The Pediatric EMS Podcast

Episode: Pediatric Agitation & Behavioral Emergencies

Brought to you by the National Association of EMS Physicians and Missouri Emergency Medical Services for Children (MO-EMSC)

Hosts:

Dr. Joelle Donofrio-Odmann

Dr. Joseph Finney

Website: https://sites.libsyn.com/414020

Guest Experts:

Elizabeth Gallagher, MA, BCBAElizabeth is a Board Certified Behavior Analyst. She now works as a Behavior Specialist at the Autism Discovery Institute and for the Autism Friendly Health System Initiative. She is passionate about training parents and hospital staff on how to better support autistic children.

Abbey Hye, M.A., BCBAAbbey is a board-certified behavior analyst. She has broad training in the implementation of behavioral and developmental interventions for children with autism and other developmental delays. She has a passion for parent coaching and is committed to supporting patients and medical staff to adapt care for neurodivergent youth in the context of hospitalization

Adam Hagar, NRP

Adam is a paramedic at Mehlville Fire Protection District in Saint Louis, Missouri. Adam has over 20 years experience as a prehospital Clinician. Beyond this, he is the father of a 10 year old with autism. Adam combines experience caring for patients with behavioral health emergencies and his lived experience with his son. This unique perspective provides insights and advice that are critical before your next prehospital encounter.

Episode Summary:

Welcome back to the Pediatric EMS Podcast. In this episode, we tackle one of the most challenging and often uncomfortable calls in prehospital care, pediatric agitation and behavioral health emergencies. Joined by paramedic Adam Hagar who brings lived experience as a parent of a child with autism as well as behavioral health specialists Elizabeth Gallagher and Abbey Hye, we explore how EMS clinicians can lead with dignity, slow down, and use patient-centered strategies to safely care for children in crisis.

Guided by the Pediatric Agitation PEAK resource from the Emergency Medical Services for Children Innovation and Improvement Center, we discuss how agitation in children is often multifactorial, with contributors including medical illness, pain, psychiatric conditions, developmental differences, and environmental triggers. We emphasize early recognition and rapid assessment to identify underlying causes such as delirium, hypoxia, intoxication, and communication barriers.

The conversation focuses on first-line, non-pharmacologic strategies, including verbal de-escalation, environmental modification, and caregiver engagement. Special attention is given to neurodivergent children, including those with autism, who may require adapted communication and reduced sensory stimulation.

We also review when pharmacologic interventions may be necessary, reinforcing that medications and restraints should be used only when required for safety and with appropriate monitoring.

This episode highlights a central message: pediatric agitation is best managed through calm, structured, and least-restrictive care, partnering with families to improve safety and outcomes.

Key Takeaways:

• Recognize pediatric agitation as a symptom with diverse underlying causes, including medical, psychiatric, and developmental factors.
• Prioritize non-pharmacologic de-escalation strategies, including calm communication and environmental control.
• Engage caregivers early to identify triggers, communication preferences, and effective calming strategies.
• Adapt care for neurodivergent children, including those with autism, by minimizing sensory stimuli and modifying communication approaches.
• Use medications and restraints only when necessary for safety, following local protocols and with appropriate monitoring.
• Leverage community tools and training programs to improve EMS response to pediatric behavioral health emergencies.

References:

Pediatric Agitation PEAK Toolkit – Emergency Medical Services for Children Innovation and Improvement Center https://emscimprovement.center/education-and-resources/peak/pediatric-agitation/

Improving Emergency Medical Services (EMS) Care for People With Autism in the Prehospital Setting Through Sensory and Communication Aids. PubMed Central

San Diego County Sheriff's Department https://sandiegoca.gov/content/sdc/sheriff/programs/take-me-home.html

San Diego County Sheriff's Department https://www.sdsheriff.gov/community/blue-envelope

Autism-Friendly Health System Initiative | Rady Children's Health

Crisis Prevention Program | Marcus Autism Center

Episode 17: Informed Pediatric Trauma Care: The Compendium

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: https://sites.libsyn.com/414020

Guest Experts:

Mark Cicero, MD

John Lyng, MD

Episode Summary: In this episode, we explore the latest NAEMSP Prehospital Trauma Compendium on Pediatric Severe and Inflicted Trauma, published in Prehospital Emergency Care (2025). Joined by pediatric EMS and trauma experts, we discuss how Emergency Medical Services (EMS) clinicians can improve outcomes for children through evidence-based assessment, early recognition of inflicted injuries, and thoughtful implementation of trauma care protocols.

Listeners will learn how unique pediatric physiology—from airway structure and head-to-body ratio to compensatory shock mechanisms—shapes both injury patterns and treatment priorities in the field. We highlight the use of tools such as the Shock Index Pediatric Age-Adjusted (SIPA) and simplified neurologic assessments (GCS-M, AVPU) to identify high-risk patients early.

The discussion emphasizes critical prehospital priorities: preventing hypoxia and hypotension in children with traumatic brain injury, using crystalloids judiciously, expanding access to prehospital blood transfusion, and ensuring rapid transport to pediatric trauma centers when indicated.

We also address inflicted trauma recognition, including sentinel bruising patterns, mechanisms inconsistent with developmental ability, and the challenges of detection in children with chronic or developmental comorbidities. The conversation underscores the importance of ongoing EMS training, simulation, and the role of Pediatric Emergency Care Coordinators (PECCs) in sustaining readiness across systems.

Through case discussion and review of the Compendium's recommendations, this episode reinforces a central message: prehospital providers are a critical first link in the chain of survival for injured children. From field assessment to destination decisions, every action can profoundly shape outcomes.

Key Takeaways:

• Recognize the physiologic and anatomic nuances that make pediatric trauma unique.

• Use SIPA and simplified GCS assessments to identify severe injury early.

