Pediatric Trauma Criteria and Destinations

[Mountain Res-Q]

I was just doing some review of local policy and procedure and really diving into the sections on trauma criteria and destinations since we are more remote and removed for major hospitals; so the deciding on appropraite transportion and destinations for the more "interesting" patients always needs to be considered carefully and early in a call.

One thing that always struck me was how "loosely" local EMSA protocol is viewed compared to another EMSA I worked under, where there was no interpretation and everything was more “this is how it is”. So, I was wondering how other protocols handle the subject of pediatric trauma.

What is your local definition for a “Pediatric” patient?

What are the criteria for “Pediatric Trauma”?

What is the protocol for transport; ground or air? (further: Does location of the patient in your area make a difference?)

What is the protocol for destination for Pediatric Trauma”? (i.e. closest hospital, closest trauma center, closest pediatric trauma center? Does that change when an air ambulance is unavailable?)

 

[Shishkabob]

I'm just going to ruin the thread and state that I have a pediatric only level 1 trauma center in Dallas

They'll take pretty much anyone under the age of 18, and will take some over 18 if they have a chronic disease and they've gone to Children's since childhood.




I also have another childrens hospital on the north end of Dallas that I can take peds to, as well.

 

[Mountain Res-Q]

I'm just going to ruin the thread and state that I have a pediatric only level 1 trauma center in Dallas

They'll take pretty much anyone under the age of 18, and will take some over 18 if they have a chronic disease and they've gone to Children's since childhood.

I also have another childrens hospital on the north end of Dallas that I can take peds to, as well.

That sounds exactly like Indy. Peds Level 1 Trauma Center downtown, right next to an adult level 1 with another adult level one less than a mile away. (Yes, I know I'm spoiled) We also have another peds hospital on the northwest side of town.

Anyone out there who does not have a Pediatric Trauma Center in their backyard with its own Starbucks, McDonalds, and WalMart in the lobby?

 

[katgrl2003]

I'm just going to ruin the thread and state that I have a pediatric only level 1 trauma center in Dallas

They'll take pretty much anyone under the age of 18, and will take some over 18 if they have a chronic disease and they've gone to Children's since childhood.

I also have another childrens hospital on the north end of Dallas that I can take peds to, as well.

That sounds exactly like Indy. Peds Level 1 Trauma Center downtown, right next to an adult level 1 with another adult level one less than a mile away. (Yes, I know I'm spoiled) We also have another peds hospital on the northwest side of town.

 

[Sassafras]

Our nearest hospital is 35 minutes away but with it being a level 3 trauma center we generally only take medical patients there. The trauma 1 center is 55 minutes away (30 if you have our drivers with lights and sirens lol) but it also houses the childrens hospital. No questions asked our SOPs dictate peds go there for almost everything. As for flying it's vaguer. Basically they have to be declining so rapidly that the transport over land could be life threatening. For being as far away from major medical facilities as we are, we rarely ever fly them. Honestly I can only remember twice since I joined the unit a year and a half ago.

 

[Veneficus]

What is "trauma?"

When considering any type of trauma, particularly that in the extremis of ages, the most important questions to ask are:

"Is this potentially surgical trauma?"

"Will this patient require intensive or longterm care and rehab to potentially avoid severely compromised quality of life?"

Having both worked and rotated in peds trauma centers, it has been my experience that many patients who do not have injuries or illness requiring such specialized facilities are often sent at great risk, expense, and stress.

Most trauma is muscle/skeletal in nature, short of a compartment syndrome, or a rhabdomyolysis. Most m/s injuries are not going to require more than can be handled by most urban or suburban EDs that have timely access to an ortho surgeon.

More serious or multisystem injuries are what requires more specialized trauma care. (almost a redundant statement because all trauma is technically "multisystem" when you count the skin, microcirculatory systems, metabolism, etc.)

I would say that the most important factors in determining the need for specialized facilities is not the age of a child, but the combination of development, severity of injury, and preexisting comorbidities that complicate care. All of this will take a knowledgable and experienced provider to evaluate.

Hazards of airmedical evacuation or prolonged transport without more advanced resuscitation/stabilization may not be in the best interest of the patient. Most emegergency departments (no matter how small) have access to blood products. While not comfortably, any residency trained general surgeon should be able to perform some level of damage control surgery. This is where multiple factors of how long will it take to get a surgeon or transport farther because it will actually mean faster access to a surgeon who is more skilled or specialized in tending to children have to be weighed.

