Pediatric Tactical Emergency Casualty Care (TECC)
Guidelines
Developed by: The Committee for Tactical Emergency
Casualty Care
 |
Current
as of July 2023
Disclaimer:
These are guidelines only intended primarily for the high-threat
environment where traditional resources
may not be available, and there are competing safety, operational, and patient
care priorities. They do not supersede or substitute for
departmental/agency operational protocols being delivered
by qualified providers
under the guidance
of direct or indirect medical
oversight.
Why did C-TECC
develop these guidelines?
Children under 18 years old comprise about 25% of the population and
are at a disproportionate disadvantage
when they become injured in the prehospital environment. This is especially true when
their injuries involve hemorrhage, hypothermia, head injury, and severe
emotional trauma. Tactical responders need to recognize and
mitigate these conditions proactively to optimize
patient outcomes. These guidelines
are complementary to the general C-TECC Guidelines and the principles of
pediatric resuscitation. They are
intended to be used as a tool for
departments and agencies to prepare to respond to the needs for patients of all
ages in the unique environments.
Defining the pediatric patient:
There is no
consensus and a high degree of variability on the definition of a pediatric
patient across healthcare systems
around the world. For operational
simplicity for the purposes of these guidelines,
a pediatric patient is one who by
observation does not appear to have reached puberty.
Organization of these guidelines:
These pediatric guidelines follow the same conceptual format as the C-TECC Guidelines, which emphasize three phases of the
tactical/operational environment, each which requires a unique approach
towards patient care:
1. Direct Threat
2.
Indirect Threat
3. Evacuation
Section I: Direct Threat
Care
Goal
·
Accomplish the mission objectives
while mitigating the risk to the injured, to responders, and to the public
Key Principles:
·
Threats and hazards in this environment are dynamic and require ongoing
assessment and mitigation
·
Minimal patient care interventions
are warranted in this phase. CPR and
other advanced interventions should not be performed in the
Direct Threat environment.
·
Accessing and removing
the injured from the threat
should be a priority
·
Mitigate the psychosocial impact to
the pediatric victim by using simple, calm language (e.g., “I’m a police officer and I’m going to help you”).
Guidelines:
1. Execute a rescue
plan to reduce the risk to the injured from ongoing direct
threat by using
one or more of these strategies:
a.
Direct the pediatric patient
to self-extricate to a safer position using simple, age- appropriate
commands. Use simple phrases that are
understandable by a child and which
are actionable (e.g., “look
at my face and crawl to
me right now”)
b.
Mitigate the risk to the patient and providers
c.
Direct another person to assist
with extricating the pediatric patient to a safer position
d.
Physically remove the patient
e.
Consider a rescue plan for a
patient that is unable to be extricated by other means (e.g., unresponsive,
inaccessible, or otherwise unable to move)
2.
Stop life threatening external
hemorrhage
a.
Apply immediate, purposeful, focused manual pressure
to the bleeding source
b.
Apply junctional pressure
if needed to supplement
c.
Apply a tourniquet to the patient
with uncontrolled severe extremity bleeding or
an amputation
i.
Apply the tourniquet as high (proximal) on the limb as possible
ii.
Apply to bare skin if possible
iii.
Apply a second tourniquet to an
extremity that continues to bleed if necessary
1.
Apply proximal to the existing
tourniquet if able
2.
Apply to bare skin if possible
iv.
Some tourniquets may not function as intended on small limbs-
know your equipment limitations
d. Continue
to apply manual pressure to the source or to a junctional location as needed
3.
Support the airway
a.
Place, or direct the patient to be
placed, into the best position to protect the airway (e.g., recovery
position or sitting up)
b. Consider rapid,
high-yield airway interventions if needed
i.
Manual positioning
ii.
Placement of an airway adjunct
Goals:
Section II: Indirect
Threat Care
·
Leverage this phase of relative safety to rapidly stabilize
additional time-sensitive life- threatening
injuries to the patient to permit safe extraction to more definitive treatment and evacuation
·
The threat remains at this point
and as such, so does the need for heightened awareness to the safety
and security of the responders and
the patients
Key Principles:
·
Conduct a rapid patient assessment and initiate life-saving interventions
·
Do not delay patient extraction for non-life-saving interventions
·
Consider establishing a casualty (patient)
collection point(s)
·
Do not unnecessarily delay the movement
of the patient towards definitive care
·
Prepare for patient
evacuation
·
Be prepared to document any care rendered
·
Anticipate for the possibility of extended/prolonged care under the phase of Indirect Threat
Guidelines:
1. Assess patient using the Pediatric Assessment Triangle (Appendix 1)
to identify major deficits
a.
General appearance
b. Work of Breathing
c. Circulation to Skin
2. Expose, assess and control ongoing
severe bleeding
a.
Apply aggressive direct manual
pressure to the source of the bleeding immediately
b.
Apply a tourniquet if necessary
c. Utilize trauma
dressings to control
bleeding at the source
i.
Hemostatic trauma dressings are
appropriate to use in pediatric patients if
available
ii.
Apply using deep wound packing technique
iii. Apply a pressure dressing
over the packed
wound
d. Re-assess any tourniquets that were already
applied to the patient
i.
Assess for distal pulses on
extremities with tourniquets applied and tighten device if present
ii.
Expose skin and apply a tourniquet
2-3 inches above wound for severe extremity bleeding if not already done (see Section I)
e.