• Prioritize oxygenation, blood pressure, and temperature control to prevent secondary injury.

• Identify and report patterns concerning for inflicted injury.

• Partner with regional systems to ensure appropriate pediatric trauma triage and interfacility transfer.

• Integrate simulation, case review, and continuous pediatric-specific education into EMS training programs.

Reference: Cicero MX, Adelgais K, Funaro MC, et al. Prehospital Trauma Compendium: Pediatric Severe and Inflicted Trauma – A Position Statement and Resource Document of NAEMSP. Prehospital Emergency Care. 2025; DOI: 10.1080/10903127.2025.2457141

Link to FULL Compendium

https://naemsp.org/position-statement/prehospital-trauma-compendium-management-of-geriatric-trauma-patients-a-position-statement-and-resource-document-of-naemsp/

Episode 16 (Short): Prehospital Croup Management

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: https://sites.libsyn.com/414020

Episode Summary

In this SHORT episode, we discuss one of the most common pediatric respiratory emergencies, croup, and what EMS providers need to know during peak viral season. Drawing from real-life experience and current field trends, we review how to recognize upper airway obstruction, differentiate it from lower airway conditions, and manage severe cases prehospitally.

Listeners learn why children's smaller airways make them especially vulnerable to swelling, how to tell croup from foreign body aspiration, and when to escalate care. Join us as we walk through the stepwise management of croup, including:

• Recognizing stridor and assessing severity

• Using nebulized (racemic) epinephrine and dexamethasone effectively

• Knowing when IM epinephrine may be lifesaving

• Avoiding unnecessary albuterol in upper airway disease

• Calming and positioning strategies to minimize distress

We also highlights the Westley Croup Score, a simple clinical tool to grade croup severity based on stridor, retractions, air entry, cyanosis, and level of consciousness — helping EMS providers communicate clearly with receiving teams and guide treatment intensity.

We emphasize timely hospital notification, monitoring for recurrence as nebulized epinephrine wears off, and when to consider admission.

For more examples of respiratory distress and croup symptoms in children, visit: 🔗 KidsHealth NZ – Signs That Children Are Struggling to Breathe

Episode 15: Prehospital Pediatric Traumatic Cardiac Arrest: Priorities for Care

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: https://sites.libsyn.com/414020

GET CEU CREDIT THROUGH PRODIGY EMS

Episode Summary

Episode 15 of the Pediatric EMS Podcast focuses on the case of a pediatric out-of-hospital traumatic cardiac arrest. Dr. Finney and Dr. Romeo Ignacio discuss the unique management priorities for traumatic arrest and how it differs compared to medical cardiac arrest. The episode recounts a real-life incident involving a child struck and pinned under an SUV, detailing the prehospital response, interventions, and decision-making process.

Guest Expert

Romeo Ignacio Jr., MD.

Dr. Romeo Ignacio is the Trauma Medical Director at Rady Children's Hospital and the Section Chief of Pediatric Surgery, affiliated with UC San Diego. A former EMT and a 24-year U.S. Navy veteran, he specializes in pediatric trauma care

Takehome Points

1. Differentiate Between Traumatic and Medical Cardiac Arrest:

   • The approach to traumatic cardiac arrest is distinct from medical arrest, with hemorrhage control and volume resuscitation taking precedence over standard CPR and epinephrine administration.

2. Follow the MARCH Algorithm for Trauma Management:

   • Prioritize Massive hemorrhage, Airway, Respirations, Circulation, and Hypothermia/Head Injury, ensuring a systematic approach to treating the most life-threatening issues first.

3. Blood Products Over Crystalloids for Volume Resuscitation:

   • If available, whole blood or blood products should be used to restore circulation in hemorrhagic shock, as excessive crystalloid fluids can dilute clotting factors and worsen coagulopathy.

4. Minimize On-Scene Time and Focus on Rapid Transport:

   • Definitive care for traumatic cardiac arrest requires hospital-level interventions; therefore, providers should avoid unnecessary scene delays and focus on rapid transport while continuing interventions en route.

5. Avoid the "H-Bombs" in Pediatric Traumatic Brain Injury (TBI):

   • Prevent Hypoxia, Hyperventilation, and Hypotension, as these factors increase mortality in pediatric trauma patients. Controlled ventilation and maintaining adequate oxygenation and perfusion are key to improving outcomes.

THANK YOU

Special Thank you to Monarch Fire Protection District and the amazing paramedics who continue to care for critically ill and injured patients each and every day.

Episode 14: Prehospital Pediatric Termination of Resuscitation (TOR)

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: https://sites.libsyn.com/414020

GET CEU CREDIT THROUGH PRODIGY EMS

Episode Summary: In this episode of the Pediatric EMS Podcast, Dr. Joseph Finney and Dr. Joelle Donofrio-Odmann are joined by Dr. Matt Harris and Dr. Jen Anders to explore groundbreaking developments in pediatric termination of resuscitation (TOR) protocols. Together, they discuss the Maryland Pediatric TOR criteria, insights from the largest pediatric cardiac arrest study to date, and practical strategies for EMS professionals to optimize care and outcomes.

The panel dives deep into the science, ethical considerations, and cultural challenges of TOR, offering actionable guidance for EMS clinicians and medical directors aiming to implement these protocols.

Episode Highlights:

1. Introduction to Pediatric TOR Criteria:

   • Key differences between BLS and ALS TOR protocols.
   • Unique considerations for pediatric medical and traumatic cardiac arrests.

2. Maryland Pediatric TOR Criteria:

   • The specific requirements for TOR in medical and trauma cases.
   • Emphasis on ensuring emotional and community support during field terminations.

3. Key Findings from the ESO Databank Analysis:

   • Analysis of over 1,500 pediatric cardiac arrest cases.
   • High specificity of TOR protocols, especially when excluding drowning cases.
   • The critical role of end-tidal CO2 monitoring in determining outcomes.

