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Aunque pueda contener afirmaciones, datos o apuntes procedentes de instituciones o profesionales sanitarios, la información contenida en el blog EMS Solutions International está editada y elaborada por profesionales de la salud. Recomendamos al lector que cualquier duda relacionada con la salud sea consultada con un profesional del ámbito sanitario. by Dr. Ramon REYES, MD

viernes, 21 de junio de 2019

El uso del torniquete en niños TQ Pediatrico/ Do commercially available tourniquets work on kids? UPDATED May 20 2019

El uso del torniquete en niños TQ Pediatrico/  Do commercially available tourniquets work on kids? UPDATED May 20 2019

Promoting STB from FirstCare Provider worldwide thanks for your help to reduce dead all around the world by Dr. Ramon Reyes, MD
Dr. Joshua Bobko, MD from #First Care Provider First Care Provider @1stCarePRovider


Posted in the Facebook Group

Thanks a lot Dr. Joshua Bobko,MD, for this professional and personal oppinion, for us, people that do not have access some times to originals TQ made in USA,,, for mw is really important somebody with your moral and professional reputation talk about this and some other items to help reduce mortality worldwide. Thanks again I hope to see you in the next CTECC meeting. Best regards hugs from remote sea in Turkey... by Dr. Ramon Reyes, MD @DrRamonReyesMD #DrRamonReyesMD




Existe suficiente científica que habla de la eficiencia del torniquete TQ en adultos, pero encontramos pocos datos sobre su uso en niños.

Version 1

En un artículo del Boston Children's Hospital, el director del centro de trauma, David Mooney, MD, habló sobre los dos niños a quienes se aplicaron torniquetes después de los atentados de la maratón de Boston. Los torniquetes demostro ser la diferencia entre salvar vidas o perderlas  ese día, y  dos niños que sí tenían torniquetes aplicados hoy continuan vivos.

Version 2

Lecciones aprendidas de la transferencia del TCCC Tactical Combat Casualty Care:
Después de los tiroteos de la Escuela Primaria Sandy Hook en 2012, el Colegio Cirujanos de los EUA (ACS) reunió al Comité Conjunto para crear una Política Nacional para mejorar la supervivencia de eventos de Heridos en Masa, que se reunieron en Hartford, Connecticut. Las deliberaciones del comité se conocen como Consensos de Hartford, que esencialmente establecen que;

El sangrado incontrolado en extremidades es la causa prevenible más importante de muerte en el ambiente prehospitalario pudiendo alcanzar un 63%.

Esta formacion esta dirigida a todos los actores que  responden profesionales y no profesionales tales como; civiles y fuerzas del orden, para que tengan la educación y el equipo necesario para el control de la hemorragia.

Hartford Consensus apoya firmemente a civiles para que actuen como "respondedores inmediatos".

El Comite  Tactical Emergency Tactical Care (C-TECC) fue convocado para acelerar la transición de las lecciones médicas militares aprendidas del campo de batalla a la respuesta civil para reducir las causas prevenibles de muerte tanto por los servicios de emergencias como por la población civil.

TCCC vs TECC

Tactical Emergency Casualty Care (TECC) con un conjunto de pautas de atención de trauma basadas en evidencia para entornos prehospitalarios de alta amenaza para civiles. Las directrices se hicieron a partir de las pautas  del TCCC (Tactical Combat Casualty Care).

En resumen, el  (TECC) es la evolución civil y la aplicación de las pautas militares de Cuidado de víctimas de combate táctico (TCCC) y el TCCC como sistema, tiene una aplicación limitada en el ámbito civil.

Los niños no se tienen en cuenta en las pautas de TCCC ya que no están en la población militar desplegada. Como tal, el C-TECC examinó específicamente la investigación y los datos específicos de la población pediátrica y creó un conjunto específico de recomendaciones para niños.

Cuidado pediátrico de urgencias tácticas.

Los puntos clave para el paciente pediátrico incluyen;

El proveedor no debe tardar en aplicar torniquetes a víctimas pediátricas
Aplicar el torniquete TQ sobre la ropa lo más proximal como sea posible en la extremidad. 

Apriete hasta que cese el sangrado (Desaparezca el pulso distal en la extremidad que hemos aplicado el TQ)
.
En cualquier amputación traumática total o parcial, se debe aplicar el torniquete independientemente del sangrado.

Cuando el tiempo y la situación lo permitan, se debe realizar una prueba de pulso distal en cualquier extremidad donde se aplica torniquete. Si todavía hay  pulso distal, considere  aprietar mas el  torniquete o un segundo torniquete, uno al lado del otro y proximal al primero, para eliminar el pulso distal.