Expose and clearly
mark tourniquet site with the time of application if possible
f. For prolonged
care under Indirect
Threat, consider a tourniquet conversion
i.
If the
delay to definitive care will
be longer than 2
hours and
1. The patient
is not in hemorrhagic shock
2. The bleeding
wound can be visualized and accessed
3.
The tourniquet is not controlling
bleeding from a partial or complete amputation
4. The patient
has not already
had a tourniquet downgrade attempted
ii.
Apply a new tourniquet proximal to
the existing device and be prepared to tighten if necessary
iii.
Expose and pack the previously bleeding wound site
1.
Use a hemostatic trauma dressing if available
iv. Apply a pressure dressing
to the wound site
v. Slowly remove
the first tourniquet and continuously assess
for bleeding
1.
If
bleeding recurs, tighten
the new tourniquet until hemostasis is obtained
g. Consider
the use of tranexamic acid (TXA) in patients with suspected or actual massive
hemorrhage
i.
TXA use should only be undertaken
in a pediatric trauma system-of-care setting
where pre-event coordination with local medical infrastructure has taken place
ii.
Suggested dose: 15 mg/kg loading
dose followed by 2 mg/kg/hour for 8 hours
iii.
Only initiate if less than 3 hours from time of injury, but ideally within
the first 30 minutes from time of injury
iv.
Consider administering TXA after
resuscitation with whole blood has occurred
3.
Support airway and breathing
a. Assess patient
for adequacy of airway and respiratory effort
i. Look, listen,
and feel
ii. Consider pulse
oximetry if available with a
goal of over 94% on room air
b. If necessary, intervene to open and maintain
a patent airway.
Consider these interventions:
i.
Manually position airway
1. Head-tilt/chin-lift, or
2. Manual jaw thrust (open
mouth first)
ii.
Suction airway (avoid putting
fingers in mouth,
and use caution for vaso-
vagal response from aggressively suctioning hypopharynx)
iii.
Allow patient to assume most
comfortable position, which may be lateral
recumbent or sitting up. For
recumbent infants and younger children, elevate
the shoulders with gentle support (e.g., folded towel) to optimize airway
positioning
iv.
Maintain a high index of suspicion
for potential airway worsening in a patient with inhalational burns or
other injuries
c. Support ventilations as needed
i.
basic airway adjunct (NP or OP
airway) and effective bag-valve-mask ventilation are the
initial intervention
ii. If unable
to ventilate, consider
more advanced airway support
1. Extraglottic (supraglottic) airway
2.
If a surgical airway is indicated,
needle cricothyroidotomy is recommended over surgical approach
for pediatric patients
3. Intubation if unable to manage airway
with extraglottic airway
iii. Consider administering oxygen
iv. Avoid hyperventilation with assisted ventilations
d. Consider the need to prevent or treat a tension pneumothorax in patients with
unstable or deteriorating respiratory effort
i.
Apply a
seal to any open chest, back, or
neck wounds
1.
Ideally this is a vented
commercial chest seal
2.
Monitor patient for possible
development of tension pneumothorax, especially if a non-vented chest seal is applied
ii.
Perform needle decompression on the side of the injury
1.
Infants and small children require
a smaller needle than adults for decompression. Consider a 5cm 14g or 16g needlei.
2. Landmarks for insertion are the same as for adults
a.
2nd intercostal
space at the mid-clavicular line
b. 4-5th intercostal space at the mid-axillary line
3.
Consider bilateral needle
decompression in the peri-cardiac arrest and traumatic arrest patient
4.
Assess circulatory status
a. For a patient in suspected shock
i. Ensure that external hemorrhage is being aggressively controlled
ii. Obtain IV/IO access promptly
iii. Warm fluids
are preferred
iv. Consider blood products for a patient
in suspected hemorrhagic shock:
1. Transfuse with low-titer O-negative whole blood (LTOWB)
10 mL/kg in children one year or older
2. Transfuse
a 1:1 ratio of packed red blood cells (PRBC) and plasma at 10 mL/kg each
v. If
blood not available, or suspected shock of non-hemorrhagic etiology, consider
a bolus of 20 mL/kg
normal saline or lactated Ringer’s
solution
vi. Consider
repeat bolus up to a maximum of 60 mL/kg if still demonstrating signs/symptoms of shock
vii.
Continually assess patient and slow
the rate of IV fluid administration if patient
improves or recovers to minimal blood pressure range for age or recovers a strong peripheral pulse
1. Systolic
BP goal: 60 mmHg <1 month of age,
70 mmHg + [2 x age in years] in
children 1 month to 10 years of age, 90 mmHg in children 10 years of
age or older
b. Cardiopulmonary
resuscitation (CPR) and defibrillation are typically not successful in patients of any age who have suffered traumatic
cardiac arrest or blast injuries. In certain circumstances (e.g., electrical
injuries, drowning, suffocation,
etc.), CPR may be of benefit and should be considered in the context of available resources.
c.
Oral intake of fluids may be
encouraged if the patient is conscious and the airway is patent
5.
Prevent and treat hypothermia
a. Reduce heat loss from conduction with the ground
b. Remove wet clothing and dry the patient
c.
Cover the patient with warm, dry
insulating material covered with a barrier to
keep it dry
6.
Prevent and treat hypoglycemia
a.
Check fingerstick blood glucose if
able-- low blood sugar is a common co- pathology
in injured children. Consider using
70 mg/dL as the threshold for hypoglycemia in infants and children.
b.