4. Exclusion of Drowning Cases:

   • Why drowning victims are not included in TOR protocols due to their high resuscitation and neurologic recovery rates.

5. Cultural Barriers to Pediatric TOR Implementation:

   • Addressing the belief that "everything must be done" for children.
   • Shifting the focus toward high-quality, on-scene resuscitation.

6. Real-World Impact of TOR in Maryland:

   • Adoption of TOR protocols in Maryland since 2020.
   • Improved ROSC and survival rates for pediatric cardiac arrest cases.
   • Collaborative efforts with community stakeholders to support families during TOR events.

7. Practical Guidance for EMS Agencies:

   • Steps to implement pediatric TOR protocols effectively.
   • Importance of education, community engagement, and support systems.

Key Takeaway: Pediatric TOR protocols empower EMS professionals to deliver effective, evidence-based care while prioritizing the well-being of patients, families, and communities. By focusing on data-driven criteria and robust training, EMS teams can confidently navigate these critical, high-stress situations.

Resources:

Harris MI, Crowe RP, Anders J, D'Acunto S, Adelgais KM, Fishe J. Applying a set of termination of resuscitation criteria to paediatric out-of-hospital cardiac arrest. Resuscitation. 2021 Dec;169:175-181. doi: 10.1016/j.resuscitation.2021.09.015. Epub 2021 Sep 20. PMID: 34555488.

Shetty P, Ren Y, Dillon D, Mcleod A, Nishijima D, Taylor SL; CARES Surveillance Group. Derivation of a clinical decision rule for termination of resuscitation in non-traumatic pediatric out-of-hospital cardiac arrest. Resuscitation. 2024 Nov;204:110400. doi: 10.1016/j.resuscitation.2024.110400. Epub 2024 Sep 18. PMID: 39299508.

Study highlights:

• Study Purpose: The study aimed to derive a Pediatric Termination of Resuscitation (PToR) rule for non-traumatic out-of-hospital cardiac arrests (OHCA) in patients under 18 years of age, utilizing data from the CARES database (2013–2022).

• Study Population:

  • Analyzed 21,240 pediatric OHCA cases.
  • 11.0% of patients survived to hospital discharge, and 8.9% survived with favorable neurologic outcomes.

• Criteria Derived: The PToR rule for non-survival to hospital discharge includes:

  • Unwitnessed cardiac arrest.
  • Absence of sustained ROSC (return of spontaneous circulation).
  • Initial rhythm of asystole.
  • Arrest not caused by drowning or electrocution.

• Performance Metrics:

  • Specificity: 99.1%.
  • Positive Predictive Value (PPV): 99.8% for predicting non-survival to hospital discharge.
  • For non-survival or survival with unfavorable neurologic status, specificity was 99.1%, and PPV was 99.8%.

• Significance of Drowning/Electrocution Cases:

  • These etiologies were excluded from PToR due to improved survival outcomes compared to other causes of cardiac arrest.

• Model Validation:

  • The PToR criteria were validated on a test dataset, showing consistent high specificity and PPV.
  • Performance was stable across different age groups (infants, children, and adolescents).

• Comparison with Adult ToR Rules: The PToR criteria shared similarities with adult ToR rules but were tailored to pediatric cases, emphasizing improved predictive accuracy for this population.

• Implications for Practice:

  • The criteria provide a systematic framework to guide prehospital termination of resuscitation for pediatric patients, potentially reducing unnecessary transport and resource use.
  • Adoption may improve decision-making consistency among EMS providers while reducing emotional burden and ethical challenges.

• Limitations:

  • Retrospective design limits causation analysis.
  • Excluded field-terminated cases may have introduced selection bias.
  • ROSC duration criteria may differ from typical EMS practices, necessitating further prospective validation.

• Conclusions: The study offers robust PToR criteria with high specificity and PPV for prehospital decision-making. Future research should focus on prospective validation and understanding the criteria's practical implementation and impact on patient care.

Episode 11: Prehospital Pediatric Respiratory Distress

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: https://sites.libsyn.com/414020

GET CEU CREDIT THROUGH PRODIGY EMS

Content Experts: Joelle Donofrio-Odmann, DO and Joseph Finney, MD

Overview: This podcast episode focuses on pediatric respiratory distress in prehospital settings, providing key insights for EMS providers to assess and manage these cases effectively. Dr. Joelle Donofrio-Odmann emphasizes the importance of recognizing early signs of respiratory failure and understanding pediatric anatomy, which makes young children more vulnerable to airway obstruction. The episode introduces practical tools, such as the Pediatric Assessment Triangle, to differentiate distress from failure and ensure timely interventions.

Highlighted Teaching Points

• Pediatric Respiratory Distress is Common

  • Pediatric calls constitute 12-15% of EMS cases, with respiratory distress being the top reason for calls in children under two years old.

• Anatomy Makes Kids Vulnerable

  • Young children have smaller airways, large heads, and obligate nose-breathing, increasing their risk of obstruction.
  • Minor nasal congestion can cause significant breathing issues, so suctioning the nose is often lifesaving.

• Pediatric Assessment Triangle (PAT)

  • Work of Breathing: Look for signs such as retractions, nasal flaring, tracheal tugging, and head bobbing.
  • Mental Status: Lethargy or a lack of responsiveness indicates a worsening condition.
  • Circulation: Cyanosis, poor perfusion, and pallor signal late stages of respiratory failure.
  • PAT allows providers to identify patients at risk of crashing early and intervene before "all three sides of the triangle fail" (referred to as the Triangle of Death).

