Prehospital interventions in severely injured pediatric patients

Sokol, K; Black, George; Azarow, Kenneth S.; Long, William W.; Martin, Matthew J.; Eckert, Matthew J.

doi:10.1097/ta.0000000000000706

Cited by 33 publications

(21 citation statements)

References 44 publications

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“…The evidence supporting the systematic Airway, Breathing, and Circulation (ABC) approach to injured patients is based on expert consensus with little literature to support the clinical application of the order in which this sequence should be applied [ 1 ]. Early intubation can result in deleterious effects in adult and pediatric patients with traumatic brain injury [ 2 – 6 ]. There are many physiological explanations why intubation in hypovolemic shock might result in worse perfusion [ 2 – 6 ].…”

Section: Introductionmentioning

confidence: 99%

“…Early intubation can result in deleterious effects in adult and pediatric patients with traumatic brain injury [ 2 – 6 ]. There are many physiological explanations why intubation in hypovolemic shock might result in worse perfusion [ 2 – 6 ]. After rapid sequence intubation (RSI), there is a vasodilatory response placing the hypovolemic patient at very high risk for more pronounced hypotension and decreased perfusion [ 7 – 11 ].…”

Section: Introductionmentioning

confidence: 99%

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Circulation first – the time has come to question the sequencing of care in the ABCs of trauma; an American Association for the Surgery of Trauma multicenter trial

et al. 2018

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BackgroundThe traditional sequence of trauma care: Airway, Breathing, Circulation (ABC) has been practiced for many years. It became the standard of care despite the lack of scientific evidence. We hypothesized that patients in hypovolemic shock would have comparable outcomes with initiation of bleeding treatment (transfusion) prior to intubation (CAB), compared to those patients treated with the traditional ABC sequence.MethodsThis study was sponsored by the American Association for the Surgery of Trauma multicenter trials committee. We performed a retrospective analysis of all patients that presented to trauma centers with presumptive hypovolemic shock indicated by pre-hospital or emergency department hypotension and need for intubation from January 1, 2014 to July 1, 2016. Data collected included demographics, timing of intubation, vital signs before and after intubation, timing of the blood transfusion initiation related to intubation, and outcomes.ResultsFrom 440 patients that met inclusion criteria, 245 (55.7%) received intravenous blood product resuscitation first (CAB), and 195 (44.3%) were intubated before any resuscitation was started (ABC). There was no difference in ISS, mechanism, or comorbidities. Those intubated prior to receiving transfusion had a lower GCS than those with transfusion initiation prior to intubation (ABC: 4, CAB:9, p = 0.005). Although mortality was high in both groups, there was no statistically significant difference (CAB 47% and ABC 50%). In multivariate analysis, initial SBP and initial GCS were the only independent predictors of death.ConclusionThe current study highlights that many trauma centers are already initiating circulation first prior to intubation when treating hypovolemic shock (CAB), even in patients with a low GCS. This practice was not associated with an increased mortality. Further prospective investigation is warranted.Trial registrationIRB approval number: HM20006627. Retrospective trial not registered.

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Section: Introductionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Circulation first – the time has come to question the sequencing of care in the ABCs of trauma; an American Association for the Surgery of Trauma multicenter trial

et al. 2018

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“…Whole blood was shown to provide balanced resuscitation much more quickly at a civilian pediatric hospital compared to using components . However, data on the appropriate indications and outcomes of pre‐hospital use of blood products for pediatric patients, specifically for infants, are lacking . While there is no physiologic reason not to use whole blood in children with life‐threatening hemorrhage, the decision to transfuse whole blood to an infant is challenging due to the relative paucity of evidence supporting the use of whole blood for pediatric patients and the lack of specific guidelines for pediatric damage control resuscitation, as well as the decision regarding the volume of LTOWB to transfuse .…”

Section: Discussionmentioning

confidence: 99%

Early experience with transfusing low titer group O whole blood in the pre‐hospital setting in Israel