Treatment could involve oral intake
of high-carbohydrate food or IV administration
of dextrose at 2 mg/kg. D10 is the
preferred formulation for pediatric dosing.
7.
Provide analgesia as needed
a. Assess the pain level
b. Consider acetaminophen (15 mg/kg) every
four hours for mild to moderate
pain
c.
In patients over 3 months old,
consider ketamine for analgesia for moderate to severe pain as it has a favorable risk profileii. Use weight-based dosing and administer slowly to mitigate possible
side effects.
i.
Suggested oral dose is
0.2-0.5 mg/kg every 8 hours
ii. Suggested IM dose
is 0.2-0.5 mg/kg slow push
iii. Suggested IV dose
is 0.1-0.2 mg/kg slow push
d. In
an infant, sugar is a proven analgesic. If
the airway is patient and the child is awake,
dip a pacifier or gloved finger into a sugary solution (not honey) and offer as often as needed
e.
Narcotic pain medications are also
appropriate for use in the pediatric population under local protocol guidance, with IV, IM, and intranasal (IN)
options available. Use weight-based
dosing and ensure that there is immediate access to the reversal agent
naloxone. Suggested dosages:
i. Fentanyl IM/IN:
1 mcg/kg (not to exceed
100mcg)
ii. Fentanyl
IV/IO: 1 mcg/kg titrate to effect at rate of 50 mcg/min slow IVP (not to exceed 100mcg)
iii. Morphine IM: 0.1 mg/kg
iv. Morphine
IV/IO: 0.1 mg/kg titrate to effect at rate of 2 mg/min slow IVP (not
to exceed 20 mg)
f.
Consider the use of
ondansetron if nausea or vomiting occurs in a child over 8kg.
i. Suggested dose: 0.1 mg/kg IV for patients 1 month-12 years
ii. Suggested dose:
4 mg IV for patients over 12 years
iii. Suggested dose:
4 mg PO children 4-12 years
iv. Suggested dose:
8 mg PO children over 12
years
8.
Head injury
a.
Consider use of a
pediatric-modified GCS scale for infants and children in patients with
traumatic head injuriesiii (Appendix
1)
i. Peds GCS £ 12 suggests
non-mild traumatic brain
injury
ii. Peds GCS £ 8 suggests need for airway
support
iii. Peds GCS £ 6 suggests
need for surgical
management of TBI
b. Restrict cervical
spine motion if indicated based on mechanism of injury
i. In
the absence of commercial immobilization devices, consider manual stabilization, a towel roll, or
other improvised technique
c.
Avoid hypoxia (see above)
d. Avoid
hyper- or hypoventilation- the goal is normocarbia (ETCO2 of 35-40 mmHg)
e. Consider elevating the head to about 30°
f.
Treat aggressively for shock if
present. Hypotension can double the
mortality associated with traumatic brain injury.
g.
Avoid hypothermia
9. Package for Movement
a.
Utilize a movement assistive device
if possible (basket, portable stretcher, wheeled litter, etc.)
b.
Minimize unnecessary movement
c. Ensure patient
is well secured
and is ready for the anticipated mode of extraction
d.
Prevent hypothermia
10.
Mitigate the psychosocial impact
a. As detailed
above, plus
b. With
all ages of children it is important to express empathy-- tell them the truth about what to expect, warn them if
something will hurt, and describe what you are
doing to help them
c. Talk to the child
directly if possible
d.
Keep the patient
with the caregiver
to the extent possible
Goals:
Section III: Evacuation Care
·
Now that the patient and providers
are removed from the probability of ongoing injuries from the threat, the top priority is the maintenance and
improvement of the lifesaving interventions initiated during the Direct and Indirect
Threat phases of care
·
Additionally, a more comprehensive
patient management approach can be taken to
identify and treat any
remaining threats to the
patient’s health
·
The focus continues toward moving the patient to definitive care with minimal
delays Key Principles:
·
Closely monitor the patient for changes in condition
·
The medical management goals for
this section overlap significantly with those from Indirect Threat
Guidelines:
1. Assess patient using the Pediatric Assessment Triangle (Appendix 1)
to identify major deficits
a. General appearance
b.
Work of Breathing
c.
Circulation to Skin
2.
Reassess and control any ongoing severe
bleeding
a.
Apply aggressive direct manual
pressure to the source of the bleeding immediately
b. Apply a tourniquet if necessary
c.
Utilize trauma dressings to control bleeding
at the source
i.
Hemostatic trauma dressings are
appropriate to use in pediatric patients if
available
ii. Apply using
deep wound packing technique
iii. Apply a pressure dressing
over the packed
wound
d. Re-assess any tourniquets that were already
applied to the patient
i.
Assess for distal pulses on
extremities with tourniquets applied and tighten device if present
ii.
Expose skin and apply a tourniquet
2-3 inches above wound for severe extremity bleeding if not already done
e.
Expose and clearly
mark tourniquet site with the time of application if possible
f. For longer
transport times, consider
a tourniquet conversion
i.
If the
delay to definitive care will
be longer than 2
hours and
1. The patient
is not in hemorrhagic shock
2. The bleeding
wound can be visualized and accessed
3.
The tourniquet is not controlling
bleeding from a partial or complete amputation
4. The patient
has not already
had a tourniquet downgrade attempted
ii.
Apply a new tourniquet proximal to
the existing device and be prepared to tighten if necessary
iii.