• Respiratory Distress Progression

  • Retractions progress from intercostal (mild) to severe patterns like head bobbing and sternal rocking, which indicate respiratory failure.
  • Recognize these signs early to prevent hypoxia, bradycardia, and arrest.

• Common Upper Airway Conditions

  • Croup: Most common cause of stridor; responds well to inhaled epinephrine and steroids.
  • Bacterial Tracheitis: Consider if croup-like symptoms persist despite treatments.
  • Epiglottitis: Rare due to vaccinations but still possible; presents with fever, drooling, and tripod positioning.

• Foreign Body Aspiration

  • Common in toddlers (12-24 months); consider aspiration in recurrent respiratory cases.
  • EMS providers should practice airway maneuvers and foreign body removal techniques with tools like Magill forceps.

• Management and Reassessment

  • Intervene early with oxygen, suction, and positive pressure ventilation as needed.
  • Reassess interventions regularly (e.g., after nasal suctioning or oxygen delivery) to ensure improvement or escalate care.

This episode provides practical, actionable guidance for EMS providers to master pediatric airway management and prevent rapid deterioration in respiratory emergencies.

Check out The Medic Mindset!

https://medicmindset.com/

Resources:

EMSC Innovation and Improvement Center https://emscimprovement.center/

Pediatric Emergency Applied Care Research Network (PECARN)

PEDI-PART

NAEMSP Airway Compendium Position Statement

Check out https://www.prodigyems.com/ and create a free account to access EMSC resources on pediatric respiratory distress and more.

This episode is brought to you by Styker Medical Corporation with their comittment to improving medical education. In this episode we discuss the priorities of pediatric head and cervical spine imagine with the experts in the fields of Pediatric Emergency Medicine and Neurosurgery. Learn from those who know about how to manage your next pediatric patient with traumatic brain injury or cervical spine injury. With TBI a major cause of pediatric death, you don't want to miss this episode with all you need to know.

Rememer:

Avoid the H bombs

• Hypotension (
• Hypoxia (
• Hyperventilation (Goal ETCO2 35-45)

Serious mechanism + LOC:

• 15L NRB
• 1L Bolus (20cc/kg for peds)
• Goal ETCO2 35-45

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: https://sites.libsyn.com/414020/how-to-approach-pediatric-traumatic-brain-injury-the-evidence-and-the-anatomy

GET CEU CREDIT THROUGH PRODIGY EMS

Content Experts: Joelle Donofrio-Odmann, DO and Joseph Finney, MD

Guest Experts:

Joshua B. Gaither, MD, FACEP

Dr. Joshua Gaither is a professor in the Department of Emergency Medicine with fellowship training in Emergency Medical Services (EMS) and Disaster Medicine. He is the EMS Fellowship Director the Medical Director for Tucson Fire Department as well as several EMS training programs. Dr. Gaither also teaches in and is the director for the EMS Degree Program.

Dr. David Gonda

Dr. Gonda is the director of Epilepsy Surgery at Rady Children's Hospital-San Diego and an assistant clinical professor of neurosurgery at UC San Diego School of Medicine. He comes to Rady Children's from Texas Children's Hospital, where he was a pediatric neurosurgery fellow, and Baylor College of Medicine, where he was a clinical instructor. Dr. Gonda completed his residency training at UC San Diego and earned his medical degree at The Ohio State University. Dr. Gonda's clinical areas of expertise are epilepsy surgery, MRI laser thermal ablation surgery, pediatric spine abnormalities and craniovertebral junction abnormalities. His research area of expertise is minimally invasive epilepsy surgery.

Sources:

Association of Statewide Implementation of the Prehospital Traumatic Brain Injury Treatment Guidelines With Patient Survival Following Traumatic Brain Injury: The Excellence in Prehospital Injury Care (EPIC) Study., Spaite, Daniel W., Bobrow Bentley J., Keim Samuel M., Barnhart Bruce, Chikani Vatsal, Gaither Joshua B., Sherrill Duane, Denninghoff Kurt R., Mullins Terry, P Adelson David, et al. , JAMA Surg, 2019 07 01, Volume 154, Issue 7, p.e191152, (2019) In reply., Spaite, Daniel W., Bobrow Bentley J., Gaither Joshua B., and Hu Chengcheng , Ann Emerg Med, 2017 Aug, Volume 70, Issue 2, p.263-264, (2017) Association of Out-of-Hospital Hypotension Depth and Duration With Traumatic Brain Injury Mortality., Spaite, Daniel W., Hu Chengcheng, Bobrow Bentley J., Chikani Vatsal, Barnhart Bruce, Gaither Joshua B., Denninghoff Kurt R., P Adelson David, Keim Samuel M., Viscusi Chad, et al. , Ann Emerg Med, 2017 May 27, (2017) Mortality and Prehospital Blood Pressure in Patients With Major Traumatic Brain Injury: Implications for the Hypotension Threshold., Spaite, Daniel W., Hu Chengcheng, Bobrow Bentley J., Chikani Vatsal, Sherrill Duane, Barnhart Bruce, Gaither Joshua B., Denninghoff Kurt R., Viscusi Chad, Mullins Terry, et al. , JAMA Surg, 2016 Dec 07, (2016) The Effect of Combined Out-of-Hospital Hypotension and Hypoxia on Mortality in Major Traumatic Brain Injury., Spaite, Daniel W., Hu Chengcheng, Bobrow Bentley J., Chikani Vatsal, Barnhart Bruce, Gaither Joshua B., Denninghoff Kurt R., P Adelson David, Keim Samuel M., Viscusi Chad, et al. , Ann Emerg Med, 2016 Sep 27, (2016) The Effect of Combined Out-of-Hospital Hypotension and Hypoxia on Mortality in Major Traumatic Brain Injury, Spaite, Daniel W., Hu Chengcheng, Bobrow Bentley J., Chikani Vatsal, Barnhart Bruce, Gaither Joshua B., Denninghoff Kurt R., P. Adelson David, Keim Samuel M., Viscusi Chad, et al. , Annals of Emergency Medicine, Jan-09-2016, (2016) Lulla A, Lumba-Brown A, Totten AM, Maher PJ, Badjatia N, Bell R, Donayri CTJ, Fallat ME, Hawryluk GWJ, Goldberg SA, Hennes HMA, Ignell SP, Ghajar J, Krzyzaniak BP, Lerner EB, Nishijima D, Schleien C, Shackelford S, Swartz E, Wright DW, Zhang R, Jagoda A, Bobrow BJ. Prehospital Guidelines for the Management of Traumatic Brain Injury - 3rd Edition. Prehosp Emerg Care. 2023;27(5):507-538. doi: 10.1080/10903127.2023.2187905. Epub 2023 Apr 20. PMID: 37079803.

