Safety and Prevention

Safety and Prevention

2006 American Heart Association

2006 American Heart Association 2

Scene Assessment for Out-of-Hospital Providers

Conduct a Scene Assessment

For out-of-hospital providers a scene assessment is always the first step before patient assessment. It is natural to want to rush to a seriously ill or injured child and immediately begin providing care. A brief survey of the environment, however, will identify safety concerns and risks to emergency personnel, to caregivers, and to the child. Once you identify risks, you can implement proper safety precautions and improve the chances of successful rescue or resuscitation. In assessing the scene be alert for the following: Contaminants or communicable diseases Environmental safety hazards Warning signs of crime scenes or other violence Hazardous material

Contaminants or Communi-cable Diseases

Survey the scene for risks of contamination by blood or body fluids communicable diseases (eg, evidence of chicken pox or

meningococcemia) airborne contaminants other potentially infectious material Consistent with standard precautions, treat all human blood and body fluids (eg, saliva) as infectious. Take other precautions based on identified risks present at the scene. For example, in one situation disposable gloves might be the only precaution necessary. In another situation emergency personnel might need to protect themselves with not only disposable gloves but also protective eyewear, masks, and in some cases an N95 or HEPA respirator.

Environ-mental Safety Hazards

Survey the scene for possible environmental safety hazards. Take appropriate measures to ensure the safety of all emergency personnel, caregivers, and the child before performing a patient assessment. Examples of possible safety hazards are downed power lines unstable buildings due to fire or earthquakes unstable vehicles at crash sites oncoming traffic


Warning Signs of Crime Scenes or Other Violence

If dispatched to a possible crime scene or a scene where violence or abuse has occurred, proceed cautiously. Be alert for the following warning signs: Loud voices or arguing Evidence of forced entry Weaponseither used or visible Evidence of alcohol or drug use Unusual silence Evaluate the scene carefully and take appropriate actions. Remember that your safety and the safety of your coworkers is a top priority. If the telecommunications center did not identify the site as a crime scene and you suspect that a crime has taken place, summon proper authorities immediately. Never enter the scene if your safety is not ensured. Once at the scene note the childs environment. Look for evidence of child abuse or possible maltreatment by the caregiver. Include any relevant observations of the scene in the information you provide to the receiving facility or attending physician.

Hazardous Material

Be alert to incidents that may involve hazardous materials. Examples of hazardous materials that you might encounter in the home or workplace include fuel spills or leaking gasoline paint spills pesticides and fertilizers carbon monoxide (eg, detector is alarming) unusual odors that might indicate drug manufacturing chemicals unidentified powders possible explosives Labels, shipping papers, or other materials can provide important clues to the identification of a substance as hazardous. Special personnel may need to be called to the scene to properly identify the involved substances. Many cities have trained personnel that respond to hazardous materials (hazmat) incidents as part of their duties. Local fire departments have contact information for agencies that provide guidance in toxicology, biologic and disease hazards, and hazardous chemicals. The local poison control center is another resource if there is a concern about an ill or injured child.


Reducing the Risk of SIDS

Introduction Sudden infant death syndrome (SIDS) is a major cause of death

in infants under 1 year of age, with the most deaths occurring in infants from 2 to 4 months of age.1 SIDS is sometimes called crib death. This type of death occurs suddenly and cannot be explained, even after a thorough case investigation, a complete autopsy, examination of the death scene, and review of the clinical history.2

Risk Factors for SIDS

The cause of SIDS is unknown. Probably a variety of conditions caused by several mechanisms are involved, including rebreathing asphyxia with decreased arousal and possibly blunted response to hypoxemia or hypercarbia.3 SIDS occurs much more frequently in infants who sleep prone (on their abdomen) than in infants who sleep supine (on their back) or on their side.4-6 The prone position, particularly on a soft surface, is thought to contribute to rebreathing asphyxia.3 This type of asphyxia occurs when air is trapped close to the infants mouth and nose, resulting in rebreathing (breathing of expired air). Rebreathing reduces inspired oxygen and increases carbon dioxide. Primary risk factors of SIDS include

prone sleeping position sleeping on a soft surface5,6 second-hand smoke7,8

Other factors that have been associated with an increased risk of SIDS include winter months, lower family income, male gender, a mother who smokes cigarettes or is addicted to drugs, a history of apparent life-threatening events, and low birth weight. Parent-infant bed sharing may also increase the risk of SIDS.9

Risk Reduction of SIDS

The incidence of SIDS declined 40%10 after the Back to Sleep public education campaign was introduced in the United States in 1992. This campaign educates caregivers to place infants on their backs to sleep as opposed to placing them on their abdomens.


