The Pediatric EMS Podcast

jfinney31@gmail.com

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. read less

Breaking Down Silos: Pediatric Disaster Preparation and Management
Oct 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: https://sites.libsyn.com/414020/breaking-down-silos-pediatric-disaster-preparation-and-management   Direct Download: https://traffic.libsyn.com/34eda738-c0e3-471c-94e6-5d7bb718e70f/Episod_3.mp3  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: PreparationCommunicationAdaptationReunificationCaring for respondersQuality ImprovementCaring for survivors Resources for preparing your hospital or agency: The Pediatric Pandemic Network https://pedspandemicnetwork.org/ EIIC Prehospital Emergency Care Coordinators https://emscimprovement.center/collaboratives/pecclc/ The Pediatric Readiness Project https://emscimprovement.center/domains/pediatric-readiness-project/ American Academy of Pediatrics: Disaster Medicine https://www.aap.org/en/patient-care/disasters-and-children/ Resource for Disaster Preparedness https://www.aap.org/en/news-room/aap-voices/pediatric-readiness-for-the-everyday-emergency-and-disasters/ CDC Resource: Caring for Children in a Disaster https://www.cdc.gov/childrenindisasters/index.html 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 https://onlinelibrary.wiley.com/doi/pdf/10.1111/j.1553-2712.2012.01289.x   Talking To Children about Disaster Events: Be proactive, don’t wait for the child to start the conversationWhat is the child’s understanding of the eventAsk what they are feelingExpress supportSeek additional support from counselors and healthcare expertsKeep communication openKnow that healing is a life-long process so support them on their journeyWatch for warning signs of Post-Traumatic Stress Disorder, Anxiety, and Depression Milestone regressionActing outIntroversionBehavioral changes Resource for helping children cope with disasters https://www.cdc.gov/childrenindisasters/helping-children-cope.htmlhttps://kidshealth.org/en/parents/news.html https://extension.psu.edu/programs/betterkidcare/early-care/tip-pages/all/talking-with-children-about-the-news https://www.npr.org/2019/04/24/716704917/when-the-news-is-scary-what-to-say-to-kidshttps://www.apa.org/topics/journalism-facts/talking-childrenPodcast https://podcasts.google.com/feed/aHR0cHM6Ly9wb2RjYXN0cy52cHIubmV0L2J1dC13aHk/episode/cHJ4XzMyNl80YjQ2NGMwNy1mODcyLTRlYmQtOTZjNy1kOWU4YWVhNTA1YWQ?hl=en&ved=2ahUKEwj_iciylNT6AhVwLkQIHf_jA6sQjrkEegQICBAF&ep=6
Your Hand is Their Heart
Jul 23 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: https://sites.libsyn.com/414020/your-hand-is-their-heart Direct Download: https://traffic.libsyn.com/34eda738-c0e3-471c-94e6-5d7bb718e70f/Episode_2_FINAL-_POHCA.mp3   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 CPRPEA/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 https://emscimprovement.center/domains/pediatric-readiness-project/readiness-toolkit/   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 https://www.heart.org/?s_src=22U5W1AEMG&s_subsrc=evg_sem&gclid=Cj0KCQjwuO6WBhDLARIsAIdeyDIcTX32jP4p9AfuoAzx-GL5li7mtInhOxkeeopw1t-ahn4tqjG40acaAl0tEALw_wcB&gclsrc=aw.ds   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 (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   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 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​​​​​
Ouch-less Pediatrics
May 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! https://nasemso.org/projects/model-ems-clinical-guidelines/ 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.   https://emscimprovement.center/education-and-resources/toolkits/pediatric-pain-management-toolkit/   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 included63% male48% African AmericanMedian age 6yo72% fracture in upper arm, 77% sent home   Outcome: 28% received no pain medicationMedian time to document a pain score was 6 minutesPain medication order time was 63 minutes87 minutes to time of administration of pain medicationsFactors related to undertreatment African American childrenPublic insuranceSingle fracturePOV arrival to ED Factors related to faster treatment Arriving when ED is busierPrivate insuranceLower extremity fractureEMS 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   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.  Only 29.5% had pain documented as a symptomSignificantly 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 > 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:   What: Updated pain protocols and implemented mandatory CE   Outcome: No improvement after implementation of evidence-based guidelines for managing pain3600 pre and 3700 post interventionOpioid 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 capabilityNo 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 availableIV 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 appropriateIV ketamine or IV opioids for initial pain management prehospital is appropriateIf IV opioids are selected for prehospital pain management, Morphine or fentanyl are preferredAvoid 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 opioidsIf 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 km@emscimprovement.center 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 fuEducational Module on Prehospital Pain Management in Children (Targeted Issues Grant): http://www.youtube.com/watch?v=Tn3MF_4-9iQ&feature=youtu.beLorin 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