Keep in mind that the trauma that requires surgical intervention has and is declining significantly compared to when many trauma guidlines were written. It is the responsibility of every provider to know the potential levels of service required by patients and how to access them.

It is impossible to come up with hard/fast rules for the many possibilities of injuries, comorbidities, and logistical conditions. If you think your patient warrents a high level of specialized care because of presentation or complexity, by all means send them there by the safest way possible. (most likely not the fastest) If in your judgement the patient will need more help than you can render if initial resuscitation or stabilization is successful, the patient can always be transferred to a higher level of care later.

some injuries such as intracranial hemorrhage will not be able to be helped at all by local assets anymore than in the back of a moving ambulance or helicopter. In such cases, safe transport to specialty care is the only reasonable option.

Following the wisdom of many critical care surgeons I have had the honour to work with and learn from, patient transport should not be delayed for diagnostics, only life saving treatments.

In common terms, "Don't wait to call for help until after your CT scan if you know you cannot do anything about it if the findings are positive."

"Don't open a chest if you have no ability to close it after."

like the answer to any medical question: "It depends."

I encourage people to always be a proactive part of safety. If the conditions are questionable or potentially hazardous, don't call for air evac. If the patient is stable and likely to remain so, don't call for air evac if there are other options. There is no legitimate reason to have a pilot decide whether to risk a flight from a remote location when you are standing on scene and can see or reasonably assume the danger exceeds the benefits to the patient.

 

[usafmedic45]

That sounds exactly like Indy. Peds Level 1 Trauma Center downtown, right next to an adult level 1 with another adult level one less than a mile away. (Yes, I know I'm spoiled) We also have another peds hospital on the northwest side of town.

If my kid ever gets hurt, I'm taking them to St. V's. Riley can kiss my pasty white Germanic butt.

On a more functional comment:
-Keep "mechanism of injury" criteria out of the protocols
-Downplay the use of helicopters other than for transfers between hospitals

 

[usafmedic45]

If my kid ever gets hurt, I'm taking them to St. V's. Riley can kiss my pasty white Germanic butt.

On a more functional comment:
-Keep "mechanism of injury" criteria out of the protocols
-Downplay the use of helicopters

"Don't wait to call for help until after your CT scan if you know you cannot do anything about it if the findings are positive."

Also well stated as "Don't ask a question if you really don't want to know the answer."

 

[Mountain Res-Q]

-Keep "mechanism of injury" criteria out of the protocols
-Downplay the use of helicopters other than for transfers between hospitals

1. Or keep them as a Paramedic Consideration, but ALWAYS treat the patient not the MOI.
2. No matter what? 6 month old with a suspected hemo/pneumo. 45 minute tx by ground to a Rural ED who is probably gonna transfer anyway or skip a step and fly the child 30 minutes to a Pediatric Trauma Center?

Vene - I have always agreed that protocols should never be absolute. They should be guidlines that can be manipulted based on (good) medical judgement. That is why I like my local EMSA (which keeps the protocols simple and only creates them if needed) over the EMSA I worked under on ambulance. i.e. That EMSA had a protocol that said (with no interpretation) that if a pregant woman over 20 weeks gestation is in a MVC with speeds in excess of 25 mph the recieving hospital will be a level 2 trauma center and on the mednet you will declare a tier 2 trauma. The hospital will have the full trauma team and OB paged to be waiting for the ambulance. The first month that protocol went into effect there was a woman in her 20th week who was rearended at 25 mph. No medical need; the medic crew checked her out and were gonna ama her on her request, but her husband wanted her checked out at the hospital. So the ambo provided comfort messures and considered it a routine transport. The EMSA called a review of the call a month latter on the grounds that protocol was violated; they wanted to waste resources over a fender bender. Not saying that there might not have been some unseen injury to the woman or child, but let's allow medicine and not protocol to dictate care...

However, vene, my original question was one of local protocol; I am just curious as to the thinking of various EMSA's when it comes to pediatric trauma and if the protocol makes sense to ya'll...

 

[usafmedic45]

No matter what? 6 month old with a suspected hemo/pneumo. 45 minute tx by ground to a Rural ED who is probably gonna transfer anyway or skip a step and fly the child 30 minutes to a Pediatric Trauma Center?