This series is a collaboration with the EMS for Children Innovation and Improvement Center (EIIC) and will be part of the pre-hospital resources for its Pediatric Education and Advocacy Kit (PEAK) for multisystem trauma. Click on the link to learn more! https://emscimprovement.center/education-and-resources/peak/.

In this episode we kick off a multipart series on pediatric trauma just in time for summer and trauma season. Join your two hosts as they tackle the prehospital management of pediatric trauma. Everything from head to toe and the pathophysiology that makes pediatric trauma unique from the adult population. Below are the episode talking points you don't want to miss.

Objectives

• Assess the current landscape of pediatric trauma.
• Recognize the physiologic differences between adults and children in trauma.
• Evaluate how the mechanism of injury informs the management.
• Analyze how to approach a pediatric trauma patient.
• Summary and take-home points.

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: https://sites.libsyn.com/414020

GET CEU CREDIT THROUGH PRODIGY EMS

Content Experts: Joelle Donofrio-Odmann, DO and Joseph Finney, MD

Pediatric Assessment Triangle

The Changing Landscape of Traumatic Pediatric Death

Goldstick, 2022

Trimodal Distribution of Death

From McLaughlin et al, 2017:

74% of pediatric deaths age 1-14y were in first 24 hours. Of children who die from traumatic injuries, most die within 24 hours of arriving to the hospital. When compared to adult trauma patients, children are more likely to die in the emergency department (ED) rather than surviving long enough for hospital admission or transfer to the operating room.

Where you are treated matters

Theodorou et al in 2021 reviewed over 7000 pediatric trauma admissions and found, of the 134 patients who died, Traumatic brain injury was the most common cause of death (66%), followed by anoxia (9.7%) and hemorrhage (8%). 54% died in the ED. More likely to die if suffered penetrating trauma.

Pediatric Trauma: ATC vs PTC

The United States Government Accountability Office found 57 percent of the nation's 74 million children lived within 30 miles of a pediatric trauma center that can treat pediatric injuries, regardless of severity.

The presence of pediatric trauma centers was associated with lower rates of MVC death in children. Adult level 1/2 trauma centers appear to offer comparable risk reduction. Where population differences in pediatric trauma mortality are observed, addressing disparities in county-level access to pediatric trauma care may serve as a viable target for system-level improvement.

Pediatric patients

Why Does All This Matter: Anatomic and Physiologic Differences in Pediatric Trauma

A Case

A 5-year-old boy injured while crossing the street when he was struck by a vehicle at city speeds (w50 km/h). He is crying and pale, with a hematoma to the right forehead; bruising to the left side of the upper abdomen; and an obvious, closed, deformity of his femur. His vital signs are heart rate (HR), 135 beats/min, respiration rate (RR), 30 breaths/min; blood pressure (BP), 95/65 mm Hg; and O2 saturations of 91% on room air, which improve to 97% with supplemental O2

Factors to Consider when approaching pediatric trauma:

Head and Neck

• Large head on short weak neck with fulcrum out away from the center of gravity

• Traumatic brain injury likely present and must be investigated.

• 80% of pediatric multisystem trauma involves the head.

• Remember TBI is a major cause of trauma mortality.

• Heavy head compared to body, often first impact point so affected by rapid acceleration deceleration forces. Also, higher risk of axonal injury from shearing forces given limited myelin development. Prehospital management focused on H bombs.

Airway

• Airway is crowded and easily obstructed.

• Use a shoulder roll anytime you are managing a pediatric airway under 8 years.

• Intubation is for your ego; SGA is for your patient

• Cuffed tubes are both safe and effective for pediatric patients.

Pediatric Airway Considerations:

Head: In the supine position, a young child's head will cause a natural flexion of the neck due to its large size. This neck flexion can create a potential airway obstruction. Patients usually benefit from a towel to elevate the shoulders as well as someone to assist to help hold the head, as it can be floppy.

Nose:

Tongue: A child's tongue is proportionally larger in the oropharynx when compared to adults, and it may obstruct the airway due to this size.

Larynx: Located opposite C2—C3, a child's larynx is higher up than in an adult, creating a more anterior location that often results in difficulty when a provider attempts to visualize a child's airway. HARDER TO INTUBATE.

Epiglottis: The adult epiglottis is flat and flexible, while a child's is U-shaped, shorter and stiffer. This makes it more difficult to manipulate and is a common reason providers can't visualize an airway with a curved blade in a pediatric patient.

Vocal cords: The anterior attachment of a pediatric patient's vocal cords is lower than the posterior attachment, which creates an upward slant, whereas in adults, the vocal cords are horizontal. This concave shape may affect ventilation, and it's important for providers to use a jaw-lift maneuver to open the arytenoids.

