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.

The Prehospital Pediatric Readiness Project 01/13/2024

Drowning Prevention is Everyone's Responsibility: Advocacy, Research, and Prevention 12/22/2023

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 , SIM Program Director; Clinical Assistant Professor of Pediatrics, UC San Diego Chris and Christina Martin: Founders of 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 <4” from the ground, vertical supports <4” apart Fence gait opens outward away from the pool and is self-closing Gait latch >4.5ft and self-latching Climb resistant fencing Inflatable toys hidden away from the pool Pool covers alone are not adequate prevention Resources: The Gunner Martin Foundation: Instagram: @the_gunner_martin_foundation Facebook: The Gunner Martin Foundation Email: [email protected] Article on Chris and Christina: The Swim On Foundation: The Injury Free Coalition for Kids: AAP Drowning Prevention Toolkit: /episode/index/show/34eda738-c0e3-471c-94e6-5d7bb718e70f/id/28953208

A Silent Epidemic: Prehospital Priorities in the Management of Pediatric Drowning 11/20/2023

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: . 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 /episode/index/show/34eda738-c0e3-471c-94e6-5d7bb718e70f/id/28498529

Expedite The Route, Simplify The Dose: Managing Pediatric Prehospital Seizures 03/14/2023

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 /episode/index/show/34eda738-c0e3-471c-94e6-5d7bb718e70f/id/26196993

Breaking Down Silos: Pediatric Disaster Preparation and Management 10/10/2022

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 /episode/index/show/34eda738-c0e3-471c-94e6-5d7bb718e70f/id/24633714

Your Hand is Their Heart 07/20/2022

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 (<18yo) In-hospital Cardiac arrest with initial non-shockable rhythm Primary outcome: Survival to discharge Secondary outcomes ROSC, 24h survival, and neuro status Findings: Survival to discharge 487/1558 (31.3%) ROSC 993/1558 (63.7%) RR of 0.96 for every minute delay in EPI administration Favorable Neuro outcome (documented) 217/1395 (15.6) RR of 0.94 for every minute delay in EPI administration Delay of epi >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 <10min had fewer witnessed events, shockable rhythms, attempts at advanced airway, IV/IO attempts, and medications given compared to those with longer scene times. ETT vs SGA (in OHCA) Hansen ML, Lin A, Eriksson C, Daya M, McNally B, Fu R, Yanez D, Zive D, Newgard C; CARES surveillance group. A comparison of pediatric airway management techniques during out-of-hospital cardiac arrest using the CARES database. Resuscitation. 2017 Nov;120:51-56. doi: 10.1016/j.resuscitation.2017.08.015. Epub 2017 Aug 22. PMID: 28838781; PMCID: PMC5660668. 3 year retrospective review of patients with non-traumatic OHCA <18yo using the CARES database 17 states, 55 cities 1724 OHCA Odds ratio survival to discharge ETI vs BVM 0.39 (95%CI 0.26-0.59) SGA vs BVM 0.32 (95%CI 0.12-0.84) ROSC BVM 18% (n 781) ETI 20% (n 727) SGA 27% (n 215) Survival to discharge BVM 14% (n 781) ETI 7% (n 727) SGA 10% (n 215) Good neuro outcome (CPC 1 or 2) BVM 11% (n 781) ETI 5% (n 727) SGA 6% (n 215) Conclusion: BVM is associated with higher survival to hospital discharge and increased neuro-intact survival compared to ETI and SGA. Special thank you to all our guests and content experts! Sources: Jayaram, Natalie et al. “Survival After Out-of-Hospital Cardiac Arrest in Children.” Journal of the American Heart Association vol. 4,10 e002122. 8 Oct. 2015, doi:10.1161/JAHA.115.002122 Atkins, Dianne L et al. “Epidemiology and outcomes from out-of-hospital cardiac arrest in children: the Resuscitation Outcomes Consortium Epistry-Cardiac Arrest.” Circulation vol. 119,11 (2009): 1484-91. doi:10.1161/CIRCULATIONAHA.108.80267 Banerjee, Paul R et al. “Early On-Scene Management of Pediatric Out-of-Hospital Cardiac Arrest Can Result in Improved Likelihood for Neurologically-Intact Survival.” Resuscitation vol. 135 (2019): 162-167. doi:10.1016/j.resuscitation.2018.11.002 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 /episode/index/show/34eda738-c0e3-471c-94e6-5d7bb718e70f/id/23694779

