1. 2003Oklahoma EMSC Resource Center0 Pediatric Trauma And Triage Overview of the Problem and Necessary Care for Positive Outcomes… Presented by: Jim Morehead, BS, NREMT-P

2. 2003Oklahoma EMSC Resource Center1 OBJECTIVES Increase awareness of issues specific to children & trauma. Increase awareness of issues specific to children & trauma. Improve pediatric trauma Assessment & Intervention skills. Improve pediatric trauma Assessment & Intervention skills. Identify Mechanisms of Injury & key Assessment components Identify Mechanisms of Injury & key Assessment components Recognize differences btw adult & child priorities Recognize differences btw adult & child priorities Identify & avoid common errors in the pediatric trauma care Identify & avoid common errors in the pediatric trauma care Provide appropriate interventions Provide appropriate interventions

3. 2003Oklahoma EMSC Resource Center2 NATURE OF BEAST Pediatrics account for 15-25% of total emergent care patients. Pediatrics account for 15-25% of total emergent care patients. Trauma is approximately 50% of all pediatric emergencies Trauma is approximately 50% of all pediatric emergencies Usually > 2 years old Usually > 2 years old More medical cases < 2 years old More medical cases < 2 years old Injury is the leading cause of death in children Injury is the leading cause of death in children MVC = 50% MVC = 50%

4. 2003Oklahoma EMSC Resource Center3 NATURE OF BEAST contd Almost 70% of major pediatric trauma cases die due to severity of injury. Almost 70% of major pediatric trauma cases die due to severity of injury. NOT a deficit in emergent care NOT a deficit in emergent care When a child is injured, the whole family is injured too! When a child is injured, the whole family is injured too! > 40% divorce rate within 1 year after a major trauma > 40% divorce rate within 1 year after a major trauma

5. 2003Oklahoma EMSC Resource Center4 Clinical Pearls

6. 2003Oklahoma EMSC Resource Center5 Consider Possibility of Child Abuse When you see an injured child Common cause of injuries in children. Common cause of injuries in children. 50% of second hospital visits for these children result in death 50% of second hospital visits for these children result in death Awareness of signs & symptoms of abuse helps identify cases Awareness of signs & symptoms of abuse helps identify cases

7. 2003Oklahoma EMSC Resource Center6 General Principles of Pediatric Trauma Priorities are similar to adults Priorities are similar to adults All roads lead to the A-B-C (D-E)s All roads lead to the A-B-C (D-E)s Start with A, not the most obvious Start with A, not the most obvious Children have certain key differences Children have certain key differences Different energy transfer due to size Different energy transfer due to size Metabolism Metabolism Ability to respond to words & give history Ability to respond to words & give history History of accident may be critical in determining intervention plan History of accident may be critical in determining intervention plan

8. 2003Oklahoma EMSC Resource Center7 Physical Differences HEAD Is Larger HEAD Is Larger Brain injury increased during impactsBrain injury increased during impacts More leverage on neckMore leverage on neck Occiput forces neck into flexion while lying flatOcciput forces neck into flexion while lying flat Airway tends to buckle & close on adult spine board without proper shoulder support Airway tends to buckle & close on adult spine board without proper shoulder support NECK Is Shorter NECK Is Shorter Causes different injury patterns Causes different injury patterns C2-C4 more common injuries C2-C4 more common injuries

9. 2003Oklahoma EMSC Resource Center8 Physical Differences contd CHEST More Pliable CHEST More Pliable Pulmonary contusion more likely Pulmonary contusion more likely Diaphragm motion essential for ventilation Diaphragm motion essential for ventilation Energy transmitted to chest organs Energy transmitted to chest organs ABDOMINAL ORGANS Less Protection ABDOMINAL ORGANS Less Protection Liver not covered by the rib cage Liver not covered by the rib cage Less abdominal wall muscle mass Less abdominal wall muscle mass Less Sub-Q tissue to absorb energy Less Sub-Q tissue to absorb energy

10. 2003Oklahoma EMSC Resource Center9 Energy Transfer Effects of Size Children are Smaller Children are Smaller More force per square inch of body More force per square inch of body Organs are closer together=multi-system injury rule Organs are closer together=multi-system injury rule Children are Softer (More Flexible / Bouncy) Children are Softer (More Flexible / Bouncy) Bones dont break but instead pass on energy Bones dont break but instead pass on energy Internal organ damage without fractures is more common Internal organ damage without fractures is more common Larger Surface Area to Size Ratio Larger Surface Area to Size Ratio Lose heat more rapidly Lose heat more rapidly

