high stress for the paramedics and with pediatric airway management, medication dosing, and a stressful scene all piling up in the head of a paramedic, this seemingly simple call can become an immense challenge for even the most experienced clinician. But you don’t have to worry about that next call for a pediatric seizure. We at The Pediatric EMS Podcast have teamed up with 3 experts you will meet throughout the episode to break it all down and walk you through each critical aspect of pediatric seizures from understanding what a seizure is, what your priorities in treatment need to be, and finally how to systematically approach the patient to ensure you safely, effectively, and quickly manage your next prehospital Pediatric seizure. We will provide you with evidence-based recommendations to simplify the treatment of this scary EMS encounter. We are going to solidify your understanding of the priorities in managing a pediatric seizure from both the medic and medical director perspective so you can intervene rapidly and successfully the next time you get this call. Let’s get started! In this episode: Why pediatric seizures are so challenging for EMS clinicians When and how to successfully treat seizures Medication route, dosing, and monitoring What a pediatric seizure is and why we treat them Advice for medical directors to ensure medics are ready for this call Key Take-Aways: Medical directors create simple straight-forward protocols Be on the lookout for ongoing seizures, they can be subtle If you aren't sure, treat it! Keep medication routes and dosing simple Intramuscular midazolam 0.2mg/kg (max 10mg) x 2 doses seperated by 5 minutes IV NOT NEEDED! Monitor your ABCs ETCO2, monitors, pulse oximetry Shoulder roll to support the airway Hold the phone on that glucose check Check it but do it after these other interventions Our guest experts: Manish Shah, MD, MS Dr. Shah is a Professor of Pediatrics in the Division of Emergency Medicine at Baylor College of Medicine in Houston, Texas. Dr. Shah is a supremely accomplished prehospital pediatric researcher. the Co-Chair of the Assessment Subcommittee for the National Prehospital Pediatric Readiness Project since 2019. His research is focused on the integration of pediatric evidence into EMS protocols. He is The Principal Investigator (PI) for the Charlotte, Houston, and Milwaukee Prehospital (CHaMP) research node of the Pediatric Emergency Care Applied Research Network (PECARN). Dr. Shah is the Principle Investigator for Pedi-Dose, the pediatric seizure dose optimization study within PECARN working to optimize pediatric dosing for seizures in EMS.  Rejean Guerriero, DO Dr. Guerriero is a pediatric Neurologist and physician scientist at Washington University School of Medicine and Saint Louis Children's Hospital. Dr. Guerriero is an expert in Epilepsy, critical care neurology, traumatic brain injury, general neurology; ICU-EEG, status epilepticus, and refractory seizures. Dr. Guerriero works closely with the Special Needs Tracking and Awareness Response System (STARS) to ensure prompt, tailored, and effictive care for pediatric patients with complex medical needs by EMS.  Denise Whitfield, MD, MBA, FACEP, FAEMS Dr. Whitfield  is the Director of Education and Innovation at the Los Angeles County EMS Agency. She is a former Commander in the U.S. Navy with extensive experience delivering emergency medical care in diverse environments.  She spent 12 years on active duty, with combat deployments to Iraq and Afghanistan. As a Naval Flight Surgeon, she completed operational assignments with the Marine Corps.  As her final Navy assignment, she served as a White House Physician where she conducted operational medical planning and ensured medical care delivery for the President, Vice-President and First Lady.  Dr. Whitfield completed an EMS fellowship with LA County and joined the EMS Agency in July 2018.  She currently directs education programs at the EMS Agency including annual EMS Update the EmergiPress continuing education newsletter.  She is an Assistant Professor of Clinical Medicine at the David Geffen School of Medicine at UCLA and serves as faculty for the EMS Fellowship Program at Harbor-UCLA Medical Center in collaboration with the Los Angeles County EMS Agency. Dr. Whitfield recently published "The Effectiveness of Intranasal Midazolam for the Treatment of Prehospital Pediatric Seizures: A Non-inferiority Study" in the journal Prehospital Emergency Care. Episode Resources Dr. Whitfield's publication Whitfield D, Bosson N, Kaji AH, Gausche-Hill M. The Effectiveness of Intranasal Midazolam for the Treatment of Prehospital Pediatric Seizures: A Non-inferiority Study. Prehosp Emerg Care. 2022 May-Jun;26(3):339-347. doi: 10.1080/10903127.2021.1897197. Epub 2021 Mar 29. PMID: 33656973. STARS: Special Needs Tracking and Awareness Response System Resources from Dr. Shah Translating Emergency Knowledge for Kids (TREKK): Bottom line recommendations for pediatric seizure management (created through a joint collaboration between the Emergency Medical Services for Children Innovation and Improvement Center (EIIC) and TREKK:     NASEMSO Model Clinical EMS Guidelines: I contributed to the seizure guideline (among others) in this document:   Prehospital Guidelines Consortium: Great repository for prehospital evidence-based guidelines     EIIC Pediatric Education and Advocacy Kit (PEAK): I contributed to the development of this PEAK on pediatric seizures     Pediatric Emergency Care Applied Research Network (PECARN): PECARN has a prehospital-specific research node called the Charlotte, Houston, and Milwaukee Prehospital (CHaMP) node   Pediatric Dose Optimization for Seizures in EMS (PediDOSE):   Published Simulation-Based Pediatric Prehospital Curriculum on MedEd Portal: Pediatric Simulation Training for Emergency Prehospital Providers (PediSTEPPs) course curriculum  