Bibliografía
http://www.c-tecc.org/images/content/FINAL_V.1.0_Pediatric_Guidelines.pdf

Adaptado Dr. Ramon REYES, MD
VP Operacional Comite Iberoamericano de Medicina Tactica y Operacional 
Faculty y Medical Director TECC, TCCC
Miembro Grupo Internacional  Comite TECC 

Torniquetes Pediatricos en el Mercado: 

S.T.A.T.® Tourniquet 
Pero antes ver estos malos resultados hechos por un profesional de mucho prestigio ante el Comite TECC 

STAT Tourniquet 21 of 24 applications FAIL by Mike Shertz CRISIS MEDICINE 

https://emssolutionsint.blogspot.com/2018/11/stat-tourniquet-21-of-24-applications.html


Torniquete pediátrico para  extremidades pequeñas tanto como unos 20 mm. De fácil aplicación en solo  unos 5 segundos.
m2 CHILD Ratcheting Medical Tourniquet EMS World 2015 Top Innovation Award Winner
http://emssolutionsint.blogspot.com/2017/12/m2-ratcheting-medical-tourniquet-rmt.html

Tambien pudiera ser utilizado el Torniquete SOFT



 Do commercially available tourniquets work on kids? UPDATED May 20 2019 by Crisis Medicine

Jacob Hall, 6 years old, died of a femoral artery laceration after being shot by a 14-year-old while he was at recess at his school. Another student and a teacher were wounded.

“’The first-grader lost 75 percent of his blood from a bullet, which pierced his femoral artery in his thigh,’ officials said. He was rushed to Greenville Health System Children’s Hospital, where he had multiple surgeries after going into cardiac arrest.” NBC News, October 2016.
Tragically, Jacob ultimately succumbed to his wounds. No commercially available tourniquets were available at his school, leaving the school nurse with few good hemorrhage control options.
Despite over 10,000 applications and 2,000 lives saved by tourniquet placement during the Global War on Terror, the commercially available tourniquets being used by the Department of Defense were never designed for pediatric use.
Conceptually the two most common of the DOD issued tourniquets, the CAT and SOFT-Wide should work on kids as long as they can adequately circumferentially constrict the limb they are placed on. However, those devices are specified for adult service member limbs, not smaller sized child limbs.

The question becomes will commercially available tourniquets work on kids?



With the recent publication of Dr. Harcke’s study1 using 7th Generation CAT tourniquets on 60 children aged 6 to 16, we have even more data that commercially available tourniquets work just fine on children.

In the study, 7th generation CATs were placed on both the upper arm and thigh of 60 children.  The tourniquets were tightened until distal Doppler pulse ceased or the windlass had been twisted 3 full turns (1080 degrees).  This limit was chosen to decrease the pain of the tourniquet placement for the study.  They acknowledged in actual application pain is irrelevant.

The CATS occluded 100% of the upper extremities and 93% of the thighs.  One subject quit during thigh application secondary to pain, and another three could not be occluded despite three twists of the windlass.  The three tourniquet applications that failed to occlude were in the oldest (14 to 16 years) age group and were obese.

This is the largest tourniquet study using Doppler ultrasound to verify artery occlusion we are aware of in either adults or children. It is a nice compliment to the previous study by Dr. John Kragh.
Previously, Dr. John Kragh, an orthopedic surgeon and military researcher on tourniquet use, studied 88 children seen in US Military Hospitals in Iraq and Afghanistan on whom US DOD tourniquets were placed. Children ranged in age from 4 to 17 years old. 64% were injured by explosions and 30% gunshot wounds. 7 of the 88 died. They identified no pediatric-specific problems in applying the tourniquets on kids despite the tourniquets being designed for adult casualties. The tourniquets seemed to work on kids just fine.
That is not surprising. Commercial tourniquets are more prone to failure on larger circumference limbs where they cannot fully occlude arterial flow. Placing adult spec’d devices on kids limbs, which are generally much smaller, might actually increase their likelihood of effectiveness. Additionally, kids are generally squishier than adults who may have co-morbidities like calcified and incompressible arteries. All of which should make it easier to occlude a child’s arterial flow.
Once again, the medical literature supports that commercial tourniquets work just fine on children. Now we have one study showing successful application of commercially available tourniquets on kids in a lab setting and another showing similar efficacy in real-world, combat applications.

How young of a kid might the tourniquet work on?

According to the World Health Organization and US CDC, 50% of boys and girls have arm circumferences at least 16.5 to 17.7 cm. There is no specific data on thigh circumference, but the average 6 to 12-month-old American baby is felt to have a thigh circumference of 8 inches / 20 cm. The SOFT Wide circumference is 6.75 inches / 17 cm. The CAT 6th and 7th generation are both about 7.75 inches / 19.5 cm.

What does all this mean?