11. 2003Oklahoma EMSC Resource Center10 Metabolic Differences in Kids Have Higher Metabolic Rates Have Higher Metabolic Rates Nearly Twice as Rapid O 2 Consumption Nearly Twice as Rapid O 2 Consumption Increased Blood Flow Increased Blood Flow More Frequent Feedings More Frequent Feedings More Fluid Intake per Size Ratio More Fluid Intake per Size Ratio

12. 2003Oklahoma EMSC Resource Center11 Metabolic Differences contd Children SHOCK OUT Differently Children SHOCK OUT Differently Children Compensate Better INITIALLY Children Compensate Better INITIALLY May show minimal signs & symptoms May show minimal signs & symptoms Children have less reserves than adults Children have less reserves than adults Platinum Half-Hour in Trauma Resuscitation Platinum Half-Hour in Trauma Resuscitation Rapid Intervention Critical Rapid Intervention Critical Once Reserves Exhausted Once Reserves Exhausted BAD THINGS HAPPEN!!!

13. 2003Oklahoma EMSC Resource Center12 THE BAD THINGS Decompensation can be rapid Decompensation can be rapid A conscious, crying child can become pulseless and apneic in less than 2 minutes A conscious, crying child can become pulseless and apneic in less than 2 minutes Once decompensated, may be too late Once decompensated, may be too late Limited Reserves are gone; whole system collapses Limited Reserves are gone; whole system collapses RAPID & EARLY RECOGNITION & INTERVENTION ARE CRITICAL!!!

14. 2003Oklahoma EMSC Resource Center13 ASSESSMENT For Survival

15. 2003Oklahoma EMSC Resource Center14 Safety First Bodily Substance Isolation Bodily Substance Isolation Potential Hazards on, around, or with Patient Potential Hazards on, around, or with Patient Available Resources Available Resources

16. 2003Oklahoma EMSC Resource Center15 Prepare Yourself The first step in a cardiac arrest or other critical situation is to: The first step in a cardiac arrest or other critical situation is to: Take your own pulse!!! Assign roles ahead of time Assign roles ahead of time Respiratory Management Respiratory Management Spine Management Spine Management Circulatory Management Circulatory Management Hx, Equipment, etc. Hx, Equipment, etc.

17. 2003Oklahoma EMSC Resource Center16 Careful Attention Initial Assessment CRUCIAL Dont be distracted by the blood and screams A QUIET KID SHOULD SCARE the @$% of YOU!!! If practical, keep parents with child to help reduce child's fear Lots of blood Cant breathe crying Fxs Everyone scared Quiet Uncon.

18. 2003Oklahoma EMSC Resource Center17 Clinical Pearls

19. 2003Oklahoma EMSC Resource Center18 Brilliance vs. Basics For every BRILLIANT maneuver/diagnosis you make which saves a life, youll save 10 by just doing a good, solid job. STAY FOCUSED ON THE BASICS IN THE HEAT OF THE MOMENT!!!

20. 2003Oklahoma EMSC Resource Center19 Consider MOI Mechanism Of Injury

21. 2003Oklahoma EMSC Resource Center20 Clinical Pearls

22. 2003Oklahoma EMSC Resource Center21 Remember s Proper basic airway management is often performed inadequately if at all, apparently due to fear and panic. Proper basic airway management is often performed inadequately if at all, apparently due to fear and panic. Theodore M. Barnett, M.D. Children's Mercy Hospital, Kansas City, MO

23. 2003Oklahoma EMSC Resource Center22 Pediatric Assessment Triangle AppearanceWork of Breathing Circulation to Skin

24. 2003Oklahoma EMSC Resource Center23 Appearance Look at the patient from a slight distance - What do you see? Look at the patient from a slight distance - What do you see? Mental Status Mental Status Color Color Interaction / Movement Interaction / Movement Recognition Recognition STOP

25. 2003Oklahoma EMSC Resource Center24 Remember A Quiet Kid is one that should, SCARE You!!!