Trachea: The trachea is shorter in pediatric patients, which increases the likelihood of right mainstem intubation and of the tube becoming dislodged. At birth, 1/3 the diameter of an adult (narrow the tube and increase resistance by a power of 4: Poiseuilles law)

Airway diameter: A child's airway is narrowest at the cricoid ring. As a result, secretions can easily obstruct the airway, due to its small size, and even a small amount of cricoid pressure can cause complete airway obstruction.

Residual lung capacity: Smaller lung capacity in pediatric patients means that a child can become hypoxic more quickly than an adult. Providers should make sure to closely monitor oxygen saturation and avoid prolonged periods without ventilation. Children also have higher respiratory rates than adults making them more susceptible to agents in the air.

The ribs in infants and young children are oriented more horizontally than in adults and older children lessening the movement of the chest.

Rib cartilage is more springy in children making the chest wall less rigid. This can allow the chest wall to retract during episodes of respiratory distress and decrease tidal volume.

The intercostal muscles that run between the ribs are not fully developed until a child reaches school age. This can make it difficult to lift the rib cage especially when lying flat on the back or if the diaphragm is inhibited by blood in the abdominal cavity or air in the belly.

Spinal Injuries

• Overall uncommon, but devastating if they do occur.

• Primarily due to high-speed blunt trauma

• Associated with birth trauma (Forceps extraction)

• Higher cervical spine (C1-C2)

• Chance Fractures common in pediatrics

• High suspicion for internal organ injury with thoracolumbar injury

• To Collar or Not To Collar

• Consider in the following situations.

• AMS

• Neck pain

• Neck stiffness

• Neurologic deficit

• High speed MVC

• Diving injury (not drowning)

• Substantial torso injury present

Cardiovascular Considerations

• Hypotension occurs after 30% blood loss.

• Decompensated potentially irreversible shock.

• Tachycardia is the pediatric body screaming at you.

• Always investigate tachycardia.

• Do not assume pain.

• Compensation

Chest and Abdominal Anatomy

• Compliant and cartilaginous skeletal structure

• Force is transferred internally.

• May be no broken ribs or external signs of trauma.

• Maintain high suspicion for internal injury.

• Pulmonary contusion common

• Horizontal ribs, exposed organs

• Low set pelvis, higher risk of hollow organ injury

• Shortened AP diameter meaning retroperitoneal structures closer to front of body and more exposed.

• Minimal peri-organ fat and subcutaneous tissue

Back to our case: What are your priorities?

A 5-year-old boy injured while crossing the street when he was struck by a vehicle at city speeds (w50 km/h). He is crying and pale, with a hematoma to the right forehead; bruising to the left side of the upper abdomen; and an obvious, closed, deformity of his femur. His vital signs are heart rate (HR), 135 beats/min, respiration rate (RR), 30 breaths/min; blood pressure (BP), 95/65 mm Hg; and O2 saturations of 91% on room air, which improve to 97% with supplemental O2

• Lethal Triad (hypothermia, acidosis, coagulopathy): Hypothermia is a modifiable prehospital factor

• Large surface area to body mass ratioà rapid heat loss

• Large head

• Prioritize warming the patient both prehospital and in the ED

• Turn on the heat in the ambulance.

• Resuscitation: On-scene Priorities

• C-ABC

Common Prehospital Pitfalls

• Failure to recognize/investigate/act on tachycardia.

• Fear and stress are diagnoses of exclusion in the tachycardic pediatric trauma.

• Failure to identify abnormal behavior for age.

• Sleeping or tired or quiet is NOT NORMAL

• Should be assumed to be impaired cerebral perfusion.

• Failure to suspect/assume internal injury in the absence of external signs of trauma.

• Mechanism informs the injuries.

• Treat Pain

• Numerous studies underscore the failures of EMS to adequately address and treat pediatric pain

• Worse for minority populations

• Get pain medication on board early

• Delayed pain treatment can have devastating psychologic effects long term

• PTSD

• Chronic pain syndrome

• Behavioral abnormalities

Non-Accidental Trauma

• Always consider NAT in your altered pediatric patient

• Even without a history to support it.

• Watch for red flags (TEN4FACES)

• History doesn't match developmental level.

• Delayed presentation

• Unwitnessed

• Vague story

• We are all mandated reporters if we suspect abuse.

Where to transport

• Take a stroke to a stroke center.

• Take a pediatric trauma to a pediatric trauma center whenever possible. This will decrease mortality and exposure to radiation and unnecessary procedures.

Review of The Pediatric Traumatic Hemorrhagic Shock Consensus Conference Research Priorities

Whole Blood in Pediatric Hemorrhagic Shock

• 100% Agreement among experts

• Practical application

• Severe cases-->straight to blood

• Less severe patients-->one bolus of crystalloid with close monitoring and immediate transition to blood if worsens/fails to improve.

• Use Low Titer O Whole Blood if available.

• If LTWOWB not available, use 1:1:1 plasma to RBCs to platelets.

• MTP with balanced blood product administration

• Consider calcium when giving blood: Siegler's Lethal Diamond

• Prehospital Blood in Pediatric Hemorrhagic Shock: "Reasonable based on availability and clinical judgement"

• 100% Expert Agreement

• Death due to bleeding most common early after injury

• Delays in transfusion associated with increased mortality and prolonged time to hemostasis.

• Current evidence supports both the safety and feasibility of prehospital pediatric blood product.

Tranexamic Acid in Pediatric Hemorrhagic Shock

• Use within 3 hours might be considered.

• 80% agreement among experts

• Strong evidence in adults: CRASH-2

• No high-quality evidence in pediatrics

Tourniquet Application in PHS

• 88% Agreement

• Has shown benefit.

• Biggest issues

• Applied when unnecessary.

• Applied incorrectly.