Dr. Kragh’s study is the only prehospital review on commercial tourniquet use on kids. However, the CAT and SOF-T Wide would be expected to work as tourniquets on thighs as young as 6 to 12 months and arms beginning at about the 5-year-old range.
Just recently, the first case report of a commercially available tourniquet being placed on a child was published. A 7-year-old sustained a femoral artery laceration when a piece of metal flew out of a running lawnmower. Although in shock by the time prehospital providers arrived, he survived after a commercial tourniquet was placed, before transport to the hospital.
What do you do for massive hemorrhage on a kid’s arm too small for a tourniquet? Good clamshell direct pressure. It’s strong enough to occlude arterial flow in an adult male’s arm; it should work easily on a kid.
For an improvised tourniquet using the kid’s own clothing, check out a video using the child’s pants as a tourniquet with a windlass. Works on adults too.
1Harcke HT, Lawrence BA, Gripp HK, et all. Adult Tourniquet Use in School-Age Emergencies. Pediatrics. 2019,143(6)










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Pediatric Tactical Emergency Casualty Care

DIRECT THREAT CARE (DTC)

Goals:

1.     Accomplish the mission with minimal casualties

2.     Prevent any casualty from sustaining additional injuries

3.     Keep response team maximally engaged in neutralizing the existing threat (e.g. active shooter, unstable building, confined space HAZMAT, etc.)
4.     Minimize public harm


Principles:

1.     Mitigate ongoing direct threat (e.g. active fire fight, unstable building collapse, dynamic explosive scenario, etc.).
2.     Threat mitigation techniques will minimize risk to casualties and the providers. These should include techniques and tools for rapid casualty access and egress.

3.     Minimal trauma interventions are warranted.

4.     Consider hemorrhage control

a.     TQ application is the primary “medical” intervention to be considered in Direct Threat Care.
b.     Consider instructing casualty to apply direct pressure to the wound if no tourniquet available or application is not tactically feasible.

5.     Consider quickly placing or directing casualty to be placed in position to protect airway.

Guidelines:

1.      Mitigate any threat and move to a safer position (e.g. Return fire, utilize less lethal technology, assume an overwhelming force posture, extraction from immediate structural collapse, etc.).
2.      Direct the casualty to move to a safer position and apply self aid if able.

a.      Attention must be paid to the type of instruction that will be presented to this population.
b.      Use of tactile direction, visual signaling and simple language may improve communication.
3.      Casualty Extraction

a.      If a casualty can move to safety, they should be instructed to do so.

Pediatric Tactical Emergency Casualty Care

b.      If a casualty is unresponsive, the scene commander or team leader should weigh the risks and benefits of a rescue attempt in terms of manpower and likelihood of success. Remote medical assessment techniques should be considered.
c.      If the casualty is responsive but cannot move, a tactically feasible rescue plan should be devised.
d.      Recognize that threats are dynamic and may be ongoing, requiring continuous threat assessments.
4.      Stop life threatening external hemorrhage if tactically feasible:

a.      Provider should not hesitate to apply tourniquets to pediatric casualties.

b.      Apply a tourniquet over the clothing as proximal-- high on the limb-- as possible.

c.      Tighten until cessation of bleeding and move to safety. Consider moving to safety prior to application of the TQ if the situation warrants.
d.      Consider instructing casualty to apply direct pressure to the wound if no tourniquet available or application is not tactically feasible
5.      Consider quickly placing casualty, or directing the casualty to be placed, in position to protect airway if tactically feasible


Skill Sets:

1.      Tourniquet application

2.      Consider PACE Methodology- Primary, Alternative, Contingency, Emergency

3.      Commercially available tourniquets

4.      Field expedient tourniquets

5.      Tactical casualty extraction

6.      Rapid placement in recover position

Pediatric Tactical Emergency Casualty Care



INDIRECT THREAT CARE (ITC)

Goals:


1.     Goals 1-4 as above with DTC care

2.     Stabilize the casualty as required to permit safe extraction to dedicated treatment sector or medical evacuation assets

Principles:

1.     Maintain tactical supremacy, mitigate threats and complete the overall mission.

2.     Conduct dedicated patient assessment and initiate appropriate life-saving interventions as outlined in the ITC guidelines. DO NOT DELAY casualty extraction/evacuation for non life-saving interventions.

3.     Consider establishing a casualty collection point if multiple casualties are encountered

4.     Establish communication with the tactical and/or command element and request or verify initiation of casualty extraction/evacuation.
5.     Prepare casualties for extraction and document care rendered for continuity of care purposes.

