Episode 12: 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 D'Onofrio-Udman 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 D'Onofrio-Odman 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 (

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

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

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

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

Website: https://directory.libsyn.com/episode/index/show/34eda738-c0e3-471c-94e6-5d7bb718e70f/id/31363087

Direct Download: 

GET CEU CREDIT THROUGH PRODIGY EMS 

In this episode we bring you two experts in pediatric prehospital care who are working tirelessly to identify why caring for children in cardiac arrest is so unique and so challenging. Join us as we review two papers that shed light on this critical care scenario and offer opportunities to elevate care for you and your agency.

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

Guest Experts:

Matt Hansen, MD

 Carl Errikson, MD

Papers reviewed in this episode:

• https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2805000
• https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2813917

Take home points:

• Caring for children is challenging, strive to find ways to offload the cognitive burden of pediatric resuscitation
• It isn't just about training, you have to go deeper into education, skill performance, and simplification of tasks
• Do the basic skills well! BVM and CPR are basic skills, but frequently performed incorrectly and unsafely. 
• Do your homework. Matt and Carl work to bring you the very best in evidence based pediatric care. Do your part in reading and understanding how this work can inform your own care of children. 

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

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

Website: 

Direct Download: 

GET CEU CREDIT THROUGH PRODIGY EMS: Unfortunately, not this episode but check out episode 8 in a few weeks for CEU credits!

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

Guest Experts:

Kathleen Adelgais, MD, MPH/MSPH Project Director, Colorado EMS for Children Program

Professor of Pediatrics - Children's Hospital Colorado 

Kathryn Kothari, MD Medical Director, Emergency Medical Services

Assistant Professor, Pediatrics - Emergency Medicine, Baylor College of Medicine

Episode Details:

Welcome back for a special episode outside our normal schedule! This episode was recorded in collaboration with Phil Moy of The Prehospital Emergency Care Journal Podcast. We came together to discuss The Prehospital Pediatric Readiness Project which is an amazing project focused on improving prehospital pediatric care. 

Is your agency pediatric ready? Are you ready to care for that next critically ill or injured child? Do you have the right equipment, the necessary training, and the adequate knowledge to care for children? 

We can get you there!

Check out this episode as we discuss the upcoming release of the prehospital pediatric readiness assessment survey and find out where your agency ranks on pediatric readiness. 

Survey opens on Tuesday, April 23rd, 2024

Our guests will give you all the how and why for this amazing program. If you want to get your agency up to speed or need resources for pediatric focused education, training, and protocols, listen up as we get you everything you need to know to complete the survey and get your agency on the road to pediatric readiness!

Resources:

Emergency Medical Services for Children (EMSC):

https://mchb.hrsa.gov/programs-impact/emergency-medical-services-children-emsc

Roadmap to pediatric readiness: https://publications.aap.org/pediatrics/article/145/1/e20193308/36984/Pediatric-Readiness-in-Emergency-Medical-Services

Joint policy statement on pediatric readiness:

https://www.tandfonline.com/doi/full/10.1080/10903127.2019.1685614

 

 

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

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

Website: 

Direct Download: https://traffic.libsyn.com/34eda738-c0e3-471c-94e6-5d7bb718e70f/Drowning_part_2-_Drowning_Prevention_Is_Everyones_Responsibility.mp3

GET CEU CREDIT THROUGH PRODIGY EMS: https://frontend.prodigyems.com/class/EA5EDAC0-EB23-4CF4-8735-6565BBD1599F

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

Special Guests: 

Molly A. Greenshields, MD: Assistant Professor of Pediatrics at Children's Minnesota 

Caitlin Farrell, MD: Associate Physician in Pediatrics, Division of Emergency Medicine and Assistant Professor of Pediatrics and Emergency Medicine, Harvard Medical School. 