• Inadequate training

There is no such thing as permissive hypotension in pediatrics

Resources and Sources:

• Khalil M, Alawwa G, Pinto F, O'Neill PA. Pediatric Mortality at Pediatric versus Adult Trauma Centers. J Emerg Trauma Shock. 2021 Jul-Sep;14(3):128-135. doi: 10.4103/JETS.JETS_11_20. Epub 2021 Sep 30. PMID: 34759630; PMCID: PMC8527062.

• McLaughlin C, Zagory JA, Fenlon M, Park C, Lane CJ, Meeker D, Burd RS, Ford HR, Upperman JS, Jensen AR. Timing of mortality in pediatric trauma patients: A National Trauma Data Bank analysis. J Pediatr Surg. 2018 Feb;53(2):344-351. doi: 10.1016/j.jpedsurg.2017.10.006. Epub 2017 Oct 8. PMID: 29111081; PMCID: PMC5828917.

• Theodorou CM, Galganski LA, Jurkovich GJ, Farmer DL, Hirose S, Stephenson JT, Trappey AF. Causes of early mortality in pediatric trauma patients. J Trauma Acute Care Surg. 2021 Mar 1;90(3):574-581. doi: 10.1097/TA.0000000000003045. PMID: 33492107; PMCID: PMC8008945.

• Mikrogianakis A, Grant V. The Kids Are Alright: Pediatric Trauma Pearls. Emerg Med Clin North Am. 2018 Feb;36(1):237-257. doi: 10.1016/j.emc.2017.08.015. PMID: 29132580.

• Andrade EG, Onufer EJ, Thornton M, Keller MS, Schuerer DJE, Punch LJ. Racial disparities in triage of adolescent patients after bullet injury. J Trauma Acute Care Surg. 2022 Feb 1;92(2):366-370. doi: 10.1097/TA.0000000000003407. PMID: 34538831.

• Calhoun A, Keller M, Shi J, Brancato C, Donovan K, Kraus D, Leonard JC. Do Pediatric Teams Affect Outcomes of Injured Children Requiring Inter-hospital Transport? Prehosp Emerg Care. 2017 Mar-Apr;21(2):192-200. doi: 10.1080/10903127.2016.1218983. Epub 2016 Sep 16. PMID: 27636186.

• Byrne JP, Nance ML, Scantling DR, Holena DN, Kaufman EJ, Nathens AB, Reilly PM, Seamon MJ. Association between access to pediatric trauma care and motor vehicle crash death in children: An ecologic analysis of United States counties. J Trauma Acute Care Surg. 2021 Jul 1;91(1):84-92. doi: 10.1097/TA.0000000000003110. PMID: 33605706.

• Träff H, Hagander L, Salö M. Association of transport time with adverse outcome in paediatric trauma. BJS Open. 2021 May 7;5(3):zrab036. doi: 10.1093/bjsopen/zrab036. PMID: 33963365; PMCID: PMC8105622.

• Frank Lodeserto MD, "Approach to the Critically Ill Child: Shock", REBEL EM blog, October 15, 2018. Available at: https://rebelem.com/approach-to-the-critically-ill-child-shock/.

• Dai LN, Chen CD, Lin XK, Wang YB, Xia LG, Liu P, Chen XM, Li ZR. Abdominal injuries involving bicycle handlebars in 219 children: results of 8-year follow-up. Eur J Trauma Emerg Surg. 2015 Oct;41(5):551-5. doi: 10.1007/s00068-014-0477-5. Epub 2014 Nov 26. PMID: 26038003.

• Ten-4 bruising rule. Face It website. Accessed January 20, 2023,

• Newgard, Craig D. MD, MPH, FACEP; Fischer, Peter E. MD; Gestring, Mark MD; Michaels, Holly N. MPH; Jurkovich, Gregory J. MD, FACS; Lerner, E. Brooke PhD, FAEMS; Fallat, Mary E. MD; Delbridge, Theodore R. MD, MPH; Brown, Joshua B. MD, MSc, FACS; Bulger, Eileen M. MD; the Writing Group for the 2021 National Expert Panel on Field Triage. National guideline for the field triage of injured patients: Recommendations of the National Expert Panel on Field Triage, 2021. Journal of Trauma and Acute Care Surgery 93(2):p e49-e60, August 2022. | DOI: 10.1097/TA.0000000000003627

• Russell RT, Bembea MM, Borgman MA, Burd RS, Gaines BA, Jafri M, Josephson CD, Leeper CM, Leonard JC, Muszynski JA, Nicol KK, Nishijima DK, Stricker PA, Vogel AM, Wong TE, Spinella PC. Pediatric traumatic hemorrhagic shock consensus conference research priorities. J Trauma Acute Care Surg. 2023 Jan 1;94(1S Suppl 1):S11-S18. doi: 10.1097/TA.0000000000003802. Epub 2022 Oct 7. PMID: 36203242; PMCID: PMC9805504.

In this episode we discuss the future of pediatric head and cervical spine imagine with the very physicians who brought us the groundbreaking research that will forever change how we approach these pediatric injuries. This episode will have you rethinking the evidence behind your own protocols and making adjustments going forward.