Guidelines:

1.      Bleeding:

a.      Assess for unrecognized hemorrhage and control all sources of major bleeding:

i.       If not already done, use a tourniquet for potentially life-threatening bleeding.
i.       Apply the tourniquet over the clothing as proximal-- high on the limb-- as possible. If able and tactical situation permits, consider fully exposing the wound, applying tourniquet directly to the skin.

ii.     For any traumatic total or partial amputation, a tourniquet should be applied regardless of bleeding.
ii.     Apply pressure dressing with deep wound packing to control life-threatening external hemorrhage that is anatomically amenable to such treatment.
b.      For compressible hemorrhage not amenable to tourniquet use, or as an adjunct to tourniquet removal (if evacuation time is anticipated to be longer than two hours),

Pediatric Tactical Emergency Casualty Care

apply a hemostatic agent in accordance with the directions for its use with an appropriate pressure bandage. Before releasing any tourniquet on a casualty who has received IV fluid resuscitation for hemorrhagic shock, ensure a positive response to resuscitation efforts (i.e., a peripheral pulse normal in character and normal mentation).

c.      Reassess all tourniquets that were applied during previous phases of care. Consider exposing the injury. Tourniquets applied hastily during DTC phase that are determined to be both necessary and effective in controlling hemorrhage should remain in place if the casualty can be rapidly evacuated to definitive medical care. If ineffective in controlling hemorrhage or if there is any potential delay in evacuation to care, expose the wound fully, identify an appropriate location immediately proximal to the first tourniquet, and apply a new tourniquet directly to the skin.
d.      When time and the tactical situation permit, a distal pulse check should be accomplished on any limb where a tourniquet is applied. If a distal pulse is still present, consider additional tightening of the tourniquet or the use of a second tourniquet, side by side and proximal to the first, to eliminate the distal pulse.

e.      Expose and clearly mark all tourniquet sites with the time of tourniquet application.
2.      Airway Management:

a.      Unconscious casualty without airway obstruction:

iii.   Chin lift or jaw thrust maneuver

iv.    Nasopharyngeal airway

v.     Place casualty in the recovery position

vi.    Caution advised in patients with suspected C-spine injury.

b.      Casualty with airway obstruction or impending airway obstruction:

i.       Chin lift or jaw thrust maneuver

ii.     Nasopharyngeal airway

iii.   Allow casualty to assume position that best protects the airway- including sitting up
iv.    Place unconscious casualty in the recovery position

c.      If previous measures unsuccessful:

i.       Airway positioning may be enhanced by elevation of the shoulders

Pediatric Tactical Emergency Casualty Care

ii.     Bag mask ventilation is preferred to intubation in the pediatric pre-hospital population with suspected hemorrhagic shock

iii.   Oral/nasotracheal intubation

iv.    Consider surgical/invasive airway

iii.   Needle cricothyroidotomy recommended if signs of puberty are absent
iv.    Surgical cricothyroidotomy only recommended in pediatric patients with signs of puberty
v.     Consider Supraglottic Devices (e.g. King LT or LMA) per protocol.

d.      Apply oxygen if available

3.      Breathing:

e.      In a casualty with progressive respiratory distress and known or suspected torso trauma, consider tension pneumothorax. Needle thoracostomy should be performed on the side of the injury, using the largest gauge (minimum 18-gauge) and the longest length appropriate for body size/chest wall thickness:

vi.    In the second intercostal space at the mid-clavicular line. Ensure that the


needle entry into the chest is lateral to the nipple line and is not directed towards the heart.

vii.  If properly trained, consider a lateral decompression, inserting the needle in the 4-5th intercostals space, anterior to the mid-axillary line on the injured side.
f.       All open chest wounds should be treated by immediately applying an occlusive material to cover the defect and securing it in place. Monitor the casualty for the potential development of a subsequent tension pneumothorax.
4.      Intravascular (IV/IO) access:

a.      If rapid fluid resuscitation is indicated consider primary intraosseous (IO) route (per agency protocol).
b.      Consider IV saline lock

5.      Fluid resuscitation: Assess for hemorrhagic shock; altered mental status (in the absence of head injury) and weak or absent peripheral pulses are the best field indicators of shock.
a.      If not in shock:

i.       No IV fluids necessary

ii.     PO fluids permissible if:

Pediatric Tactical Emergency Casualty Care

v.     Conscious, can swallow, and has no injury requiring potential surgical intervention
vi.    If confirmed long delay in evacuation to care

b.      If in shock:

i.       Administer appropriate IV fluid bolus (20cc/kg NS/LR) and re-assess casualty. Repeat bolus after 30 minutes if still in shock.
ii.     If a casualty with an altered mental status due to suspected TBI has a weak or absent peripheral pulse, resuscitate to mid age-specific systolic blood pressure range, or return of strong peripheral pulse.
6.      Prevention of hypothermia (Note, due to high total body surface area ratio and other physiological variables, children are at high risk of hypothermia):
c.      Initiate all efforts to eliminate heat loss as soon as operationally feasible, after life-saving interventions have been employed.
d.      Minimize casualty’s exposure to the elements.

e.      Replace wet clothing with dry if possible. Place the casualty onto an insulated surface as soon as possible.
f.       Cover the casualty with commercial warming device, dry blankets, poncho liners, sleeping bags, or anything that will retain heat and keep the casualty dry.
g.      Warm fluids are preferred if IV fluids are required.