Ouch-less Pediatrics 05/11/2022

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 <18yo captured in the database Outcome: > 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: <18yo prehospital patients with blunt, penetrating, laceration, and/or burn trauma What: Updated pain protocols and implemented mandatory CE Outcome: No improvement after implementation of evidence-based guidelines for managing pain 3600 pre and 3700 post intervention Opioid administration pre/post remained 5% (15% if moderate to severe pain score 4 or higher) 18% had pain score documented pre/post (75% moderate to severe pain) Only one agency gave intranasal opioids despite all three agencies having the capability No implementation of QI protocols along with these changes Implications: Implementation of protocol changes alone does not translate to clinical practice change. If you make changes “you really have to own it” Consider adding quality improvement projects to improve adherence to protocol changes. Robust QA/QI is a must for any medical director. Measuring an intervention over time before deciding if they worked or not helps to avoid false results during the "washout period". Consider an EMR prompt to encourage assessing and treating pain. Evidence-Based Guidelines for Prehospital Pain Management: Recommendations published in Prehospital Emergency Care in 2021 Objective: Provide evidence-based guidelines for the management of pain prehospital in adults and pediatrics What: RECENT Systematic review of the comparative effectiveness of analgesics in the prehospital setting prepared by the University of Connecticut Evidence-Based Practice Center for the Agency for Healthcare Research and Quality (AHRQ) with funding by NIHTSA. (Mostly) Pediatric-focused Recommendations Intranasal fentanyl is preferred over IM/IV fentanyl for prehospital pain management in pediatrics. Don’t delay for IV access. IV acetaminophen is preferred over IV opioids for the management of moderate to severe pain IF it is available IV NSAIDs or IV opioids is appropriate for initial prehospital pain management. IV NSAIDS are preferred over IV acetaminophen, also consider PO for both. IV ketamine or IV NSAIDs for initial pain management prehospital is appropriate IV ketamine or IV opioids for initial pain management prehospital is appropriate If IV opioids are selected for prehospital pain management, Morphine or fentanyl are preferred Avoid mixing opioids and ketamine IV Implications: Follow evidence-based guidelines when developing your pediatric pain management protocols Don't Forget: Don’t forget intranasal options and be careful when mixing IV ketamine and IV opioids If administering sedating medication to pediatric patients, ALWAYS use ETCO2. Implement both non-pharmacologic and pharmacologic pain treatments into EMS protocols. For pharmocologic treatments, have both opioid and non-opioid options available. Have PO meds as well as IN, IM and IV options. Teach your medics how to document and treat pain. Disclaimer The Emergency Medical Services for Children Innovation and Improvement Center is supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) as part of an award (U07MC37471) totaling $3M with 0 percent financed with nongovernmental sources. The contents are those of the author(s) and do not necessarily represent the official views of, nor an endorsement, by HRSA, HHS, or the U.S. Government. For more information, please visit HRSA.gov. To learn more about the Emergency Medical Services for Children Innovation and Improvement Center visit https://emscimprovement.center Email [email protected] Follow on Twitter @EMSCImprovement Sources: International Association for the Society of Pain Subcommittee on Taxonomy WT Zempsky NL Schechter 2003 What’s new in the management of pain in children Pediatrics Rev 24 10 337 347 16 SJ Weisman B Bernstein NL Schechter 1998 Consequences of inadequate analgesia during painful procedures in children Arch Pediatrics Adolescent Med 152 2 147 149 17 JT Pate 1996 Childhood medical experience and temperament as predictors of adult fu Educational Module on Prehospital Pain Management in Children (Targeted Issues Grant): Lorin R. Browne, Manish I. Shah, Jonathan R. Studnek, Daniel G. Ostermayer, Stacy Reynolds, Clare E. Guse, David C. Brousseau & E. Brooke Lerner (2016) Multicenter Evaluation of Prehospital Opioid Pain Management in Injured Children, Prehospital Emergency Care, 20:6, 759-767, DOI: 10.1080/10903127.2016.1194931 /episode/index/show/34eda738-c0e3-471c-94e6-5d7bb718e70f/id/23081153

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