In the extreme rural setting, they have their place as I have said before. However, I would strongly advocate that you work with your local HEMS provider(s) and perhaps the local FAA Flight Standards District Office (FSDO or "Fiz-do") to predesignate appropriate landing sites or to identify all the airports (private and otherwise) to improve safety by minimizing the risks to the crew related to makeshift landing sites on or near scenes. If you agency would like my help in this regard (if, for example, the HEMS providers or the FSDO don't want to help), please feel free to PM me. I would be happy to talk or meet with anyone as my goal in life is to improve aviation safety, especially in regards to HEMS operations.

 

[Mountain Res-Q]

In the extreme rural setting, they have their place as I have said before. However, I would strongly advocate that you work with your local HEMS provider(s) and perhaps the local FAA Flight Standards District Office (FSDO or "Fiz-do") to predesignate appropriate landing sites or to identify all the airports (private and otherwise) to improve safety by minimizing the risks to the crew related to makeshift landing sites on or near scenes. If you agency would like my help in this regard, please feel free to PM me. I would be happy to talk or meet with anyone as my goal in life is to improve aviation safety, especially in regards to HEMS operations.

LOL... usaf, no need. Our county has been rural for quite some time. We have guidlines for proper air ambulance uses and have many LZ's designated and set up across the county, although anyone worth a damn in this county can select and set up a site for an LZ (like in the SAR setting) if needed, but we try not to need it. The last Air Ambulance to crash in my mountain county was in the early 80's (gust of wind pushed the bird into a pine tree on lift off and killed the entire crew. Not a good deal and under no circumstances will an air ambulance fly at night above 3000 feet, nor will they fly at night to any non-designated LZ.

My question about using the helo for a pediatric trauma patient was just to make clear your point that we should "downplay the use of helicopters other than for transfers between hospitals". When the closest adult trauma center (as well as cath lab and stroke center) is 45-120 minutes away and the closest pediatric trauma center is 90-180 minutes away, helos become critical in more cases than anyone would like. As a result, when it comes to pediateric trauma, the county protocols list a number of reasons when an air ambulance should be considered, and most of that has to do with transport time to an appropriate facility being too great for a patient with injuries sever enough to require more than a local rural ED can manage. Although, with the winter weather, those guidlines can become useless.

 

[usafmedic45]

Not a good deal and under no circumstances will an air ambulance fly at night above 3000 feet, nor will they fly at night to any non-designated LZ.

Obviously you don't have AirEvac Lifeteam in your part of the country.

LOL... usaf, no need. Our county has been rural for quite some time. We have guidlines for proper air ambulance uses and have many LZ's designated and set up across the county, although anyone worth a damn in this county can select and set up a site for an LZ (like in the SAR setting) if needed, but we try not to need it.

Gotcha. I just figured I would offer since most counties have not bothered to put that much effort into protecting their HEMS crews.

Although, with the winter weather, those guidlines can become useless.

Has the county considered working with a fixed wing operator to overcome at least the marginal weather conditions (too low of a ceiling for the helo, etc)? That is a very viable option in extremely rural areas with frequent bad weather that hinders the proper use of HEMS?

 

[Mountain Res-Q]

Obviously you don't have AirEvac Lifeteam in your part of the country.

Gotcha. I just figured I would offer since most counties have not bothered to put that much effort into protecting their HEMS crews.

Has the county considered working with a fixed wing operator to overcome at least the marginal weather conditions (too low of a ceiling for the helo, etc)? That is a very viable option in extremely rural areas with frequent bad weather that hinders the proper use of HEMS?

Not familiar with AirEvac Lifeteam. We have 2 differnt Air Ambulance providers that operate locally; PHI AirMed (with a helo at the local airport that serves most of the mountain counties) and MediFlight of Northern California (with a helo in the central valley). Neither of them will fly about at night to anything other than a pre-designated LZ, which isn't a big deal since we have many pre-designated LZ's. Of course, the pilot hsa the power to decide what they feel comfortable with, but largely air ambulances locally don't take chances in my county, and I can not say I blame them. No patient is worth dying for.