7.      Penetrating Eye Trauma: If a penetrating eye injury is noted or suspected:

a.      Perform a rapid field test of visual acuity.

b.      Cover the eye with a rigid eye shield (NOT a pressure patch). If a commercial eye shield is not available, use casualty’s eye protection device or anything that will prevent external pressure from being applied to the injured eye.
8.      Reassess casualty:

a.      Complete secondary survey checking for additional injuries. Inspect and dress known wounds that were previously deferred.
b.      Consider splinting known/suspected fracture to include applying pelvic binding techniques for suspected pelvic fractures.
9.      Provide analgesia as necessary.

a.      Consider oral or rectal (if available) non-narcotic medications such as Tylenol for mild to moderate pain.


Pediatric Tactical Emergency Casualty Care

b.      Avoid the use of non-steroidal anti-inflammatory medications (e.g. aspirin, ibuprofen, naproxen, ketorolac, etc) in the trauma patient as these medications interfere with platelet functioning and may exacerbate bleeding.
c.      Narcotic pain medications should be utilized per protocol. Consider utilization of mucosal atomizer devices (MAD). Exercise caution when using narcotic medications (e.g. fentanyl citrate.) and/or Ketamine for moderate to severe pain in pediatric patients due to their higher volumes of distribution.

i.       Consider adjunct administration of anti-emetic medicines

ii.     Have naloxone readily available whenever administering opiates

iii.   Monitor for adverse effects such as respiratory depression or hypotension.

10.   Antibiotics: Consider initiating antibiotic administration for casualties with open wounds and penetrating eye injury when evacuation to definitive care is significantly delayed or infeasible. This is generally determined in the mission planning phase and requires medical oversight.

11.   Burns:

a.      Facial burns, especially those that occur in closed spaces, may be associated with inhalation injury. Look for singed nasal hairs or facial hair or soot in and around the nares which may indicate possible inhalational injury. Aggressively monitor airway status and oxygen saturation in such patients and consider early definitive airway management for respiratory distress or oxygen desaturation.

b.      Smoke inhalation, particularly in a confined space, may be associated with significant carbon monoxide and cyanide toxicity. Patients with signs of significant smoke inhalation plus:
i.       Significant symptoms of carbon monoxide toxicity should be treated with high flow oxygen if available
ii.     Significant symptoms of cyanide toxicity should be considered candidates for cyanide antidote administration
c.      Estimate total body surface area (TBSA) burned to the nearest 10% using the appropriate locally approved burn calculation formula.
d.      Cover the burn area with dry, sterile dressings and initiate measures to prevent heat loss and hypothermia.
e.       If burns are greater than 20% of Total Body Surface Area, fluid resuscitation should be initiated under medical control as soon as IV/IO access is established. If


Pediatric Tactical Emergency Casualty Care

hemorrhagic shock is also present, resuscitation for hemorrhagic shock takes precedence over resuscitation for burn shock as per the guidelines.

f.       All previously described casualty care interventions can be performed on or through burned skin in a burn casualty.
g.      Analgesia in accordance with TECC guidelines may be administered.

h.      Aggressively act to prevent hypothermia for burns greater than 20% TBSA.

12.   Monitoring: Apply appropriate monitoring devices and/or diagnostic equipment if available. Obtain and record vital signs.
13.   Prepare casualty for movement: Consider environmental factors for safe and expeditious evacuation. Secure casualty to a movement assist device when available. If vertical extraction required, ensure casualty secured within appropriate harness, equipment assembled, and anchor points identified.

14.   Communicate with the casualty if possible. Encourage, reassure and explain care.

15.   Cardiopulmonary resuscitation (CPR) within a tactical environment for victims of blast or penetrating trauma who have no pulse, no ventilations, and no other signs of life will not be successful and should not be attempted unless appropriate manpower is available. However, consider bilateral needle decompression for victims of torso or polytrauma with no respirations or pulse to ensure tension pneumothroax is not the cause of cardiac arrest prior to discontinuation of care.

a.      In certain circumstances, such as electrocution, drowning, atraumatic arrest, or hypothermia, performing CPR may be of benefit and should be considered in the context of the tactical situation.
16.   Documentation of Care: Document clinical assessments, treatments rendered, and changes in the casualty’s status in accordance with local protocol. Consider implementing a casualty care card that can be quickly and easily completed by non-medical first responders. Forward this information with the casualty to the next level of care.