The American Academy of Pediatrics Task Force on SIDS issued a policy statement in 2005.11 Recommendations to reduce the risk of SIDS are outlined in this statement and are summarized below.

More information on the AAP policy statement is available on the world wide web at: http://aappolicy.aappublications.org/cgi/content/full/pediatrics;116/5/1245. Accessed August 31, 2006.

Recommendation 1 Place the infant on the back (ie, in a supine position)

for sleeping. Note: Side sleeping is not as safe and is not advised.

2 Place the infant on a firm sleep surface. A firm mattress with appropriate covering is recommended.

3 Do not place soft objects or loose bedding around the infant during sleep.

4 Avoid smoking during pregnancy. 5 Place the infant in a separate but proximate sleeping

environment. Bed sharing for infant sleeping, as practiced in the United States and other Western countries, is associated with an increased risk of SIDS compared with the alternative of a separate sleep surface. The risk of SIDS has been shown to be reduced when the infant sleeps in a crib, bassinet, or alternative in the same room as the mother. The American Academy of Pediatrics recommends that the infant may be brought into the parents bed for nursing or comforting but should be returned to the infants own crib or bassinet when the parent is ready to return to sleep.

6 Consider offering a pacifier. The reduced risk of SIDS associated with pacifier use is compelling.

7 Avoid overheating. Clothe the infant lightly for sleeping. Bedroom temperature should be kept comfortable for a lightly clothed adult. Avoid overbundling.

8 Avoid commercial devices that are marketed to reduce the risk of SIDS. There is no evidence that use of various commercial devices decreases the incidence of SIDS.

9 There is no evidence that the use of home monitors decreases the incidence of SIDS.


References 1. Changing concepts of sudden infant death syndrome: implications for infant

sleeping environment and sleep position. American Academy of Pediatrics. Task Force on Infant Sleep Position and Sudden Infant Death Syndrome. Pediatrics. 2000;105:650-656.

2. Willinger M, James LS, Catz C. Defining the sudden infant death syndrome (SIDS): deliberations of an expert panel convened by the National Institute of Child Health and Human Development. Pediatr Pathol. 1991;11:677-684.

3. Brooks J. Sudden infant death syndrome. Pediatr Ann. 1995;24:345-383. 4. Positioning and sudden infant death syndrome (SIDS): update. American

Academy of Pediatrics Task Force on Infant Positioning and SIDS. Pediatrics. 1996;98:1216-1218.

5. American Academy of Pediatrics AAP Task Force on Infant Positioning and SIDS: Positioning and SIDS. Pediatrics. 1992;89:1120-1126.

6. Willinger M, Hoffman HJ, Hartford RB. Infant sleep position and risk for sudden infant death syndrome: report of meeting held January 13 and 14, 1994, National Institutes of Health, Bethesda, MD. Pediatrics. 1994;93:814-819.

7. Tong EK, England L, Glantz SA. Changing conclusions on secondhand smoke in a sudden infant death syndrome review funded by the tobacco industry. Pediatrics. 2005;115:e356-e366.

8. Anderson ME, Johnson DC, Batal HA. Sudden Infant Death Syndrome and prenatal maternal smoking: rising attributed risk in the Back to Sleep era. BMC Med. 2005;3:4.

9. Carroll-Pankhurst C, Mortimer EA, Jr. Sudden infant death syndrome, bedsharing, parental weight, and age at death. Pediatrics. 2001;107:530-536.