Expose and pack the previously bleeding wound site
1.
Use a hemostatic trauma dressing if available
iv. Apply a pressure dressing
to the wound site
v. Slowly remove
the first tourniquet and continuously assess
for bleeding
1.
If
bleeding recurs, tighten
the new tourniquet until hemostasis is obtained
g. Consider
the use of tranexamic acid (TXA) in patients with suspected or actual massive
hemorrhage
i.
TXA use should only be undertaken
in a pediatric trauma system-of-care setting
where pre-event coordination with local medical infrastructure has taken place
ii.
Suggested dose: 15 mg/kg loading
dose followed by 2 mg/kg/hour for 8 hours
iii.
Only initiate if less than 3 hours
from time of injury, but ideally within the
first 30 minutes from time of
injury
iv.
Consider administering TXA after
resuscitation with whole blood has occurred
3.
Reassess and support airway
and breathing
a.
Assess patient for adequacy of airway and respiratory effort
i. Look, listen,
and feel
ii. Consider pulse
oximetry if available with a
goal of over 94% on room air
b. If necessary, intervene to open and maintain
a patent airway.
Consider these interventions:
i.
Manually position airway
1. Head-tilt/chin-lift, or
2. Manual jaw thrust (open
mouth first)
ii.
Suction airway (avoid putting
fingers in mouth,
and use caution
for vaso- vagal
response from aggressively
suctioning hypopharynx)
iii.
Allow patient to assume most
comfortable position, which may be lateral
recumbent or sitting up. For
recumbent infants and younger children, elevate
the shoulders with gentle support (e.g., folded towel) to optimize airway
positioning
c.
Support ventilations as needed
i.
basic airway adjunct (NP or OP
airway) and effective bag-valve-mask ventilation are the
initial intervention
ii.
If unable to ventilate, consider
more advanced airway support
1. Extraglottic (supraglottic) airway
2.
If a surgical airway is indicated,
needle cricothyroidotomy is recommended over surgical approach
for pediatric patients
3. Intubation if unable to manage airway
with extraglottic airway
iii. Consider administering oxygen
iv. Avoid hyperventilation with assisted ventilations
d. Consider the need to prevent or treat a tension pneumothorax in patients with
unstable or deteriorating respiratory effort
i.
Apply a
seal to any open chest, back, or
neck wounds
1.
Ideally this is a vented
commercial chest seal
2.
Monitor patient for possible
development of tension pneumothorax, especially if a non-vented chest seal is applied
ii.
Perform NEEDLE DECOMPRESSION
(terminology change at SOMA?) on the side of the injury
1. Infants
and small children require a smaller needle than adults for decompression. Consider a 5cm 14g or 16g needleiv.
2. Landmarks for insertion are the same as for adults
a. 2nd intercostal space at the mid-clavicular line
b. 4-5th intercostal space at the mid-axillary line
3.
Consider bilateral needle
decompression in the peri-cardiac arrest and traumatic arrest patient
4.
Reassess circulatory status
a.
For a patient
in suspected shock
i. Ensure that external hemorrhage is being aggressively controlled
ii. Obtain IV/IO access promptly
iii. Warm fluids
are preferred
iv. Consider blood products for a patient
in suspected hemorrhagic shock:
1. Transfuse with low-titer O-negative whole blood (LTOWB)
10 mL/kg in children one year or older
2.
Transfuse a 1:1 ratio of packed red
blood cells (PRBC) and plasma at 10 mL/kg
each
v.
If blood not available, or
suspected shock of non-hemorrhagic etiology,
consider a bolus
of 20 mL/kg normal saline
or lactated Ringer’s
solution
vi. Consider
repeat bolus up to a maximum of 60 mL/kg if still demonstrating signs/symptoms of shock
vii.
Continually assess patient and slow
the rate of IV fluid administration if patient
improves or recovers to minimal blood pressure range for age or recovers a strong peripheral pulse
1. Systolic
BP goal: 60 mmHg <1 month of age,
70 mmHg + [2 x age in years] in
children 1 month to 10 years of age, 90 mmHg in children 10 years of
age or older
b.
Cardiopulmonary resuscitation (CPR)
and defibrillation are typically not successful
in patients who have suffered from traumatic cardiac arrest or blast injuries.
In certain circumstances (e.g., electrical injuries, drowning,
suffocation, etc.) CPR may be of
benefit and should be considered in the context of available resources.
c.
Oral intake of fluids may be
encouraged if the patient is conscious and the airway is patent
5.
Prevent and treat hypothermia
a. Reduce heat loss from conduction with the ground
b. Remove wet clothing and dry the patient
c.
Cover the patient with warm, dry
insulating material covered with a barrier to
keep it dry
6.
Prevent and treat hypoglycemia
a.
Check fingerstick blood glucose if
able-- low blood sugar is a common co- pathology in injured
children
b.
Treatment could involve oral intake
of high-carbohydrate food or IV administration of dextrose at 2 mg/kg.
D10 is the preferred formulation for pediatric dosing.
7. Reassess for pain and provide
analgesia as needed
a. Assess the pain level
b. Consider acetaminophen (15 mg/kg) every
four hours for mild to moderate
pain
c.
In patients over 3 months old,
consider ketamine for analgesia for moderate to severe pain as it has a favorable risk profilev. Use weight-based dosing and administer slowly to mitigate possible
side effects.
i.