et al. 2020

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BACKGROUND The Israeli Defense Force Medical Corps (IDF‐MC) recently implemented the use of low titer group O whole blood (LTOWB) in the airborne combat search and rescue unit (CSAR) for both military and civilian patients during transport to definitive care. LTOWB is preferentially used by the CSAR instead of red blood cell units and freeze‐dried plasma (FDP) for patients with signs of hemorrhagic shock. Ten percent of group O donors were eligible to donate LTOWB as they had anti‐A and ‐B IgM titers of <50. METHODS All patients treated by CSAR providers with LTOWB between July 2018 and June 2019 were included. RESULTS Between July 2018 and June 2019, eight patients have received 10 units of LTOWB. All patients suffered blunt injuries, 6 out of 8 (75%) of whom were due to motor vehicle accidents. Four patients (4 out of 8, 50%) received a single LTOWB unit, two patients (2 out of 8, 25%) received two units. Two pediatric patients received fewer than one unit of LTOWB. Median (range) heart rate was 130 (30‐150) bpm, median systolic blood pressure was 107 (80‐124) mmHg, and median Glasgow coma scale was 8 (on a scale of 3‐15). For four (4 out of 8, 50%) patients, LTOWB was the only blood product used for volume resuscitation. All six adult patients were treated with 1 g of tranexamic acid at the point of injury. CONCLUSIONS The CSAR has successfully implemented a LTOWB program for the pre‐hospital treatment of bleeding patients, and as its experience grows this product will be made available to other units and in civilian hospitals.

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“…In a cohort of adult traumatic cardiac arrest patients, Kleber et al report missing or insufficient chest decompression in 37% of the patients with tension pneumothorax [14]. In a retrospective analysis of children injured during the Afghanistan war, Sokol et al found that only 14/95 patients with an indication for pleural decompression received a prehospital intervention [15]. Especially in children, experience of Emergency Medicine Service (EMS) personnel performing needle decompression is scarce, let alone open finger thoracostomy.…”

Section: Discussionmentioning

confidence: 99%

“…Due to publication bias the true rate is most likely clearly higher. In their aforementioned work, Sokol et al report of 16 prehospital pleural decompressions in children, of which 2 (12.5%) were performed without a clear indication [15]. These data show that a false positive diagnosis of tension pneumothorax has to be considered and the risk of injury to intrathoracic vital structures has to be taken into account when choosing the site for needle decompression.…”

Section: Discussionmentioning

confidence: 99%

Chest wall thickness and depth to vital structures in paediatric patients – implications for prehospital needle decompression of tension pneumothorax

Terboven

Leonhard

Wessel

et al. 2019

Scand J Trauma Resusc Emerg Med

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Background Recommendations regarding decompression of tension pneumothorax in small children are scarce and mainly transferred from the adult literature without existing evidence for the paediatric population. This CT-based study evaluates chest wall thickness, width of the intercostal space (ICS) and risk of injury to vital structures by needle decompression in children. Methods Chest wall thickness, width of the intercostal space and depth to vital structures were measured and evaluated at 2nd ICS midclavicular (MCL) line and 4th ICS anterior axillary line (AAL) on both sides of the thorax using computed tomography (CT) in 139 children in three different age groups (0, 5, 10 years). Results Width of the intercostal space was significantly smaller at the 4th ICS compared to the 2nd ICS in all age groups on both sides of the thorax. Chest wall thickness was marginally smaller at the 4th ICS compared to the 2nd ICS in infants and significantly smaller at 4th ICS in children aged 5 years and 10 years. Depth to vital structure for correct angle of needle entry was smaller at the 4th ICS in all age groups on both sides of the thorax. Incorrect angle of needle entry however is accompanied by a higher risk of injury at 2nd ICS. Furthermore, in some children aged 0 and 5 years, the heart or the thymus gland were found directly adjacent to the thoracic wall at 2nd ICS midclavicular line. Conclusion Especially in small children risk of iatrogenic injury to vital structures by needle decompression is considerably high. The 4th ICS AAL offers a smaller chest wall thickness, but the width of the ICS is smaller and the risk of injury to the intercostal vessels and nerve is greater. Deviations from correct angle of entry however are accompanied by higher risk of injury to intrathoracic structures at the 2nd ICS. Furthermore, we found the heart and the thymus gland to be directly adjacent to the thoracic wall at the 2nd ICS MCL in a few children. From our point of view this puncture site can therefore not be recommended for decompression in small children. We therefore recommend 4th ICS AAL as the primary site of choice. Electronic supplementary material The online version of this article (10.1186/s13049-019-0623-5) contains supplementary material, which is available to authorized users.

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Prehospital interventions in severely injured pediatric patients

Abstract: Care management/therapeutic study, level IV.

Cited by 33 publications

References 44 publications

Circulation first – the time has come to question the sequencing of care in the ABCs of trauma; an American Association for the Surgery of Trauma multicenter trial

Circulation first – the time has come to question the sequencing of care in the ABCs of trauma; an American Association for the Surgery of Trauma multicenter trial

Early experience with transfusing low titer group O whole blood in the pre‐hospital setting in Israel

Chest wall thickness and depth to vital structures in paediatric patients – implications for prehospital needle decompression of tension pneumothorax

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