10. Hoyert DL, Kochanek KD, Murphy SL. Deaths: final data for 1997. Natl Vital Stat Rep. 1999;47:1-104.

11. Filiano JJ, Kinney HC. Sudden infant death syndrome and brainstem research. Pediatr Ann. 1995;24:379-383.


Sudden Cardiac Arrest

Introduction Sudden cardiac arrest (SCA) due to ventricular fibrillation (VF)

or ventricular tachycardia (VT) is uncommon in infants and children. SCA becomes more common in adolescents. An estimate of cases in the United States is approximately 500 episodes per year1 Warning prodromal symptoms such as syncope, near-syncope, or chest pain are experienced in only half of patients.3

Causes of SCA

Causes of pediatric SCA are largely cardiac (see the Table and the Figure).2,4 Hypertrophic cardiomyopathy was present in approximately 36% of patients with SCA in one study.5 Anomalous origin of the left coronary artery from the right coronary cusp (with the coronary vessel coursing between the aorta and pulmonary artery) was present in another 19% of patients in the same study.5 Long QT syndrome, another cause of pediatric SCA, is being diagnosed with increased frequency in children and adolescents.6 Commotio cordis, caused by a sudden blow to the chest during the repolarization of the myocardium, is also a rare cause of SCA in children and adolescents. Among drugs of abuse and stimulants causing pediatric SCA are ephedra and cocaine. All of the conditions listed in the Table can lead to VF or VT.

Figure. Causes of SCA in Young Athletes. Based on percentages from Maron BJ. Sudden death in young athletes. N Engl J Med. 2003;349:1064-1075.


Prevention Prevention of SCA involves both primary and secondary

prevention measures. Primary prevention involves

screening for risk factors identifying the patient at risk and referring for treatment increasing public awareness

Secondary prevention involves

prompt recognition, high-quality resuscitation, and AED use in the out-of-hospital setting (CPR training and lay rescuer AED)

school emergency medical response plan

Screening for SCA Risk Factors

Healthcare providers should screen for SCA risk factors. Because many of the causes of SCA are genetic, once a first affected family member is identified, comprehensive investigation of further familial involvement is critical. Routine screening with a preparticipation athletic evaluation form listing questions about the patient and family history that may reveal a risk of SCA is appropriate. Such a form endorsed by the American Academy of Pediatrics (AAP), American Academy of Family Physicians, American College of Sports Medicine, American Medical Society for Sports Medicine, American Orthopaedic Society for Sports Medicine, and American Osteopathic Academy of Sports Medicine can be found at www.aap.org/sections/sportsmedicine/spmedeval.pdf. Routine electrocardiogram and echocardiogram screening is not cost-effective and can lead to misdiagnosis.7 Such tests should be used at the discretion of the healthcare provider based on findings of the history and physical examination.

Identifying the Patient at Risk and Referring for Treatment

Questions that may reveal patient risk or family history of SCA should be asked of any active child or adolescent in the office setting or emergency department. This is particularly true if the patient is being evaluated for seizure, syncope, complex ventricular arrhythmia, or palpitations. The physical examination may reveal specific findings, such as abnormal blood pressure or pulses, heart murmur, arrhythmia, or syndromic features.8 Attention, however, should be focused primarily on patient and family history because many children and adolescents at risk for SCA do not have significant physical examination findings.


If the history or physical examination leads to a suspicion of risk for SCA, refer the patient to a pediatric cardiologist with expertise in diagnosing and managing the uncommon cardiac disorders causing SCA. Appropriate treatment including medical therapy, activity restriction, and other modalities may be implemented once a diagnosis of risk factors for SCA is confirmed.

Increasing Public Awareness

Make the effort to educate families and your local community about warning signs of SCA.

Resuscitation in the Field

When SCA is suspected (a sudden collapse in an otherwise healthy person), the lone healthcare provider should activate the EMS system and get an AED (if available) and then return to the victim to start CPR, because rapid defibrillation and CPR are the keys to survival. When several bystanders are present, one rescuer can remain with the victim to begin CPR while another activates the EMS system and gets the AED. CPR training and lay rescuer AED programs offering comprehensive training in the use of an AED are proliferating in public sites and schools around the United States. When an AED is not immediately available, high-quality CPR can prolong the duration of VF (thus prolonging the duration of time defibrillation may be attempted) and may double or triple survival at any interval to defibrillation.