26. 2003Oklahoma EMSC Resource Center25 Respiratory AIRWAY: Patent with Precautions AIRWAY: Patent with Precautions BREATHING: Respiratory Rate; too fast vs too slow, Abnormal Sounds BREATHING: Respiratory Rate; too fast vs too slow, Abnormal Sounds A slow or irregular respiratory rate in a child is an OMINOUS SIGN. (Bad JU JU) A slow or irregular respiratory rate in a child is an OMINOUS SIGN. (Bad JU JU) Watch for the EFFORT NEEDED to BREATHE Watch for the EFFORT NEEDED to BREATHE Chest, neck, or abdominal muscle retractions Chest, neck, or abdominal muscle retractions Flaring of the nostrils Flaring of the nostrils Adventitious Sounds -Crackles, Crows, Grunts (Rice Krispies, Rosters, Pigs) Adventitious Sounds -Crackles, Crows, Grunts (Rice Krispies, Rosters, Pigs)

27. 2003Oklahoma EMSC Resource Center26 A=Airway: Control C-Spine Unconscious kids cant protect their airway Unconscious kids cant protect their airway Tongue most common obstruction Tongue most common obstruction Little airways are easily blocked Little airways are easily blocked JAW THRUST: Neutral Alignment for kids includes Pad under the Shoulders JAW THRUST: Neutral Alignment for kids includes Pad under the Shoulders May need Oral/Nasal Airway May need Oral/Nasal Airway Infants in first 30 days of life are obligate nasal breathers Infants in first 30 days of life are obligate nasal breathers May need to suction out blood/mucus May need to suction out blood/mucus

28. 2003Oklahoma EMSC Resource Center27 B=Breathing All Children get Oxygen & LOTS OF IT All Children get Oxygen & LOTS OF IT May need to assist with B-V-M May need to assist with B-V-M Good mask seal is the KEY to bagging Good mask seal is the KEY to bagging Two people should bag when possible Two people should bag when possible Avoid distending the stomach Avoid distending the stomach Cricoid pressure / Easy does it Cricoid pressure / Easy does it Distended stomach = less room for air in lungs Distended stomach = less room for air in lungs Blue BAD - Oxygen GOOD

29. 2003Oklahoma EMSC Resource Center28 C=Circulation: Peripheral vs Central Pulse Pulse Color, Temperature, Texture of Skin Color, Temperature, Texture of Skin CAPILLARY REFILL CAPILLARY REFILL < 2 seconds GOOD NEWS < 2 seconds GOOD NEWS 2-4 seconds WATCH OUT 2-4 seconds WATCH OUT > 4 seconds > 4 seconds DEEP DOODOO NOW!!!

30. 2003Oklahoma EMSC Resource Center29 Clinical Pearls

31. 2003Oklahoma EMSC Resource Center30 Pediatric Trauma Messages 1. A little bleeding is a lot the smaller you are. 2. BP often maintained until very late in hemorrhage by young patients because of their overactive vasoconstrictive responses. Tom Terndrup, MD Director of Pediatric Emergency Medicine Director of Pediatric Emergency Medicine University Hospital / Syracuse, N.Y. University Hospital / Syracuse, N.Y.

32. 2003Oklahoma EMSC Resource Center31 D=Disability: Neuro Eval Use the AVPU system firstUse the AVPU system first –Avoid "lethargic, "semi-conscious, etc. because everyone has different meanings with these terms. Use the Pediatric Glasgow Coma ScaleUse the Pediatric Glasgow Coma Scale –If time and circumstance permit –Age and behavior adjusted TBIs need adequate oxygen ! TBIs need adequate oxygen ! Hyperventilate only if they deteriorate Hyperventilate only if they deteriorate Otherwise High Flow O 2 Otherwise High Flow O 2

33. 2003Oklahoma EMSC Resource Center32 E=Exposure Kids lose heat quicklyKids lose heat quickly Keep them COVERED UPKeep them COVERED UP Expose only as you needExpose only as you need If YOU are COMFORTABLE, its probably TOO COLD for themIf YOU are COMFORTABLE, its probably TOO COLD for them

34. 2003Oklahoma EMSC Resource Center33 S-A-M-P-L-E Hx S=Signs and SymptomsS=Signs and Symptoms A=AllergiesA=Allergies M=Medications currently takenM=Medications currently taken P=Pertinent Past/ Present IllnessesP=Pertinent Past/ Present Illnesses L=Last MealL=Last Meal E=Events/environment related to the injuryE=Events/environment related to the injury

35. 2003Oklahoma EMSC Resource Center34 Positive Outcomes Resulting from early & rapid recognition, assessment, & management of shock…