Director, Section on EMS and Prehospital Care at Boston Children's Hospital 

Elise Zimmerman, M.D., SIM Program Director; Clinical Assistant Professor of Pediatrics, UC San Diego   Chris and Christina Martin: Founders of The Gunner Martin Foundation and advocates for drowning prevention 

Jon Boisvert: City of San Diego Oceanfront Lifeguard, San Diego Junior Lifeguard instructor

B-side Narrator: Joelle Donofrio-Odmann, DO and Joseph Finney, MD 

Editing and Publication: Joseph Finney, MD 

Episode Summary

We have a terrific episode for you today for this part 2 of our pediatric drowning series. To recap, episode one focused on the experiences of ocean front lifeguards and Midwest paramedics where we laid out prehospital priorities for the management of pediatric drowning. If you haven’t listened already, check that episode out before this one. The foundation of episode one will inform the understanding of this episode so go check that one out now. Ok, now for part 2 of our series. Today we are focusing on the story of two very special individuals who have made it their mission to ensure no more children die from drowning. They will take us on a personal journey that changed the trajectory of their lives forever leading to a career as a firefighter and a vocation of advocacy to help them heal after a tragic event. And it is in that advocacy that today’s episode really originates from because, as we will learn, the key to successful prehospital pediatric drowning management is ensuring the event never happens in the first place. And it’s there that we meet 3 experts in quality improvement and injury prevention as well as research. We will discuss some amazing work focused on drowning prevention and exploring the factors associated with disparities in pediatric drowning.  

A word of caution, this episode recounts a real-life emergency that may be difficult for some listeners. And one last thing, although we normally guide the discussion for you the listener with pauses and summaries, this first part of the episode is so powerful and so real, it needs no guidance. On the back half of the episode, we will be there to highlight and reinforce but for this first part, just try and follow our guests. This is worth your full attention.

Ok, let’s get to it!

EMS Professionals are the frontline of drowning prevention and advocacy!! You can be the difference. 

Key Tips for EMS Medical Directors and Agencies:

• Any drowning or water training should include a pediatric resuscitation scenario
• Know your pediatric destinations for a drowning victim. They may require ECMO!
• Work with community partners to advocate for water safety and encourage swim lessons
• Collaborate with CPR programs in your area to teach bystander CPR

5 keys to water safety:

1. Adult supervision: Sober designated water watcher
2. Avoid water wings or floaties
3. Set up barriers to water access (door alarm, 4-sided fence, pool alarm, self latching gait)
4. Multiple layers of barriers
5. Swim lessons (As early as 1 year if developmentally appropriate, all kids by age 4 years)

Critical Factors in an effective water barriers:

• Isolation fences (enclosed on all 4 sides, can’t enter the pool directly from the house​

• Fence height >4ft, bottom of fence

 

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/a-silent-epidemic-prehospital-priorities-in-the-management-of-pediatric-drowning

Direct Download: https://traffic.libsyn.com/34eda738-c0e3-471c-94e6-5d7bb718e70f/Episode_5-_Drowning-_Swimming_is_a_fundamental_right_but_water_safety_isnt_fundamental.mp3

GET CEU CREDIT THROUGH PRODIGY EMS: https://link.prodigyems.com/pemsp5

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

Special Guests: 

Bryan Clark: Marine Safety Lieutenant at San Diego Fire-Rescue Lifeguard and Paramedic 

Gina Pellerito: Critical Care Paramedic with Mehlville Fire Protection District, Research Analyst/MOEMSC Chair at MU school of Medicine 

 

Jon Boisvert: City of San Diego Oceanfront Lifeguard, San Diego Junior Lifeguard instructor

B-side Narrator: Joelle Donofrio-Odmann, DO

Editing and Publication: Joseph Finney, MD 

Episode Summary

Welcome back to the Pediatric EMS podcast. Where I (Joe) live, summer is winding down, but this episode topic knows no seasonality. It affects everyone and it can happen at any moment. Today, on episode 5 of the pediatric EMS podcast, Joelle and I bring you a two-part episode focused on the silent epidemic of pediatric drowning. Today, in part one, we hear from two San Diego lifeguards who break down how experts in drowning prevention approach water safety, drowning prevention, rescue, and resuscitation. But we will also have a guest from one of our first episodes, Gina Pellerito who will take us through a call she will never forget, one that put her on a career path focused on improving prehospital pediatric care. In part two, we will hear from a whole new group of experts in advocacy, prevention, and expert research including a story you won’t want to miss. You have waited long enough, let’s get into part one and learn how to manage a drowning event.