Fized wing tends to be used only for transfers of great distances. Usually by the time a fixed wing could be called in (I don't even know where the closest is) a ground ambulance moving code (not the best option) could have made it the 50-60 minutes from the local ED to the closest adult trauma center. That versus the 15 minute code 3 ground transport to the airport (in the opposite dirrection) to meet the fixed wing. Logistically I don't think it is a viable option, although I am sure it is a possibility in the right circumstances.

 

[MrBrown]

...I would strongly advocate that you work with your local HEMS provider..

Did somebody say HEMS?

"Oi Brown you lazy sod, wake up, its a go!"
"Oh bloody hell Oz, what is it?"
"Paediatric"
"Mmm, best we be off then, call up and see if Arizona Robbins is avaliable, do we have a spare 'DOCTOR' jumpsuit?"
"No, I recall it went missing when you started here"
"Ah yes, well, best we be off at any rate, get the Thomas packs, good lad"

City Traffic, Westpac Rescue lifting .....

This is from 2006 so it might be a bit old

Major Trauma:
Major Trauma (for the purposes of this document) is defined as any of the following:
• status 1 or 2 with any of the following
• abnormal airway and/or breathing
• depressed level of consciousness with GCS < 14
• signs of shock
• penetrating injury to the head, neck, chest, abdomen or pelvis
• spinal cord injury with altered sensation or motor power
• burns > 20% or burns involving the airway
• significant crush injury
• two or more long bone fractures (femur, tibia or humerus)
• laceration with significant arterial bleeding

Patients with major trauma will be taken to a hospital according to the following guidelines:

...

• children with major trauma will be taken to Starship as a preference, but will
be taken to Middlemore if it is ten or more minutes nearer than Starship; if
the child is in a helicopter, they will be taken direct to Starship; in the unusual circumstances
that an adult and a child are both in a helicopter, they will be taken to the Auckland/Starship site

• patients with major burns will be taken direct to Middlemore unless an
immediate life-threatening problem exists that requires the patient to stop at
Auckland or Starship

Paediatric illness and injury:

For the purposes of this document ‘children’ are defined as being less than 15 years of age and adults as 15 years of age or older.

Children being transported to hospital will be taken to the appropriate ED for that catchment area, except for the following circumstances:

• children with Major Trauma will be taken to Starship by preference, but
should be taken to Middlemore if it is 10 or more minutes nearer in time than
Starship (see Major Trauma above for more details)
• children in the North or Northwest areas who meet bypass criteria will bypass North Shore
and go direct to Starship. Criteria for bypass are:
• Status 1 or Status 2 with any of the following
• Abnormal airway (e.g. stridor) or
• More than one febrile seizure or
• Head injury associated with drowsiness or vomiting in child < 5 years
of age
• children with orthopaedic injuries will be taken to Starship or Middlemore,
whichever is the nearest (see Orthopaedic policy above)
• children with burns >10% will be taken to Middlemore; children with arm or
hand injuries will be taken to Starship or Middlemore, whichever is the
nearest (see Burn / Arm / Hand Injury above)
• children in the Northwest area who are nearer to Starship than North Shore
will be taken to Starship
• children who open letters for a particular hospital will be taken to that hospital
• children with long involvement with a specialist at a particular hospital (and
the current problem is related) will be taken to that hospital

Outside of the Auckland Metroplex children go to the nearest usual ED and if required are sent to Starship here in Auckland

 

[Mountain Res-Q]

MrBrown,

Did I see that right that anything with a GCS <14 might be considered significant truama and require a helo? Heck, most mornings my GCS is <12 for the first 2 hours of the day! ^_^

 

[MrBrown]

MrBrown,

Did I see that right that anything with a GCS <14 might be considered significant truama and require a helo? Heck, most mornings my GCS is <12 for the first 2 hours of the day! ^_^

No, you must have a GCS < 14 with one of the others

Status 1 is critical and 2 is unstable so you need a pretty significant problem to go along with your low GCS.

 

[WTEngel]

I have seen the benefits of both decisions (closest available facility, closest trauma facility, closest pediatric trauma facility)

I worked for Children's in Dallas on the critical care transport team, and we were on speed dial for most of east Texas and a good majority of west Texas and southern Oklahoma. For those facilities, they knew that generally they had us available as a resource, so the idea of taking significant trauma to a more rural facility was not a bad idea for the rural EMS providers, as they had a speciality transport team available within the hour by rotor or fixed wing...