36. 2003Oklahoma EMSC Resource Center35 Pediatric Trauma Score (PTS) All components are scored: All components are scored: +2 +2 +1 +1 -1 -1 Total score can range Total score can range +12, the best +12, the best - 6, the worst - 6, the worst The threshold score is 8 The threshold score is 8 Anyone scoring < 8 send to Pediatric Trauma Center Anyone scoring < 8 send to Pediatric Trauma Center

37. 2003Oklahoma EMSC Resource Center36 PTS Components SIZESIZE –The most obvious of all the components –Automatically weights the infant-toddler due to increased mortality associated to their smaller size AIRWAYAIRWAY –Assesses functionability and management parameters –The more toys it takes, the lower the score

38. 2003Oklahoma EMSC Resource Center37 PTS Components contd SYSTOLIC B/P: Weighted to find the evolving shock patient (50-90 mmHg). SYSTOLIC B/P: Weighted to find the evolving shock patient (50-90 mmHg). New DOT EMT Basic uses capillary refill as an indicator of cardiovascular status. New DOT EMT Basic uses capillary refill as an indicator of cardiovascular status. 4 sec 4 sec Central vs Peripheral Central vs Peripheral PALS recommends use of peripheral and central pulses as an indicator PALS recommends use of peripheral and central pulses as an indicator

39. 2003Oklahoma EMSC Resource Center38 PTS Components contd MENTAL STATUSMENTAL STATUS –Any change in Mental Status warrants a lower score SOFT TISSUE INJURYSOFT TISSUE INJURY –Surface Area / Volume Issue MUSCULO-SKELETAL INJURY/FXMUSCULO-SKELETAL INJURY/FX –High incidence in kids –Energy transmission instead of localized fracture MULTI-SYSTEMS TRAUMA IS RULE

40. 2003Oklahoma EMSC Resource Center39 Recognizing Signs of Shock Early signs can be subtle Early signs can be subtle May be minimal signs with under 20% blood loss May be minimal signs with under 20% blood loss 50% and over blood loss usually pulseless and unconscious (Read as DEAD) 50% and over blood loss usually pulseless and unconscious (Read as DEAD) Any injured kid who is Cool & Tachycardic is in SHOCK until proven otherwise!!! Any injured kid who is Cool & Tachycardic is in SHOCK until proven otherwise!!!

41. 2003Oklahoma EMSC Resource Center40 Shock Recognition contd Altered mental status may be first sign of shock Altered mental status may be first sign of shock Another early sign is DELAYED CAPILLARY REFILL Another early sign is DELAYED CAPILLARY REFILL Next comes a decrease in pulse pressure Next comes a decrease in pulse pressure Systolic minus Diastolic Systolic minus Diastolic Drop in Blood Pressure is a LATE SIGN Drop in Blood Pressure is a LATE SIGN Systolic should be > [ 70 + 2(age in years)] but it rarely falls below this until 25-30% blood loss Systolic should be > [ 70 + 2(age in years)] but it rarely falls below this until 25-30% blood loss

42. 2003Oklahoma EMSC Resource Center41 Shock Recognition contd Anxiety, fear, and cold weather can all mimic early shock Anxiety, fear, and cold weather can all mimic early shock Increased heart rate Increased heart rate Decreased capillary refill Decreased capillary refill Pale, cool extremities Pale, cool extremities Weak peripheral pulses Weak peripheral pulses History alone can be a good enough reason History alone can be a good enough reason Remember the MOI Remember the MOI

43. 2003Oklahoma EMSC Resource Center42 Shock Intervention O 2 (shoot the juice) O 2 (shoot the juice) Protection Protection Spinal Stabilization/Immobilization Spinal Stabilization/Immobilization Preserve Body Temperature Preserve Body Temperature Hemorrhage Control Hemorrhage Control Volume Replacement Volume Replacement Crystalloids (NS/LR) 20 mL/kg Crystalloids (NS/LR) 20 mL/kg Length-Based Resuscitation Tape Length-Based Resuscitation Tape

44. 2003Oklahoma EMSC Resource Center43 Clinical Pearls

45. 2003Oklahoma EMSC Resource Center44 Infant Transport by EMS Keep infants in car seats unless treatment of injuries requires removal (IV, ETT, BVM, control of hemorrhage). If they survived the crash in an intact car seat, they are usually better off to stay in it for the ride to the hospital.Keep infants in car seats unless treatment of injuries requires removal (IV, ETT, BVM, control of hemorrhage). If they survived the crash in an intact car seat, they are usually better off to stay in it for the ride to the hospital. William E. Hauda, II, MD Pediatric Emergency Medicine Fellow Attending Emergency Medicine Physician Fairfax Hospital, Falls Church, VA