Skill set:

1.     Hemorrhage Control:

a.     Apply Tourniquet

b.     Apply Direct Pressure

c.     Apply Pressure Dressing

d.     Apply Wound Packing

e.     Apply Hemostatic Agent

2.     Airway:

Pediatric Tactical Emergency Casualty Care

a.     Apply Manual Maneuvers (chin lift, jaw thrust, recovery position, shoulder elevation)

b.     Insert Nasal pharyngeal airway

c.     Insert Supraglottic Device (LMA, King-LT, etc)

d.     Perform Tracheal Intubation

e.     Perform Surgical Cricothyrotomy (Not recommended for under 10 yrs)

f.      Perform Needle Cricothyrotomy

3.     Breathing:

a.     Application of effective occlusive chest seal

b.     Assist Ventilations with Bag Valve Mask

c.     Apply Oxygen

d.     Apply Occlusive Dressing

e.     Perform Needle Chest Decompression

4.     Circulation:

a.     Gain Intravascular Access

b.     Gain Intraosseous Access

c.     Apply saline lock

d.     Administer IV/IO medications and IV/IO fluids

e.     Administer blood products

5.     Wound management:

a.     Apply Eye Shield

b.     Apply Dressing for evisceration

c.     Apply Extremity Splint

d.     Apply Pelvic Binder

e.     Initiate Basic Burn Treatment

f.      Initiate Treatment for Traumatic Brain Injury

6.     Prepare Casualty for Evacuation:

a.     Move Casualty (drags, carries, lifts)

b.     Apply Spinal Immobilization Devices

c.     Secure casualty to litter

d.     Initiate Hypothermia Prevention

7.     Other Skills:

a.     Perform Hasty Decontamination

a.     Initiate Casualty Monitoring

b.     Establish Casualty Collection Point

c.     Perform Triage

Pediatric Tactical Emergency Casualty Care

EVACUATION CARE (EVAC):

Goals:

1.      Maintain any life saving interventions conducted during DTC and ITC phases

2.      Provide rapid and secure extraction to a appropriate level of care

3.      Avoid additional preventable causes of death


Principles:

1.      Reassess the casualty or casualties

2.      Rapidly evacuate patients/casualties is critical

3.      Utilize additional resources to maximize advanced care

4.      Avoid hypothermia

5.      Communication is critical, especially between tactical and non tactical EMS teams.

Guidelines:

1.      Reassess all interventions applied in previous phases of care. If multiple wounded, perform primary triage.
2.      Airway Management:

a.      The principles of airway management in Evacuation Care are similar to that in ITC with the addition of increased utility of supraglottic devices and endotracheal intubation.
b.      Unconscious casualty without airway obstruction:

i.       Chin lift or jaw thrust maneuver

ii.     Nasopharyngeal airway

iii.   Place casualty in the recovery position

iv.    Caution advised in patients with suspected C-spine injury

b.     Casualty with airway obstruction or impending airway obstruction:

i.       Recovery position

ii.     Naso/oropharyngeal airway

iii.    Airway positioning may be enhance by elevation of shoulders

iv.    Bag mask ventilation is equivalent to intubation in the pediatric pre-hospital setting

Pediatric Tactical Emergency Casualty Care

v.      If previous measures unsuccessful, it is prudent to consider supraglottic Devices (King LT, LMA, etc), endotracheal intubation with Rapid Sequence Intubation.
vi.    Needle cricothyroidotomy recommended if signs of puberty are absent

vii.  Surgical cricothyroidotomy only recommended in patients with signs of puberty
c.      Following intubation, continuously monitor for ETT dislodgment, obstruction and equipment failure.
d.      If attached to a mechanical ventilator, consider lung protective strategies and reassess for respiratory decline in patients with potential pneumothoraces.
e.      Use of end-tidal CO2 monitoring is recommended when available.

f.       Prophylactic hyperventilation is not recommended

3.      Breathing:

a.      Reassess casualties who have had chest seals applied or had needle thoracostomy. If there are signs of continued or progressive respiratory distress:
i.       Consider repeating needle decompression. If this results in improved clinical status, the decompression can be repeated multiple times.
ii.     If appropriate provider scope of practice and approved local protocol, consider placing a chest tube if no improvement of respiratory distress after decompression if long duration or air transport is anticipated.
b.     All open chest wounds should be treated by immediately applying an occlusive material to cover the defect and securing it in place. Monitor the casualty for the potential development of a subsequent tension pneumothorax. Tension pneumothoraces should be treated as described in ITC.

c.      Administration of oxygen may be of benefit (absent an environmental risk for fire or explosion) for all traumatically injured patients, especially for the following types of casualties:
i.       Low oxygen saturation by pulse oximetry

ii.     Injuries associated with impaired oxygenation

iii.    Unconscious casualty

iv.    Casualty with TBI (maintain oxygen saturation > 90%)

v.      Casualty in shock


Pediatric Tactical Emergency Casualty Care

vi.    Casualty at altitude

vii.  Casualties with pneumothoraces

4.      Bleeding:

a.      Fully expose wounds to reassess for unrecognized hemorrhage and control all sources of major bleeding.
b.     If not already done, use a tourniquet or an appropriate pressure dressing with deep wound packing to control life-threatening external hemorrhage that is anatomically amenable to such treatment. For any traumatic total or partial amputation, a tourniquet should be applied regardless of bleeding.