Suggested oral dose is
0.2-0.5 mg/kg every 8 hours
ii. Suggested IM dose
is 0.2-0.5 mg/kg slow push
iii. Suggested IV dose
is 0.1-0.2 mg/kg slow push
d.
In an infant, sugar is a proven
analgesic. If the airway is patient
and the child is awake, dip a
pacifier or gloved finger into a sugary solution (not honey) and offer as often as needed
e.
Narcotic pain medications are also
appropriate for use in the pediatric population under local protocol guidance, with IV, IM, and intranasal (IN)
options available. Use weight-based
dosing and ensure that there is immediate access to the reversal agent
naloxone. Suggested dosages:
i. Fentanyl IM/IN:
1 mcg/kg (not to exceed
100mcg)
ii. Fentanyl IV/IO:
1 mcg/kg titrate
to effect at rate of 50 mcg/min
slow IVP (not
to exceed 100mcg)
iii. Morphine IM: 0.1 mg/kg
iv. Morphine
IV/IO: 0.1 mg/kg titrate to effect at rate of 2 mg/min slow IVP (not
to exceed 20 mg)
f.
Consider the use of
ondansetron if nausea or vomiting occurs in a child over 8kg.
i. Suggested dose: 0.1 mg/kg
IV for patients 1 month-12
years
ii. Suggested dose:
4 mg IV for patients over 12 years
iii. Suggested dose:
4 mg PO children 4-12 years
iv. Suggested dose:
8 mg PO children over 12
years
8. Consider the use of antibiotics for patients with penetrating
trauma, including eye injuriesvi
a.
For situation where extraction will
be delayed beyond several hours, consider the
one-time administration of an antibiotic under local protocol guidance
to reduce to risk of infectious complications
i. Cefazolin 30 mg/kg IV (up to 2g) for open extremity or thoracic injuries
ii. Levofloxacin 16 mg/kg IV/PO (up to 750mg) for penetrating eye injuries
iii.
Cefazolin (as above) plus
metronidazole 15 mg/kg IV loading dose for
maxillofacial trauma or involvement of the esophagus, stomach, or gut
9.
Head injury
a.
Consider use of a
pediatric-modified GCS scale for infants and children in patients with
traumatic head injuriesvii (Appendix
2)
i. Peds GCS £ 12 suggests
non-mild traumatic brain
injury
ii. Peds GCS £ 8 suggests need for airway
support
iii. Peds GCS £ 6 suggests
need for surgical
management of TBI
b. Restrict cervical
spine motion if indicated based on mechanism of injury
i. In
the absence of commercial immobilization devices, consider manual stabilization, a towel roll, or
other improvised technique
c.
Avoid hypoxia (see above)
d.
Avoid hyper- or hypoventilation-
the goal is normocarbia (ETCO2 of 35-40 mmHg)
e.
Treat aggressively for shock if present. Hypotension can double the mortality
associated with traumatic
brain injury.
f. Consider elevating the head to about 30°
g. Avoid hypothermia
10.
Burn and Smoke Inhalation
a. Aggressively monitor
airway and respiratory status
b. Have a low threshold
for intubation if airway burns are suspected
c.
Apply high-flow oxygen via non-rebreather mask if carbon
monoxide toxicity is suspected
d.
Have a low threshold for suspecting cyanide toxicity
i. Symptoms are non-specific and may be similar
to CO toxicity
ii. Patients may have a “cherry red” appearance to their skin
iii. Treatment includes
oxygen and the use of an antidote:
1. Cyanide
Antidote Kit- in pediatric patients consider using only the sodium
thiosulfate component of the kit at 1.5 mL/kg up to 50 mL
IV. The other
components of the kit contain
nitrates which can cause complications in children with smoke inhalation.
2. Hydroxocobalmin
is frequently and effectively used off-label in children at a dose
of 70 mg/kg up to 5 g IV over 15 minutes
e. Manage burns
i.
Use the “rule of 9’s” in infants
and children (see Appendix 3) or estimate
burned surface area using the surface area of the palm of the patient
which represents approximately 1% of the body surface area
ii.
Cover burned areas
with dry, clean
dressings (sterile if possible)
iii.
Aggressively mitigate hypothermia (see above)
iv.
For burns >20% TBSA begin fluid
resuscitation. A suggested strategy is:
1.
If patient suffering from
hemorrhagic shock as well, this condition takes priority for fluid resuscitation strategy
(see above)
2. For TBSA ≥
20% and Weight < 30
kg
a. Calculate estimated
intravenous fluid needs
i. >10 kg use
LR, < 10kg use D5LR
ii. 3 ml x weight
in kg x %TBSA
iii.
Include previously administered
fluids in total fluid amount
iv. Administer
half of calculated amount over the first 8 hours post burn (from time of injury)
v.
Administer remaining amount over
the next 16 hours
vi. In
addition to burn resuscitation fluid requirements, also infuse maintenance IVF of D5LR
1. 4ml/kg/hr for the first
10 Kg of body weight, then
2ml/kg/hr for the next 10 Kg of body weight,
then 1ml/kg/hr for the remaining Kg of body weight
3. Proactively monitor
and maintain normal
blood sugars
4. For children
>30kg use adult
strategy for burn resuscitation
v. Provide analgesia
(see above)
11.
Transfer safely
a.
Ensure that proper restraints are
fully applied to the victim before initiating air or ground transport:
i. Including forward/deceleration restraints over the shoulders
ii. Infants and very young
children should be transported in a
car safety seat if stable
iii. Providers should
be restrained as well
iv. Equipment must be secured
b.