46. 2003Oklahoma EMSC Resource Center45 Trauma Management Kids are large headed and may have cervical spine injury without evidence Kids are large headed and may have cervical spine injury without evidence Ideal immobilization is a hard collar, spine board with pads & head-straps. Ideal immobilization is a hard collar, spine board with pads & head-straps. TBIs need adequate oxygen! TBIs need adequate oxygen! Hyperventilate only if they deteriorate Hyperventilate only if they deteriorate Otherwise High Flow O 2 Otherwise High Flow O 2

47. 2003Oklahoma EMSC Resource Center46 Pediatric Trauma Triage Identifying a possible tool to accomplish task…

48. 2003Oklahoma EMSC Resource Center47 Pediatric Problems in Triage Children often not triaged as well as adults in traumatic MCIsChildren often not triaged as well as adults in traumatic MCIs Currently no published or widely utilized Multi- Casualty Triage Tools that take into account physiology differences between children & adultsCurrently no published or widely utilized Multi- Casualty Triage Tools that take into account physiology differences between children & adults

49. 2003Oklahoma EMSC Resource Center48 Triage Problems contd Pediatric Multi-Casualty triage may be affected by the emotional states of providersPediatric Multi-Casualty triage may be affected by the emotional states of providers May be tendencies to upgrade triage categories out of compassion or lack of confidence in pediatric assessment & intervention skillsMay be tendencies to upgrade triage categories out of compassion or lack of confidence in pediatric assessment & intervention skills

50. 2003Oklahoma EMSC Resource Center49 May 3, 1999

51. 2003Oklahoma EMSC Resource Center50 May 3, 1999 contd

52. 2003Oklahoma EMSC Resource Center51 Multi-Casualty Triage Goal To do the BEST for the MOST with the LEAST.

53. 2003Oklahoma EMSC Resource Center52 Simple Triage And Rapid Tx Triage categories Triage categories Green (ambulatory) Green (ambulatory) Red (immediate) Red (immediate) Yellow (delayed) Yellow (delayed) Black (dead or non-salvageable) Black (dead or non-salvageable) Components of Assessment Components of Assessment Ambulation Ambulation Respirations Respirations Perfusion Perfusion Mental status Mental status

54. 2003Oklahoma EMSC Resource Center53 START Triage RESPIRATIONS NO YES Non- salvageable Immediate Position Airway NOYES Over 30/min Immediate Under 30/min PERFUSION Radial Pulse Absent Control Bleeding Immediate Radial Pulse Present MENTAL STATUS Failure to follow simple commands Can follow simple commands ImmediateDelayed

55. 2003Oklahoma EMSC Resource Center54 Pediatric Problems with START Apneic child more likely to have a primary respiratory problem than adult Apneic child more likely to have a primary respiratory problem than adult Perfusion may be maintained for a short time & child may be salvageable Perfusion may be maintained for a short time & child may be salvageable RR +/- 30 may either over-triage or under-triage a child, depending on age RR +/- 30 may either over-triage or under-triage a child, depending on age

56. 2003Oklahoma EMSC Resource Center55 Problems with START contd Capillary refill may not adequately reflect peripheral hemodynamic status in a cool environment Capillary refill may not adequately reflect peripheral hemodynamic status in a cool environment In fact START has changed to reflect peripheral pulse checks instead of cap refill In fact START has changed to reflect peripheral pulse checks instead of cap refill Obeying commands may not be an appropriate gauge of mental status for younger children Obeying commands may not be an appropriate gauge of mental status for younger children

57. 2003Oklahoma EMSC Resource Center56 JUMPSTART Goals Modify an existing tool for use with children Modify an existing tool for use with children Utilize decision points that are flexible enough to serve children of all ages & reflective of the unique points of pediatric physiology Utilize decision points that are flexible enough to serve children of all ages & reflective of the unique points of pediatric physiology Reduce over- and under-triage Reduce over- and under-triage Accomplish triage for most patients within 15 second/pt goal Accomplish triage for most patients within 15 second/pt goal