c.      Reassess all tourniquets that were applied during previous phases of care. Expose the injury and determine if a tourniquet is needed.
i.       Tourniquets applied in prior phases that are determined to be effective in controlling hemorrhage should remain in place if the casualty can be rapidly evacuated to definitive medical care.
ii.     If ineffective in controlling hemorrhage or if there is any potential delay in evacuation to care, apply a new tourniquet immediately above the first.
iii.    If delay to definitive care longer than 2 hours is anticipated and wound for which tourniquet was applied is anatomically amenable, attempt a tourniquet downgrade as described in ITC (this should be a paramedic or MD action).

iv.    A distal pulse check should be performed on any limb where a tourniquet is applied. If a distal pulse is still present, consider additional tightening of the tourniquet or the use of a second tourniquet, side by side and proximal to the first, to eliminate the distal pulse.

v.      Expose and clearly mark all tourniquet sites with the time of tourniquet application. Use an indelible marker.
5.       Fluid resuscitation:

a.      If casualty displays signs of shock (altered mental status in the absence of brain injury, weak or absent peripheral pulses, and/or change in pulse character) resuscitation should be directed towards restoration of peripheral pulses and improvement of mental status.

b.     If BP monitoring is available, maintain target systolic BP 70mmHg or Mean Arterial Pressure greater than 60 mm Hg in children under 10 (minimum normal systolic BP = 70 + (Age x 2).


Pediatric Tactical Emergency Casualty Care

c.      Establish intravascular access if not performed in ITC phase. Consider primary intraosseous access in Pediatric population
d.     Management of resuscitation as in ITC with the following additions:

i.       If in shock and blood products are not available or not approved under scope of practice/local protocols resuscitate as in ITC.
ii.     If in shock and blood products are available with an appropriate provider scope of practice under an approved medical protocol:
1.      Resuscitate with 10-15 cc/kg of plasma (FFP) and 10-15 cc/kg of packed red blood cells (PRBCs) in a 1:1 ratio.
2.      If blood component therapy is not available, and appropriate training, testing and protocols are in place, consider transfusing fresh whole blood.
3.      Continue resuscitation as needed to maintain target BP or clinical improvement.
iii.    If a casualty with an altered mental status due to suspected TBI has a weak or absent peripheral pulse, resuscitate as necessary to maintain mid age-specific systolic blood pressure range, or a strong peripheral pulse.
iv.    If suspected TBI and casualty not in shock, raise the casualty’s head to 30 degrees and maintain MAP > 60mm Hg with volume resuscitation or vasopressor medications, if indicated and approved under scope of practice/local protocols.

6.      Prevention of hypothermia:

a.      Continue all efforts to eliminate heat loss as operationally feasible, after life-saving interventions have been employed.
b.     Minimize casualty’s exposure to the elements. Move into a medic unit, warmed vehicle, or warmed structure if possible. Ensure transport vehicle climate control system does not worsen hypothermia.
c.      Replace wet clothing with dry if possible. Place the casualty onto an insulated surface as soon as possible.
d.     Cover the casualty with commercial warming device, dry blankets, poncho liners, sleeping bags, or anything that will retain heat and keep the casualty dry.
e.      Warm fluids are preferred if IV fluids are required.

7.      Monitoring


Pediatric Tactical Emergency Casualty Care

a.      Institute electronic monitoring if available, including pulse oximetry, cardiac monitoring, etCO2 (if assisted ventilation or altered mental status), and blood pressure.
b.     Obtain and record vital signs.

8.      Reassess casualty:

a.      Complete secondary survey checking for additional injuries. Inspect and dress known wounds that were previously deferred.
b.     Determine mode and destination for evacuation to definitive care.

c.      Splint known/suspected fractures and recheck pulses.

d.      Apply pelvic binding techniques for suspected pelvic fractures.

e.      Consider the mechanism of injury and the need for spinal immobilization. Spinal immobilization is not necessary for casualties with penetrating trauma if the patient is neurologically intact. Patients may be clinically cleared from spinal immobilization under a locally approved protocol if they have none of the following:

i.       Midline c-spine tenderness

ii.     Neurologic impairment

iii.    Altered mental status

iv.    Distracting injury

9.      Provide analgesia as necessary.

a.      Mild pain:

i.       Consider oral non-narcotic medications

ii.     Avoid the use of non-steroidal anti-inflammatory medications (e.g. aspirin, ibuprofen, naproxen, ketorolac, etc) in the trauma patient as these medications interfere with platelet functioning and may exacerbate bleeding

b.     Moderate to severe pain:

i.       Narcotic pain medications should be utilized per protocol. Consider utilization of mucosal atomizer devices (MAD). Exercise caution when using narcotic medications (e.g. fentanyl citrate.) and/or Ketamine for moderate to severe pain in pediatric patients due to their higher volumes of distribution.


Pediatric Tactical Emergency Casualty Care

i.       Place patient on appropriate monitor

ii.     Consider adjunct administration of anti-emetic medicines

iii.   Have naloxone readily available whenever administering opiates
iv.    Monitor for adverse effects such as respiratory depression or hypotension.