62:09 3/14/23
Breaking Down Silos: Pediatric Disaster Preparation and Management
Breaking Down Silos: Pediatric Disaster Preparation and Management Is your community ready for a disaster event involving children? Well, it’s time to get ready. In this episode of The Pediatric EMS Podcast our guest experts recount firsthand experience of Hurricane Katrina and the shooting at Robb Elementary School in Uvalde, Texas as they guide you through the necessary components of preparing for the next pediatric disaster event. We have experts in Disaster Medicine, EMS, and Pediatric Emergency medicine to give you critical insight into planning, preparation, management, and recovery. Let’s get started! Brought to you by The National Association of EMS Physicians (NAEMSP) Hosts: Dr. Joelle Donofrio-Odmann and Dr. Joseph Finney         Website:   Direct Download:  Editing and Publication: Joseph Finney  Technical Support: Phil Moy Narrator: Joseph Finney Content Experts:  Heidi Abraham Emergency Medicine Physician and Deputy Medical Director for Austin Travis County EMS and the Texas Department of Public Safety. Dr. Abraham is the Medical Director for The New Braunfels Fire Department in New Braunfels, Texas Brent Kaziny Pediatric Emergency Medicine Physician and Medical Director of Emergency Management at Texas Children’s Hospital. Brent is co-director of the disaster domain of the EMS for Children Innovation and Improvement Center (EIIC). He is also on the executive core of The Pediatric Pandemic Network (PPN). Amyna Husain Pediatric Emergency Medicine Physician and Pediatric Medical Control Chief at Johns Hopkins Hospital. Dr. Husain works nationally with the AAP and The Pediatric Pandemic network. Dr. Husain is also involved in the National Emerging Special Pathogens Training and Education Center regarding special populations (NETEC). Mark X. Cicero Pediatric Emergency Medicine Physician, Disaster Physician, and EMS Physician. Dr. Cicero serves as the education lead for the Pediatric Pandemic Network as well serving on the National Advisory Committee on Children and Disasters. Jeff Siegler EMS Physician and Emergency Medicine Physician at Washington University School of Medicine Dr. Siegler is the Medical Director of Saint Louis Children’s Hospital Special Needs Tracking and Awareness Response System (STARS) as well as Medical Director for both an EMS district and a Fire Department in Saint Louis. Dr. Siegler works with local SWAT teams as the team physician. Kate Spectorsky Pediatric Emergency Medicine and Disaster Medicine Physician at Saint Louis Children’s Hospital in Association with Washington University School of Medicine. Dr. Spectorsky is involved with the American Academy of Pediatrics Section on Disaster Preparedness. Critical Components of Disaster Management: Preparation Communication Adaptation Reunification Caring for responders Quality Improvement Caring for survivors Resources for preparing your hospital or agency: The Pediatric Pandemic Network EIIC Prehospital Emergency Care Coordinators The Pediatric Readiness Project American Academy of Pediatrics: Disaster Medicine Resource for Disaster Preparedness CDC Resource: Caring for Children in a Disaster Ethical implications of diversity in disaster research Hunt MR, Anderson JA, Boulanger RF. Ethical implications of diversity in disaster research. Am J Disaster Med. 2012 Summer;7(3):211-21. doi: 10.5055/ajdm.2012.0096. PMID: 23140064. MPRT: Mobile Pediatric Response Team   Talking To Children about Disaster Events: Be proactive, don’t wait for the child to start the conversation What is the child’s understanding of the event Ask what they are feeling Express support Seek additional support from counselors and healthcare experts Keep communication open Know that healing is a life-long process so support them on their journey Watch for warning signs of Post-Traumatic Stress Disorder, Anxiety, and Depression Milestone regression Acting out Introversion Behavioral changes Resource for helping children cope with disasters Podcast  
56:11 10/10/22
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: Direct Download:   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   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   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
63:01 7/23/22
Ouch-less Pediatrics
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! 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.   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:
56:01 5/11/22

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