58. 2003Oklahoma EMSC Resource Center57 The JumpSTART Field Pediatric Multi-Casualty Triage System © (Patients aged 1- 8 years) Black = Deceased/expectant Red = Immediate Yellow = Delayed Green = Minor/Ambulatory Identify and direct all ambulatory patients to designated Green area for secondary triage and treatment. Begin assessment of nonambulatory patients as you come to them. Proceed as below: Spontaneous respirations? NO Open airway Spontaneous respirations? YES IMMEDIATE NO DECEASED YES Peripheral pulse? YES Perform 15 sec. Mouth to Mask Ventilations Spontaneous respirations? YES IMMEDIATE NO DECEASED NO Check resp. rate < 15/min or > 40/min or irregular IMMEDIATE 15 - 40/ min, regular Peripheral pulse? NO IMMEDIATE YES Check mental status (AVPU) A V P (appropriate) DELAYED P (inappropriate) U IMMEDIATE MINOR © Lou Romig 1995

59. 2003Oklahoma EMSC Resource Center58 JUMPSTART Age Ages 1-8 years chosen Ages 1-8 years chosen <1 year of age is less likely to be ambulatory <1 year of age is less likely to be ambulatory – These children can be triaged using JUMPSTART but should be fully screened – If all DELAYED criteria satisfied & without significant external injuries, the child may be classified as AMBULATORY Pertinent pediatric physiology (specifically airway) approaches that of adults by approximately eight years of age Pertinent pediatric physiology (specifically airway) approaches that of adults by approximately eight years of age

60. 2003Oklahoma EMSC Resource Center59 JUMPSTART Ambulatory Identify & direct all ambulatory patients to designated GREEN area for secondary triage & treatmentIdentify & direct all ambulatory patients to designated GREEN area for secondary triage & treatment Begin assessment of non-ambulatory patients as you come to themBegin assessment of non-ambulatory patients as you come to them

61. 2003Oklahoma EMSC Resource Center60 JUMPSTART Breathing If breathing spontaneously, go on to the next step, assessing respiratory rateIf breathing spontaneously, go on to the next step, assessing respiratory rate If apneic or with very irregular breathing, open the airway using standard positioning techniquesIf apneic or with very irregular breathing, open the airway using standard positioning techniques If positioning results in resumption of spontaneous respirations, tag the patient IMMEDIATE & move onIf positioning results in resumption of spontaneous respirations, tag the patient IMMEDIATE & move on

62. 2003Oklahoma EMSC Resource Center61 JUMPSTART Part If no breathing after airway open, check peripheral pulseIf no breathing after airway open, check peripheral pulse –If no pulse, move on after tagging patient –If no pulse, move on after tagging patient DECEASED/NONSALVAGEABLE If peripheral pulse present, give 15 sec of Mouth-to-Mask ventilations (about 5 breaths)If peripheral pulse present, give 15 sec of Mouth-to-Mask ventilations (about 5 breaths) –If apnea persists, move on after tagging patient –If apnea persists, move on after tagging patient DECEASED/NONSALVAGEABLE If breathing resumes after JUMPSTART, tag patient IMMEDIATE & move onIf breathing resumes after JUMPSTART, tag patient IMMEDIATE & move on

63. 2003Oklahoma EMSC Resource Center62 JUMPSTART Respiratory Rate If respiratory rate is 15-40/min (1 breath every 2-4 sec) assess perfusion If respiratory rate is 15-40/min (1 breath every 2-4 sec) assess perfusion If respiratory rate is 40/min ( 1 breath every 2 sec) or irregular, tag patient as IMMEDIATE & move on If respiratory rate is 40/min ( 1 breath every 2 sec) or irregular, tag patient as IMMEDIATE & move on

64. 2003Oklahoma EMSC Resource Center63 JUMPSTART Perfusion If palpable peripheral pulse, proceed to assess mental status If palpable peripheral pulse, proceed to assess mental status If no peripheral pulse present (in the least injured limb), tag patient IMMEDIATE & move on If no peripheral pulse present (in the least injured limb), tag patient IMMEDIATE & move on

65. 2003Oklahoma EMSC Resource Center64 JUMPSTART Mental Status Use AVPU scale to assessUse AVPU scale to assess If Alert, responsive to Verbal, or appropriately responsive to Pain, tag as DELAYED and move onIf Alert, responsive to Verbal, or appropriately responsive to Pain, tag as DELAYED and move on If inappropriately responsive to Pain or Unresponsive, tag as IMMEDIATE & move onIf inappropriately responsive to Pain or Unresponsive, tag as IMMEDIATE & move on