10.   Burns:

c.      Burn care is consistent with the principles described in ITC.

d.      Smoke inhalation, particularly in a confined space, may be associated with significant carbon monoxide and cyanide toxicity. Patients with signs of significant smoke inhalation plus:
ii.     Significant symptoms of carbon monoxide toxicity should be treated with high flow oxygen if available
iii.   Significant symptoms of cyanide toxicity should be considered candidates for cyanide antidote administration
e.      Be cautious of off-gassing from patient in the evacuation vehicle if there is suspected chemical exposure (e.g. cyanide) from the fire.
f.       Consider early airway management if there is a prolonged evacuation period and the patient has signs of significant airway thermal injury (e.g. singed facial hair, oral edema, carbonaceous material in the posterior pharynx and respiratory difficulty).

11.   Prepare casualty for movement: Consider environmental factors for safe and expeditious evacuation. Secure casualty to a movement assist device when available. If vertical extraction required, ensure casualty secured within appropriate harness, equipment assembled, and anchor points identified.

12.   Communicate with the casualty, transporting crew and with the accepting facility. Encourage, reassure and explain care to patient and parents.
13.   Cardiopulmonary resuscitation (CPR) may have a larger role during the evacuation phase especially for patients with electrocution, hypothermia, non traumatic arrest or near drowning.
a.      Consider rescue breaths in small children with deteriorating cardiopulmonary status.

Pediatric Tactical Emergency Casualty Care

b.      Consider bilateral needle decompression for victims of torso or polytrauma with no respirations or pulse to ensure tension pneumothorax is not the cause of cardiac arrest prior to discontinuation of care.
14.   Documentation of Care: Continue or initiate documentation of clinical assessments, treatments rendered, and changes in the casualty’s status in accordance with local protocol. Forward this information with the casualty to the next level of care.

Current recommendations include the use of arterial tourniquets (TQ) in appropiate paediatric trauma patients.
But just how effective are they? The efficacy is less clear.
This study tested 5 different TQ's on two simulated paediatric models, with differing limb diameter replicating various age groups and percentiles.
This study suggested that the test windlass TQs can be applied effectively to upper and lower extremities of children aged 5 years and older in the 50%th percentile for limb circumference. In younger children windlass TQ efficacy is variable.
This study suggests that TQs should remain in use for haemorrhage control in paediatric patients and further evidence is required to better understand the true efficacy.
Have you applied a TQ to a paediatric? Was it effective?

Sweating the Little Things: Tourniquet Application Efficacy in Two Models of Pediatric Limb Circumference.

Abstract

BACKGROUND:

Current military recommendations include the use of tourniquets (TQ) in appropriate pediatric trauma patients. Although the utility of TQs has been well documented in adult patients, the efficacy of TQ application in pediatric patients is less clear. The current study attempted to identify physical constraints for TQ use in two simulated pediatric limb models.

METHODS:

Five different TQ (Combat Application Tourniquet (CAT) Generation 6 and Generation 7, SOFTT (SOF Tactical Tourniquet), SOFTT-W (SOF Tactical Tourniquet - Wide), SWAT-T (Stretch Wrap and Tuck - Tourniquet) and a trauma dressing were evaluated in two simulated pediatric limb models. Model one employed four cardiopulmonary resuscitation (CPR) manikins simulating infant (Simulaids SaniBaby), 1 year (Gaumard HAL S3004), and 5 years (Laerdal Resusci Junior, Gaumard HAL S3005). Model two utilized polyvinyl chloride (PVC) piping with circumferences ranging from 4.25" to 16.5". Specific end-points included tightness of the TQ and ability to secure the windlass (where applicable).

RESULTS:

In both models, the ability to successfully apply and secure the TQ depended upon the simulated limb circumference. In the 1-year-old CPR manikin, all windlass TQs failed to tighten on the upper extremity, while all TQs successfully tightened at the high leg and mid-thigh. With the exception of the CAT7 and the SOFTT-W at the mid-thigh, no windlass TQ was successfully tightened at any extremity location on the infant. The SWAT-T was successfully tightened over all sites of all CPR manikins except the infant. No windlass TQ was able to tighten on PVC pipe 5.75" circumference or smaller (age < 24 months upper extremity). All windlass TQs were tightened and secured on the 13.25" and 15.5" circumference PVC pipes (age 7-12 years lower extremity, age >13 years upper extremity). The SWAT-T was tightened on all PVC pipes.

DISCUSSION:

The current study suggests that commercial windlass TQs can be applied to upper and lower extremities of children aged 5 years and older at the 50%th percentile for limb circumference. In younger children, windlass TQ efficacy is variable. Further study is required to better understand the limitations of TQs in the youngest children, and to determine actual hemorrhage control efficacy.
Torniquete SICH en Pediatricos by Dr. Ramon REYES, MD

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