School Emergency Response Plans

The Medical Emergency Response Plan for Schools was introduced by the AHA in January 2004 and endorsed by the American Academy of Pediatrics, the American College of Emergency Physicians, the National Association of School Nurses, and the American Red Cross.9 This public health initiative encourages schools to implement a plan to respond to life-threatening medical emergencies. It consists of 5 core elements:

Effective and efficient campus communication (links all parts of the campus, including field houses, modular classrooms, and practice and playing fields; enables school personnel or students to activate the EMS system immediately when an emergency occurs)

Coordinated and practiced response plan (should be


developed in concert with the school nurse, school or athletic team physicians, athletic trainers, and local EMS providers)

Risk reduction (includes safety precautions to prevent injuries and identification of students and staff with medical conditions that may result in SCA)

Training and equipment for first aid and CPR (several teachers should be trained as CPR and first aid instructors, and all high school students should receive training in CPR)

Implementation of lay rescuer AED program in schools with an established need (see Criteria for Lay Rescuer AED Programs)

Criteria for Lay Rescuer AED Programs

Criteria for established need of a lay rescuer AED program are

reasonable probability of AED use within 5 years or an incident necessitating such use within the past 5 years

child or adult in the school believed to be at risk for SCA EMS call-toshock time (interval from EMS notification to

defibrillator placement) 16 hours per day.10

Four Elements for Success of Lay Rescuer AED Programs

Four elements are critical to the success of a lay rescuer AED program:

Planned and practiced response (typically this requires oversight by a healthcare provider)

Training of anticipated rescuers in CPR and use of an AED (including updates as needed)

Coordination with the local EMS system Process of ongoing quality improvement (with practice

drills and incident assessment) Article adapted from Ellison A, Riehle TJ, Berger S, Campbell RM. Preventingwith the goal of eradicatingsudden cardiac death in children. Contemporary Pediatrics. Oct 1, 2005


References 1. Berger S, Kugler JD, Thomas JA, et al. Sudden cardiac death in children and

adolescents: introduction and overview. Pediatr Clin North Am. 2004;51:1201-1209.

2. Maron BJ. Sudden death in young athletes. N Engl J Med. 2003;349:1064-1075. 3. Liberthson RR. Sudden death from cardiac causes in children and young adults.

N Engl J Med. 1996;334:1039-1044. 4. Riehle TJ, Campbell RC. Screening for sudden cardiac death using the

preparticipation physical exam. Congenital Cardiol Today. 2005;3:12. 5. Maron BJ, Shirani J, Poliac LC, et al. Sudden death in young competitive

athletes. Clinical, demographic, and pathological profiles. Jama. 1996;276:199-204.

6. Vincent GM. The Long QT and Brugada syndromes: causes of unexpected syncope and sudden cardiac death in children and young adults. Semin Pediatr Neurol. 2005;12:15-24.

7. Seto CK. Preparticipation cardiovascular screening. Clin Sports Med. 2003;22:23-35.

8. Facial features clue to new syndrome. http://www.hopkinschildrens.org/ pages/news/CCNSpring05/patient.html. Accessed September 9, 2005.

9. Hazinski MF, Markenson D, Neish S, et al. Response to cardiac arrest and selected life-threatening medical emergencies: the medical emergency response plan for schools: A statement for healthcare providers, policymakers, school administrators, and community leaders. Circulation. 2004;109:278-291.

10. The Public Access Defibrillation Trial Investigators. Public-access defibrillation and survival after out-of-hospital cardiac arrest. N Engl J Med. 2004;351:637-646.

12 2006 American Heart Association

Child and Infant Safety ChecklistThe Safety Checklist can help you learn risks for injury at home, in the car, at childcare centers, at schools, and on playgrounds. The Safety Checklist also tells you what to do to reduce risk. It is impossible to elimi-nate every risk for every child. For this reason, you must know how to respond to an emergency.

Action

I follow this safety

precaution ( = yes)

Purchase of safety item is required for all shaded boxes

( = item purchased)

Car Safety

1. Make sure that every person in the car buckles up correctly.

2. Have children who are less than 12 years old ride in the BACK seat and use correct child restraints or lap-shoulder restraints for age.

3. Use a rear-facing infant safety seat for infants until they weigh at least 20 lb (9 kg) and are 1 year old.

Secure all car seats in the BACK seat of the car. Secure the seat according to the manufacturers instruc-

tions. To see if the seat is secure, try to push the seat forward,

backward, and side-to-side. Tighten the belt to be sure that the seat does not move more than inch (1 cm).

For proper adjustment, the seat belt buckle and latch plate (if needed) must be located well below the frame or toward the center of the seat.