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: https://sites.libsyn.com/414020

GET CEU CREDIT THROUGH PRODIGY EMS

Content Experts: Joelle Donofrio-Odmann, DO and Joseph Finney, MD

Guest Experts:

Dr. Nate Kuppermann

Dr. Julie Leonard

Emergency Medical Services for Children (EMSC) Innovation and Improvement Center (EIIC)

https://emscimprovement.center/

Pediatric Emergency Care Applied Research Network (PECARN):

https://pecarn.org/

Studies from the episode:

Julie C Leonard, Monica Harding, Lawrence J Cook, Jeffrey R Leonard, Kathleen M Adelgais, Fahd A Ahmad, Lorin R Browne, Rebecca K Burger, Pradip P Chaudhari, Daniel J Corwin, Nicolaus W Glomb, Lois K Lee, Sylvia Owusu-Ansah, Lauren C Riney, Alexander J Rogers, Daniel M Rubalcava, Robert E Sapien, Matthew A Szadkowski, Leah Tzimenatos, Caleb E Ward, Kenneth Yen, Nathan Kuppermann, PECARN prediction rule for cervical spine imaging of children presenting to the emergency department with blunt trauma: a multicentre prospective observational study, The Lancet Child & Adolescent Health, 2024, ISSN 2352-4642, https://doi.org/10.1016/S2352-4642(24)00104-4. (https://www.sciencedirect.com/science/article/pii/S2352464224001044)

https://www.sciencedirect.com/science/article/pii/S2352464224001044

Holmes JF, Yen K, Ugalde IT, Ishimine P, Chaudhari PP, Atigapramoj N, Badawy M, McCarten-Gibbs KA, Nielsen D, Sage AC, Tatro G, Upperman JS, Adelson PD, Tancredi DJ, Kuppermann N. PECARN prediction rules for CT imaging of children presenting to the emergency department with blunt abdominal or minor head trauma: a multicentre prospective validation study. Lancet Child Adolesc Health. 2024 May;8(5):339-347. doi: 10.1016/S2352-4642(24)00029-4. PMID: 38609287.

https://www.thelancet.com/journals/lanchi/article/PIIS2352-4642(24)00029-4/fulltext

Gambacorta A, Moro M, Curatola A, Brancato F, Covino M, Chiaretti A, Gatto A. PECARN Rule in diagnostic process of pediatric patients with minor head trauma in emergency department. Eur J Pediatr. 2022 May;181(5):2147-2154. doi: 10.1007/s00431-022-04424-9. Epub 2022 Feb 22. PMID: 35194653; PMCID: PMC9056473.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9056473/

Kuppermann N, Holmes JF, Dayan PS, Hoyle JD Jr, Atabaki SM, Holubkov R, Nadel FM, Monroe D, Stanley RM, Borgialli DA, Badawy MK, Schunk JE, Quayle KS, Mahajan P, Lichenstein R, Lillis KA, Tunik MG, Jacobs ES, Callahan JM, Gorelick MH, Glass TF, Lee LK, Bachman MC, Cooper A, Powell EC, Gerardi MJ, Melville KA, Muizelaar JP, Wisner DH, Zuspan SJ, Dean JM, Wootton-Gorges SL; Pediatric Emergency Care Applied Research Network (PECARN). Identification of children at very low risk of clinically-important brain injuries after head trauma: a prospective cohort study. Lancet. 2009 Oct 3;374(9696):1160-70. doi: 10.1016/S0140-6736(09)61558-0. Epub 2009 Sep 14. Erratum in: Lancet. 2014 Jan 25;383(9914):308. PMID: 19758692.

https://www.sciencedirect.com/science/article/pii/S0140673609615580?via%3Dihub

Brought to you by The National Association of EMS Physicians (NAEMSP) and Missouri Emergency Medical Services for Children (MO-EMSC) and The Emergency Medical Services for Children Innovation and Improvement Center (EIIC)

Hosts: Dr. Joelle Donofrio-Odmann and Dr. Joseph Finney

Website: https://sites.libsyn.com/414020

GET CEU CREDIT THROUGH PRODIGY EMS

Content Experts: Joelle Donofrio-Odmann, DO and Joseph Finney, MD

Guest Experts:

Welcome back for a special episode outside our normal schedule! This episode was recorded in collaboration with The EMSC Innovation and Improvement Center (EIIC) to provide expert review of prehospital pediatric airway management. With respiratory complaints being one of the most common prehospital pediatric emergencies, you definitely want to join us to ensure you and your agency are ready for the next pediatric airway emergency.

Description This recorded 60-minute webinar, originally presented for EMSC Day, will share the developments on prehospital pediatric airway management, followed by a 30-minute Q&A session. Hosted by experts in the field, this session will share the historical milestones, current practices, and future advancements shaping pediatric airway management in emergency medical services (EMS). Objectives: - To review the seminal and early research in prehospital pediatric airway management -To provide updates on the current recommendations on best practices for prehospital pediatric airway management -To share information about the upcoming Pediatric Prehospital Airway Resuscitation Trial (Pedi-PART) Presenters: Marianne Gausche-Hill, MD, FACEP, FAAP, FAEMS -Professor Clinical Emergency Medicine and Pediatrics, David -Geffen School of Medicine at UCLA -Harbor-UCLA Medical Center, Departments of Emergency Medicine and Pediatrics -Interim CEO, The Lundquist Institute for Biomedical Innovation at Harbor-UCLA Medical Center Lorin R. Browne, DO -Professor, Pediatrics and Emergency Medicine Medical College of Wisconsin -Associate Medical Director (Pediatrics) -Milwaukee County Office of Emergency Management EMS Joelle Donofrio-Odmann, DO FAAP FACEP FAEMS -Co-host of The Pediatric EMS Podcast -Deputy Chief Medical Officer, City of San Diego -Medical Director, SDFD Paramedic School -EMS Medical Director, Rady Children's Hospital -Associate Professor of Clinical Pediatrics and Emergency Medicine -University of California, San Diego Henry E. Wang, MD, MS -Professor and Vice Chair for Research -Department of Emergency Medicine -Deputy Director, OSU Center for Clinical and Translational Science -The Ohio State University Kathleen Adelgais, MD MPH FAAP FAEMS Co-Lead, Prehospital Domain EMS for Children Innovation and Improvement Center University of Colorado School of Medicine Colorado EMS for Children Resources: EMSC Innovation and Improvement Center https://emscimprovement.center/

Pediatric Emergency Applied Care Research Network (PECARN)

PEDI-PART

NAEMSP Airway Compendium Position Statement