Arrive safely- be judicious with
the use of lights and sirens as they are a significant cause
of patient and provider
injuries and fatalities
c.
When considering atypical
transport platforms:
i. Address preventable causes of death
prior to initiating transport
ii. If
possible, patient should remain under care by a rescuer or responder (other
than the vehicle
operator) during transport. Maintain any lifesaving intervention initiated
during prior phases.
iii.
Ideally, patient transport platform
is enclosed and optimizes safety and minimizes environmental threats to the patient
iv.
Patient should be safely restrained to the extent
possible
d.
Consider the most appropriate receiving
facility and notify them
12. Mitigate the psychosocial impact
a.
With all ages of children it is
important to express empathy-- tell them the truth about what to expect, warn them if something will hurt, and
describe what you are doing to help them
b.
Talk to the child directly
if possible
c. Keep the patient with the caregiver
to the extent possible
d. Use techniques of distraction as needed
i. For infants-
keys, a penlight, a pacifier or blanket
ii. For older children- conversation, a toy, jokes,
electronic device
e.
Contact the caregiver
if they are not with the child
f.
Don’t make promises
you can’t keep
g.
Be calm around
the patient
APPENDIX 3
Estimating burns in the context of total body surface area (TBSA)
for infant, younger child, older child, and adolescent
Courtesy of the American
Burn Association
 |
 |
APPENDIX 4 – Limiting Factors
for Pediatric Care
Direct Threat phase:
·
Data is extremely limited
as to the comparative effectiveness of commercial tourniquet use in the
pediatric population
·
A 2021 American Heart Association
consensus statement suggests the use of a windlass tourniquet for life-threatening bleeding in the pediatric
population, but does not recommend
for or against other styles of tourniquet. For
children with extremities that do not
allow adequate tightening of a windlass tourniquet, the recommendation is for
direct manual pressure and the use
of hemostatic dressingx.
·
A 2021 systematic review found that
commercial windlass tourniquets were typically
able to obtain hemostasis in children as young as 2 years old with
minimal arm circumference of 13 cm (5.1 in)xi.
Indirect Threat phase:
1.
Some EMS systems have discontinued
the use of pediatric intubation given the availability
of less invasive airway management options that pose less risk to the patient, such as bag-valve-mask ventilation with
or without airway adjuncts such as nasopharyngeal and oropharyngeal airways, or supraglottic
airways.
2.
Observational studies have
repeatedly documented that both in-hospital and field EMS providers tend to hyperventilate patients
of all ages when they are supporting ventilations mechanically. Hyperventilation
can worsen the physiologic response to trauma and decrease survival through mechanisms such as increasing
intrathoracic pressure, diminishing venous
return, decreased coronary
perfusion pressure, and vomiting.
Evacuation phase:
1.
Whole blood transfusion continues
to be validated as safe for pediatric trauma in >1 year old in a 2021 review by the American
Association of Blood Banks Clinical Transfusion Medical Committee. Recent
observational data provides a rationale for current limited use with a trend toward superior outcomesxii.
2. While
infants <1 year do routinely receive PRBC and FFP in the neonatal ICU for catastrophic bleeding, there is very
limited data about the resuscitation of infants with whole blood or PRBCs, especially in the setting
of traumatic injuries
3.
Evidence for or against the
pediatric use of tranexamic acid (TXA), a plasminogen inhibitor, is limited for pediatric patients, especially in the
prehospital setting. A 2021 meta-analysis found that TXA use in pediatric trauma
patients did not significantly affect
in-hospital outcomes and is associated with a higher risk of seizures
and a trend towards lower risk of
thromboembolismxiii, however a military study from 2014 demonstrated
that TXA was used in about 10% of 766 pediatric combat trauma
patients, and was associated with
decreased mortality with no adverse complications identifiedxiv. A small
randomized clinical trial intending to explore the feasibility
of a
larger study was
published in 2022 and demonstrated no statistical significance of
measured clinical outcomesxv.
4. While
hypocalcemia in the pediatric trauma patient is well established and likely correlates with increased mortality, there
is extremely limited information about the use
of calcium in pediatric field trauma resuscitation. The treatment of hypocalcemia is variable
in the pediatric patient and can be complexxvi. Consult local medical direction.
APPENDIX 5 – CTECC Best Practice Recommendations
Direct Threat Care:
·
Responders must be familiar with
the limitations and use of the equipment they carry and have a PACE plan for exsanguinating hemorrhage in a patient
with small extremities, such as applying direct or circumferential pressure with:
· Primary: Use commercial windlass
tourniquet
· Alternate: Use commercial elastic
tourniquet
·
Contingency: Use a tightly
stretched elastic or polymer compression bandage (e.g., ACE® bandage)
· Emergency: Apply
direct pressure and hemostatic dressing
·
Patient age, coping skills, and
maturity level will determine their ability to take direction and share information in a
life-threatening crisis. Some
children will not be able to follow
even the simplest directions under extreme conditions, and responders must be prepared to assume positive control over
the situation. Other children may be
highly capable of assisting themselves or others.
Indirect Threat Care:
·
Do not delay the initiation of
ventilatory support to set up supplemental oxygen equipment. It is far
more important to immediately begin respiratory support if needed using
room air. Oxygen can
be added later if need be.