66. 2003Oklahoma EMSC Resource Center65 START/JUMPSTART Similarities As soon as a definitive triage category determined further assessment STOPS As soon as a definitive triage category determined further assessment STOPS Ambulatory patients are immediately moved away for secondary triage Ambulatory patients are immediately moved away for secondary triage To be in the DELAYED category pts must have adequate respirations & perfusion & mental status that is unlikely to compromise the airway To be in the DELAYED category pts must have adequate respirations & perfusion & mental status that is unlikely to compromise the airway

67. 2003Oklahoma EMSC Resource Center66 START/JUMPSTART Differences Apneic children are rapidly assessed for sustained circulation Apneic children are rapidly assessed for sustained circulation Apneic children with circulation receive a brief ventilatory trial as an additional airway opening & stimulating maneuver Apneic children with circulation receive a brief ventilatory trial as an additional airway opening & stimulating maneuver Respiratory rates are adjusted Respiratory rates are adjusted Peripheral pulse is substituted for Cap Refill Peripheral pulse is substituted for Cap Refill This is now done in START too This is now done in START too AVPU is used to assess mental status AVPU is used to assess mental status

68. 2003Oklahoma EMSC Resource Center67 POTENTIALJUMPSTARTDISADVANTAGES

69. 2003Oklahoma EMSC Resource Center68 Disadvantages Extra steps for apneic children add time to the triage process Extra steps for apneic children add time to the triage process Mouth-to-Mask ventilation increases the risk of cross-contamination between patients Mouth-to-Mask ventilation increases the risk of cross-contamination between patients Additional equipment must be carried by triage personnel Additional equipment must be carried by triage personnel TOO COMPLICATED TOO COMPLICATED NO PROOF IT WILL WORK NO PROOF IT WILL WORK

70. 2003Oklahoma EMSC Resource Center69 POTENTIALJUMPSTARTADVANTAGES

71. 2003Oklahoma EMSC Resource Center70 Advantages Provides rapid triage system specifically designed for children, taking into consideration their unique physiology Provides rapid triage system specifically designed for children, taking into consideration their unique physiology Algorithm modified from an existing system widely accepted for adult triage Algorithm modified from an existing system widely accepted for adult triage For most patients, triage can be accomplished within the 15 sec goal For most patients, triage can be accomplished within the 15 sec goal

72. 2003Oklahoma EMSC Resource Center71 Advantages contd Objective criteria for children will help eliminate role of emotions in triage process Objective criteria for children will help eliminate role of emotions in triage process Objective criteria will provide emotional support for personnel forced to make life or death decisions for children in the MCI setting Objective criteria will provide emotional support for personnel forced to make life or death decisions for children in the MCI setting

73. 2003Oklahoma EMSC Resource Center72 Transport Decisions Oklahoma s Trauma Triage and Transport Guidelines

74. 2003Oklahoma EMSC Resource Center73 Air Medical Services MEDIFLIGHT OF OKLAHOMA 1-800-522-0212 1-800-522-0212 AIR EVAC LIFE TEAM 1-918-426-4081 1-918-426-4081 TULSA LIFE FLIGHT 1-888-4TRAUMA 1-888-4TRAUMAEAGLEMED 1-800-525-5220 1-800-525-5220

75. 2003Oklahoma EMSC Resource Center74 Pediatric Special Care Facilities Childrens Hospital at OU Med Center, OKC (405) 271- 4876 University Hospital at OU Med Center, OKC University Hospital at OU Med Center, OKC (405) 271- 4363 Childrens Center of St. Francis Hospital, Tulsa (918) 584-5433

76. 2003Oklahoma EMSC Resource Center75 Summary The more critical the patient, the more important it is to focus on the basicsThe more critical the patient, the more important it is to focus on the basics IN ORDER IN ORDER Rapid Recognition & Intervention for Shock Rapid Recognition & Intervention for Shock Airway Airway Oxygen Oxygen Proper Immobilization Proper Immobilization Keep Warm Keep Warm Assign roles ahead of timeAssign roles ahead of time

77. 2003Oklahoma EMSC Resource Center76 OK-EMSC Resource Center To Contact Us: Phone: 405-271-3307 Fax: 405-271-2421 e-mail: emsc@ouhsc.edu emsc@ouhsc.edu Web Page: www.oumedicine.com/emsc www.oumedicine.com/emsc