Safety item Infant safety seat

4. Wait until a child weighs 20 lb (9 kg) and is at least 1 year old and can sit with good head control before using a convertible seat or toddler seat in the forward-facing position. Secure these seats in the BACK seat of the car.

Safety itemChild safety seat

5. Use a belt-positioning booster seat for children who weigh 40 to 80 lb (18 to 36 kg). Secure the seat with a 3-point seat belt (lap and shoulder belt) in the BACK seat of the car.

If a shield is provided, fasten it close to the childs body. Properly install the tether harness if required.

Safety item Belt-positioning booster seat

6. Children cannot be properly restrained with a lap-shoulder belt until they are at least 4 feet 9 inches (58 inches or 148 cm) tall, weigh 80 lb (36 kg), and can sit in the automobile seat with their knees bent over the edge. Always use a com-bination lap-shoulder belt to restrain children sitting in an automobile seat.

The shoulder belt should fit across the shoulder and breastbone. If it crosses the childs face and neck, use a belt-positioning booster seat to be sure that the belt is properly placed. Do not hook the shoulder belt under the childs arm.

All children 12 years old or younger should ride in the BACK seat.


Action


precaution ( = yes)


( = item purchased)

General Indoor Safety

7. Place a sticker with emergency phone numbers near or on the phone. Include numbers for the EMS system, police, fire department, local hospital or physician, the poison control center in your area, and your telephone number.

Safety item Phone sticker with emergency response numbers

8. Install smoke detectors on the ceiling in the hallway outside areas where children sleep or nap and on each floor at the head of stairs. Test the alarm monthly and replace batteries twice a year (for example, in the fall and spring when the time changes to and from daylight saving time).

Safety item Smoke detector

9. Make sure that there are two unobstructed emergency exits from the home, childcare center, classroom, or other area where children are likely to be present.

10. Develop and practice a fire escape plan.

11. Make sure that a working fire extinguisher is available. Safety item Fire extinguisher

12. Make sure that all space heaters are safety approved. They should be in safe operating condition. They should be placed out of a childs reach and at least 3 feet from cur-tains, papers, and furniture. The heaters should have pro-tective covers.

13. Make sure all wood-burning stoves are inspected yearly and vented properly. Place stoves out of a childs reach.

14. Make sure that electrical cords are not frayed or overload-ed. Place out of a childs reach.

15. Install shock stops (plastic outlet plugs) or outlet covers on all electrical outlets.

Safety item Plastic outlet plugs

16. To prevent falls, always keep one hand on an infant sitting or lying on a high surface such as a changing table.

17. Place healthy full-term infants on their back or side to sleep. Do not place infants on their stomach to sleep.

18. Make sure the crib is safe:

The crib mattress fits snugly with no more than two fingers width between the mattress and crib railing.

The distance between crib slats should be less than 2 /8 inches (so the infants head wont be caught).

Do not put any fluffy material, stuffed animals, or fluffy blankets or comforters in the crib with the infant

19. Be sure that stairs, railings, porches, and balconies are strong and in good repair.


Action


precaution ( = yes)


( = item purchased)

20. Keep halls and stairs lighted to prevent falls.

21. Put toddler gates at the top and bottom of stairs. (Do not use accordion-type gates with wide spaces at the top. The childs head could become trapped in such a gate, and the child could strangle.)

Safety item Toddler gates (NOT accordion-type)

22. Do not let your child use an infant walker.

23. To prevent falls, put locks (available at hardware stores) on all windows. Put gates on the lower part of open windows.

Safety item Window locks, gates

24. Store medicines and vitamins in child-resistant containers out of a childs reach.

Safety itemChild-resistant containers

25. Store cleaning products out of a childs sight and reach.

Store and label all household poisons in their original containers in high locked cabinets (not under sinks).

Do not store chemicals or poisons in soda bottles. Store cleaning products away from food.

26. I nstall safety latches or locks on cabinets that contain potentially dangerous items and are within a childs reach.

Safety item Safety latches or locks on cabinets

27. Keep purses that contain vitamins, medicines, cigarettes, matches, jewelry, and calculators (which have easy-to-swal-low button batteries) out of a childs reach.

28. Install a lock or hook-and-eye latch on the door to the basement or garage to keep children from entering those areas. Put a lock at the top of the doorframe.