·
Utilize length-based tapes to
estimate patient weight for medication dosing as provider and parent
estimates of pediatric patient weight are often inaccurate
·
Ketamine is gaining popularity for
analgesia in trauma patients of all ages (> 3 months), including those with head injuries given
its favorable side effect profile. Ketamine should not be used in patients 3 months or younger, howeverxvii.
Evacuation Care:
·
If a department or agency has a
blood transfusion or TXA administration protocol in place for prehospital providers, consider including pediatric patients
APPENDIX 6 – Skills Sets and Information to Reinforce
with Training Direct Threat:
·
Application of size-appropriate tourniquet using commercial and field-expedient devices
·
Rapid positioning of patient to protect airway
·
Tactical casualty extraction to
definitive care Indirect Threat
·
While these guidelines include some
interventions that are dependent on availability of certain medical equipment, the priority here is still on basic
lifesaving interventions using simple skills
·
Pediatric patients can compensate
for shock differently than adults—they may appear to be well for longer
and then rapidly deteriorate
·
Infants and children
have a smaller circulating blood volume than adults
o
A 4 kg (9
lb) infant has about
350 mL (12 oz.) total blood volume
o
A 35 kg
(80 lb) child has about 2500 mL (just over ½ a gallon)
o
For comparison, an adult
has about 5000 mL (just under
1 ½ gallons)
·
Infants and young children have
different normal respiratory rates (faster) based on agexviii so it is important to rely on
a more holistic assessment of breathing
adequacy
·
Altered mental status and the
presence of a delayed (>2 second) capillary refill time are important indicators of likely shock in
the pediatric patient. Consider
assessing capillary refill time on the forehead as well as extremities.
·
Infants and young children are at
an extreme risk for hypothermia due to an increased surface to body ratio. Hypothermia
decreases the chance for a successful outcome in trauma patients of
all ages, but especially in younger children.
· D10, D25, and D50 can all be used as a source for IV dextrose
·
Where possible, infants
typically receive D10. Children can receive D25. If necessary,
dilute D50 prior to administration to reduce the risk of a serious injury if an
IV infiltration occurs.
·
Head injuries are common in pediatric patients.
Infants and younger
children have
relatively large and heavy heads that can predispose them to
injuries during falls, accidents, and violent incidents.
·
A GCS <9 or deteriorating GCS is
suggestive of a serious traumatic brain injury
Skills Sets to Reinforce:
·
Hemorrhage Control
o
Apply tourniquet
o
Apply direct pressure
o
Apply pressure dressing
o
Apply wound packing
o
Apply hemostatic agent
·
Airway:
o Apply
manual airway maneuvers (chin lift, jaw thrust, recovery position, shoulder
elevation)
o
Insert nasopharyngeal airway
o
Insert supraglottic device
o
Perform tracheal intubation
o
Perform needle cricothyrotomy
·
Breathing:
o
Application of effective occlusive chest seal
o
Assist ventilations with Bag Valve Mask
o
Apply oxygen
o
Apply occlusive dressing
o
Perform needle chest decompression
·
Circulation:
o
Gain intravascular access
o
Gain intraosseous access
o
Apply saline lock
o
Calculate and administer IV/IO medications and IV/IO fluids
·
Wound management:
o
Apply eye shield
o
Apply dressing for evisceration
o
Apply extremity splint
o
Apply pelvic binder
·
Initiate Basic Burn Treatment
·
Initiate Treatment for Traumatic Brain Injury
·
Prepare Casualty for Evacuation:
o
Move casualty (drags,
carries, lifts)
o
Apply spinal immobilization devices
o
Secure casualty to litter
o
Initiate hypothermia prevention
·
Other Skills:
o
Perform hasty decontamination
o
Blood glucose monitoring
o
Initiate casualty monitoring
o
Establish casualty collection point
o
Perform triage
o
Utilize length-based tapes for weight
estimation and medication dosing
·
Evacuation
·
CO toxicity symptoms are
nonspecific- most common are headache, nausea, vomiting, and altered
mental status. Serious cases can result in coma, arrhythmia, and seizures.
·
Pulse oximetry is not useful for
screening for CO toxicity, but pulse CO-oximetry is a new capability on some devices in the field,
and it is useful for screening for possible CO toxicity as well as monitoring the recovery
REFERENCES
 |
i Mandt, M, Hayes,
K., Severyn, and Adelgais, K. (2019). Approprite Needle Length for Emergency Pediatric Needle Thoracostomy Using Computed Tomography. Prehospital Emergency Care, 23(5),
663-671, doi: 10.1080/10903127.2019.1566422
ii Vadivelu, N., Schermer,
E., Kodumudi, V., Belani, K., Urman, R. D., & Kaye, A. D. (2016).
Role of ketamine
for analgesia in adults and
children. Journal of anaesthesiology,
clinical pharmacology, 32(3),
298–306. https://doi.org/10.4103/0970-9185.168149
iii Children’s
Hospital of Philadelphia (ND) Emergency Department Clinical Pathway for the
Evaluation and Treatment of Children
with Acute Head Trauma. Retrived
from: https://www.chop.edu/clinical-pathway/head- trauma-acute-clinical-pathway
iv Mandt, M, Hayes,
K., Severyn, and Adelgais, K. (2019). Appropriate Needle Length for Emergency
Pediatric Needle Thoracostomy Using
Computed Tomography. Prehospital
Emergency Care, 23(5), 663-671, doi: 10.1080/10903127.2019.1566422
v Vadivelu, N., Schermer,
E., Kodumudi, V., Belani, K., Urman, R. D., & Kaye, A. D. (2016).