Now, on the flip side of that...we flew out to some rural facilities and picked up kids who might as well have still been underneath the horse that bucked them off or in the field where they crashed their ATV. I mean we are talking hospitals that had not initiated any treatment at all...

So...i guess to sum it up, even though you might not be able to transport to a pediatric facility, this does not mean that the hospitals do not have rapid access to a peds specialty team, this depends on where you are located...I am sure Linus knows how busy Children's transport was...

With that being said, the only place where you can get anything close to a garauntee of appropriate care for the pediatric trauma patient is a Level 1 pediatric trauma center, followed by a Level 1 general trauma center, and on down the line...so take into account what access the hospitals have to these facilities. Does the closest level 1 have it's own in house transport service? Do they offer on line consultation between physicians? Etc, etc....

Also, you asked what is considered pediatric these days...i believe the most commonly used standard is onset of secondary sex characteristics. This combined with some weight based standards can give you a pretty accurate picture of who can be treated with adult protocols and who can be treated with peds protocols...i agree that nothing should ever be written in stone...

 

[usafmedic45]

Not familiar with AirEvac Lifeteam

Consider yourself lucky. They have the worst safety record of any HEMS provider and will literally skirt any safety recommendation that is not an FAA mandate to increase profits. Around here they are known not so jokingly as "Death from Above" or "Scare-Evac Deathteam".

Fized wing tends to be used only for transfers of great distances. Usually by the time a fixed wing could be called in (I don't even know where the closest is) a ground ambulance moving code (not the best option) could have made it the 50-60 minutes from the local ED to the closest adult trauma center. That versus the 15 minute code 3 ground transport to the airport (in the opposite dirrection) to meet the fixed wing. Logistically I don't think it is a viable option, although I am sure it is a possibility in the right circumstances.

I heard (from a friend who worked for one of the fixed-wing operators in the Rockies) that some of the very rural services there use a system of putting the aircraft on standby for certain cases and launching them to the closest weather appropriate airport to take the patient to a trauma center (Denver, SLC, Missoula, etc). It's not going to work everywhere, but it's something to at least put some thought into especially in extremely rural settings where when you factor in bad weather the transport time may exceed 90 minutes.

 

[WTEngel]

I know the way we worked, and most other specialty transport teams for that matter...is that we were contacted by the hospital that the patient has been transported to. This means treatment is already underway at the facility (theoretically, see my other post)

Anyway, we land at the hospital direct if we were on the rotorcraft. If the transport was too far for the rotor, or weather minimums only supported the use of a fixed wing, we would fly to the nearest airport, be picked up by an ambulance and transported to the hospital, where we would initiate stabilizing care, get the report, and then transport back to the airport to fly home...

So, most rural services transported the the closest facility, which in turn contacted us, and we were deployed to the hospital. We weren't met at the airport with the patients. I know some of you may say this adds un necessary time to the process, however we were able to begin treating the patient more effectively in the hospital setting than we would have been one the runway or in the back of the plane or helicopter...this is why inter facility critical care transport differs from scene work. Reallymtwo different animals.

 

[usafmedic45]

So, most rural services transported the the closest facility, which in turn contacted us, and we were deployed to the hospital. We weren't met at the airport with the patients. I know some of you may say this adds un necessary time to the process, however we were able to begin treating the patient more effectively in the hospital setting than we would have been one the runway or in the back of the plane or helicopter...this is why inter facility critical care transport differs from scene work. Reallymtwo different animals.

Right, I work doing interfacility transfers (non-emergent), but the scenario I described was set in areas where the closest hospital of any size maybe a longer drive away than the dispatch and flight time of the aircraft. This is the case in large swathes of Wyoming and Montana for example. When I was working in eastern Wyoming it was rather surprising to realize that if you drove north in the county I was in you could drive for nearly 90 minutes before you reached the end of the county (at a reasonable speed for the type of roads in question).

we were able to begin treating the patient more effectively in the hospital setting than we would have been one the runway or in the back of the plane or helicopter...this is why inter facility critical care transport differs from scene work. Reallymtwo different animals.

Agreed. This is one of the reasons I always advocate launching helicopters to the closest hospital rather than the scene in most situations since your scene time is going to be excessive if the crew has to stabilize the patient before hand due to a lack of space to work in. With fixed wing aircraft (most of them) this is not as big of a problem since there is more space but I agree wholeheartedly with your points on this.