Safety item Latch on base-ment, garage doors

29. Keep plants that may be harmful out of a childs reach. (Many plants are poisonous. Check with your poison control center.)

30. Make sure that toy chests have lightweight lids, no lids, or safe-closing hinges.


Action


precaution ( = yes)


( = item purchased)

Kitchen Safety

31. To reduce the risk of burns:

Keep hot liquids, foods, and cooking utensils out of a childs reach.

Put hot liquids and food away from the edge of the table. Cook on back burners when possible and turn pot han-

dles toward the center of the stove.

Avoid using tablecloths and placemats that can be pulled, spilling hot liquids or food.

Keep high chairs and stools away from the stove. Do not keep snacks near the stove. Teach young children the meaning of the word hot.

32. Keep all foods and small items (including balloons) that can choke a child out of reach. Test toys for size with a toilet-paper roll. If a toy can fit inside the roll, it can choke a small child.

33. Keep knives and other sharp objects out of a childs reach.

Bathroom Safety

34. Bathe children in no more than 1 or 2 inches of water. Stay with infants and young children throughout bath time. Do not leave small infants or toddlers in the bathtub in the care of young siblings.

35. Use skid-proof mats or stickers in the bathtub. Safety itembath mats or stickers

36. Adjust the maximum temperature of the water heater to 120 to 130F (48.9 to 54.4C) or medium heat. Test tem-perature with a thermometer.

37. Keep electrical appliances (radios, hairdryers, space heat-ers, etc) out of the bathroom or unplugged, away from water, and out of a childs reach.

Firearms

38. If firearms are stored in the home, keep them locked and out of a childs sight and reach. Lock and unload guns indi-vidually before storing them. Store ammunition separate from the firearms.

Safety item trigger lock, lockboxes for firearms

Outdoor Safety

39. Make sure playground equipment is assembled and anchored correctly according to the manufacturers instruc-tions. The playground should have a level, cushioned sur-face such as sand or wood chips.


Action


precaution ( = yes)


( = item purchased)

40. Make sure your child knows the rules of safe bicycling: Wear a protective helmet. Use the correct-size bicycle. Ride on the right side of the road (with traffic). Use hand signals and wear bright or reflective clothing.

Safety item Bicycle helmet

41. Do not allow children to play with fireworks.

42. Make sure your child is properly protected while roller skat-ing or skateboarding:

Wear a helmet and protective pads on the knees and elbows.

Skate only in rinks or parks that are free of traffic.

Safety item Helmet and protective padding

43. Make sure your child is properly protected while riding on sleds or snow disks.

Sled only during daylight hours and only in a safe, super-vised area away from motor vehicles.

44. Make sure your child is properly protected while participat-ing in contact sports:

Proper adult instruction and supervision are provided. Teammates are about the same weight and size. Appropriate safety equipment is used.

Safety item Safety equipment for contact sports

45. To reduce the risk of animal bites, teach your child How to handle and care for a pet. Never to try to separate fighting animals, even when a

familiar pet is involved. To avoid unfamiliar animals.

46. If you have a home swimming pool, make sure the pool is totally enclosed with fencing that is at least 5 feet high and that all gates are self-closing and self-latching. There should be no direct access (without a locked gate) from the home into the pool area. In addition:

An adult must always supervise children while they swim. Never allow a child to swim alone.

Change young children from swimsuits into street clothes, and remove all toys from the pool area at the end of swim time.

All adults and older children should learn CPR. Pools on nearby properties should be protected from use

by unsupervised children.

Safety item 5-foot fence around swimming pool with self-closing, self-latching gate


Note: Much of the safety information presented in this table is based on the SAFEHOME program and the Childrens Traffic Safety Program at Vanderbilt University in Nashville, Tenn. The Massachusetts Department of Public Health developed the SAFEHOME program as part of its Statewide Comprehensive Injury Prevention Program. The Federal Division of Maternal and Child Health funded the SAFEHOME pro-gram. The Department of Transportation and the Tennessee Governors Highway Safety Program funded the Childrens Traffic Safety Program.

Scene Assessment for Out-of-Hospital ProvidersReducing the Risk of SIDSReferences

Sudden Cardiac ArrestReferences

Child and Infant Safety Checklist

Documents

Safety and Prevention