Role of ketamine
for analgesia in adults and
children. Journal of anaesthesiology,
clinical pharmacology, 32(3),
298–306. https://doi.org/10.4103/0970-9185.168149
vi Jones, TW,
Brady, S., and Schafermeyer, R (2020) Infections and Prophylaxis in Pediatric
Trauma Patients. Pediatric Emergency
Medicine Reports. Retrieved at: https://www.reliasmedia.com/articles/146252-infections-and- prophylaxis-in-pediatric-trauma-patients
vii Children’s
Hospital of Philadelphia (ND) Emergency Department Clinical Pathway for the
Evaluation and Treatment of Children
with Acute Head Trauma. Retrieved
from: https://www.chop.edu/clinical-pathway/head- trauma-acute-clinical-pathway
viii Horeczko, T., Enriquez, B., McGrath, N. E., Gausche-Hill, M., & Lewis, R. J. (2013). The Pediatric Assessment Triangle: Accuracy of Its Application by Nurses in the Triage
of Children. Journal of Emergency Nursing, 39(2), 182–189. https://doi.org/10.1016/j.jen.2011.12.020 Useful resource: https://www.health.ny.gov/professionals/ems/pdf/pediatricreferencecard-04.pdf
ix Das, J, Sapkota, R, Shrestha, B 2018). Pediatric dural venous sinus
thrombosis following closed head injury: an easily
overlooked diagnosis with devastating consequences. Turkish journal of trauma & emergency surgery (24), 74-77.
x Wyckoff, M. H.,
Singletary, E. M., Soar et al (2022). 2021 International Consensus on
Cardiopulmonary Resuscitation and
Emergency Cardiovascular Care Science with Treatment Recommendations: Summary
from the Basic Life Support;
Advanced Life Support; Neonatal Life Support; Education, Implementation, and
Teams; First Aid Task Forces; and the
COVID-19 Working Group. Circulation, 145(9).
https://doi.org/10.1161/cir.0000000000001017
xi Charlton, N. P., Goolsby, C. A., Zideman, D.
A., Maconochie, I. K., Morley, P. T., & Singletary, E. M. (2021). Appropriate Tourniquet Types in the
Pediatric Population: A Systematic Review. Cureus,
13(4), e14474. https://doi.org/10.7759/cureus.14474
xii Allen, E. S., Cohn, C. S., Bakhtary, S., Dunbar, N. M., Gniadek,
T., Hopkins, C. K., Jacobson, J., Lokhandwala,
P. M., Metcalf, R. A., Murphy, C., Prochaska,
M. T., Raval, J. S., Shan, H., Storch, E. K., & Pagano, M. B. (2021). Current advances in transfusion medicine
2020: A critical review of selected topics by the AABB Clinical Transfusion Medicine Committee. Transfusion, 61(9), 2756–2767. https://doi.org/10.1111/trf.16625
xiii Al-Jeabory, M.,
Gasecka, A., Wieczorek, W., Mayer-Szary, J., Jaguszewski, M. J., & Szarpak,
L. (2021). Efficacy and safety of
tranexamic acid in pediatric trauma patients: Evidence from meta-analysis. The American Journal of Emergency
Medicine, 49, 404–405. https://doi.org/10.1016/j.ajem.2021.02.009
xiv Eckert, Wertin, T. M., Tyner, S. D., Nelson,
D. W., Izenberg, S., & Martin, M. J. (2014). Tranexamic acid administration to pediatric trauma patients in a combat
setting: the pediatric
trauma and tranexamic acid study (PED-TRAX). The Journal of Trauma and Acute Care Surgery, 77(6), 852–858. https://doi.org/10.1097/TA.0000000000000443
xv Nishijima, VanBuren, J. M., Linakis, S. W.,
Hewes, H. A., Myers, S. R., Bobinski, M., Tran, N. K., Ghetti, S., Adelson, P. D., Roberts, I., Holmes, J.
F., Schalick, 3rd, Dean, J. M., Casper, T. C., & Kuppermann, N. (2022). Traumatic injury clinical trial evaluating
tranexamic acid in children (TIC-TOC): a pilot randomized trial. Academic
Emergency Medicine. https://doi.org/10.1111/acem.14481
xvi Cornelius, B. G., Clark, D., Williams, B.,
Rogers, A., Popa, A., Kilgore, P., Cvek, U., Trutschl, M., Boykin, K., & Cornelius, A. (2021). A retrospective
analysis of calcium levels in pediatric trauma patients. International Journal
of Burns and Trauma, 11(3), 267–274.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8310872/
xvii Morgan M, Perina,D, Nicole
M. Acquisto, Fallat
M, et al (2021) Ketamine
Use in Prehospital and Hospital
Treatment of the Acute Trauma Patient: A Joint Position Statement,
Prehospital Emergency Care, 25:4, 588- 592, DOI: 10.1080/10903127.2020.1801920
xviii Fleming S, Thompson M, Stevens R, et al. (2011) Normal ranges of heart rate and respiratory rate in children from birth to 18 years of age: A systematic review of observational studies. Lancet 2011; 377:1011. Reference information available at: https://www.uptodate.com/contents/image/print?imageKey=EM%2F78097
No hay comentarios:
Publicar un comentario