Disposition: “The decision to admit to an ICU or hospital bed vs observation in the ED or discharge home should consider the severity of the patient’s drowning as well as any co-morbid or premorbid conditions” (Szpilman et al 2020)

 The majority of drowning victims are well and without symptoms. Historically, despite well-appearance, all victims of drowning were admitted for observation given concern for sudden clinical deterioration (Noonan et al 1996). This thinking has changed over time, luckily. Now, only a certain group of symptomatic drowning victims will require admission.  Except for our most severe patients, if there are symptoms, they will primarily be respiratory in nature. I find it easiest to divide patients into three broad potential categories; well appearing and asymptomatic, symptomatic with respiratory distress, and those who are unresponsive with cardiorespiratory collapse. This can feel like an oversimplification but it is important to help triage patients and determine who can go home, who should be observed, and who needs to be admitted. 

Noonan et al in 1996 performed a retrospective chart review of 72 drowning victims. They found that 98% of patients who developed any symptoms did so in the first 4.5 hours. Based on their findings, they recommended the following:

1. Asymptomatic, well appearing in the ED→ Observation for 6-8 hours and discharge if no symptoms develop

2. Stable mildly symptomatic patients should be observed for 6-8 hours and admitted if they deteriorate or fail to improve, supportive care with supplemental oxygen and evaluation for aspiration/edema with CXR should be performed

3. Ill, symptomatic patients should be stabilized in the ED and subsequently admitted to the ICU or general inpatient unit

4. Consider ECG in all patients to screen for arrhythmia if history concerning

Ultimately, most patients can be observed and discharged. Management of the more critically ill patients will require a thoughtful, multidisciplinary approach with the goal of “maintaining adequate oxygenation, preventing aspiration and stabilising body temperature.” (Royal Children’s Hospital Melbourne CPG) 

In this episode:

• 3 prehospital experts take us through their experience with pediatric drowning from the perspective of two San Diego Lifeguards and 1 Paramedic
• Highlights from Joe and Joelle on exactly how to approach pediatric drowning management
• Advice for medics and medical directors on training for this low frequency high risk event
• Back to the basics with review of the fundamentals in resuscitation 

Resources

https://www.sandiego.gov/lifeguards/junior

https://www.aap.org/en/news-room/campaigns-and-toolkits/drowning-prevention/

Amazing course on pediatric drowning for EMS and bystanders:

https://health.hawaii.gov/docd-training/pediatric_emergencies_elearning/providers/#/lessons/Pn3dw1oE25gcbh9PWhmfiOK6s9w43Xgh

Clarifying terms for drowning: https://health.clevelandclinic.org/dry-drowning-separating-fact-from-fiction/#:~:text=When%20you're%20struggling%20underwater,Milk.

Prehospital Readiness: https://emscimprovement.center/domains/pediatric-readiness-project/

Key Take-Aways:

• Training is critical, drill in your agency and with community partners to make sure you are ready
• Focus on the basics: ventilation and high quality CPR
• C-collars are for trauma
• Arrhythmias are uncommon
• Survival requires rapid rescue and bystander resuscitation. Teach your community and your family
• Scene safe! Don't become a second victim
• check out the NASEMSO model guidelines for drowning protocol recommendations and other protocol guidance
  • https://nasemso.org/wp-content/uploads/National-Model-EMS-Clinical-Guidelines_2022.pdf 

Come back for part 2 where we focus on prevention and advocacy in pediatric drowning. Plus, we will have a story you DO NOT WANT TO MISS!

Stay safe and stay sharp.

Joe and Joelle