Prehospital Management

of Pediatric Trauma

EMS Outreach Conference 12.4.14Dan Park, MD MUSC Pediatric Emergency Medicine

Chris Streck, MD & Tanya Green, BSN, RN MUSC Pediatric Surgery

EMS for kids:

Numbers

& History

Quick review

of pediatric

anatomic

considerations

OBJECTIVES

Discuss

evidence

regarding

cervical

spine

immobilization

Review

essentials

of airway

management in

prehospital

care of

kids

Review

essentials

of traumatic

brain

injury

management

1 2 3 4 5

EMS: Some numbers50% of kids who die in the US die from the effects of injuries

Pediatric patients make up of all ED visits from 1997-2000

Pediatric patients represent of all EMS transports

of pediatric trauma patients arrive via EMS

27%

13%

54%

Shah MN et al. Prehosp Emerg Care 2008

13% of all EMS

transports are

kids

The acuity of

pediatric EMS

patients if often

higher than that

of adults

PREHOSPITAL CARE FOR CHILDREN

TIMELINE

Military triage

and transport

developed

during WWII

and Korean

War translated

to civilian

population

EMS

Systems Act

of 1973

created

nationwide

development

of regional

EMS systems

Research

showing half

of pediatric

deaths from

trauma might

be

preventable

In response to

deficiencies in

pediatric

prehospital care

government

created EMS-C

authorizing the

use of federal

funds for EMS

services for kids

Pediatric

emergency

medicine

becomes a

recognized

specialty by

the American

Board of

Medical

specialties

Great advances

in closing the

gap between

pediatric and

adult

prehospital care

but the

discrepancy still

exists and there

is more work to

be done

Ramenofsky ML et al. J Trauma 1984, Seidel JS et al Pediatrics 1984, Seidel JS. Circulation 1986, Seidel JS. Pediatrics 1986, Bankole S et al. Pediatr Crit Care Med 2011

PREHOSPITAL CARE OF KIDS IS SUBOPTIMAL COMPARED TO ADULTS

1Retrospective study compared prehospital care of 99 adult and 103

pediatric head injury patients with GCS <15

Compared IV access, endotracheal intubation, and fluid resuscitation

Significantly more pediatric patients had problems with intubation,

27 children (69%) vs. 11 adults (21%)

IV access was successfully established in 86% of adults compared

to 66% of children at the scene

EMS providers need more training and practice with these challenging skills in kids

2

3

4

Bankole S et al. Pediatr Crit Care Med 2011

Pediatric

trauma

system

$

Education

Standards of care

Research and development

Quality assurance

Funding

System design

Prevention

Ramenofsky ML. J Pediatr Surg 1989

Integrating needs of

children into existing

EMS infrastructure

involves high-quality

prehospital care that

uses pre-established

protocols

Protocols must be

applied by skilled EMTs

with assistance of online

medical control until

ultimate transport to an

appropriate facility

capable of providing

definitive care

Essential Components of an Integrated Pediatric Trauma System

EVIDENCE BASED MEDICINE

IN PREHOSPITAL CARE IS LACKING

IOM report in 2006 highlighted evidence-based

practices for prehospital care of pediatric trauma

have not been adequately addressed:

Institute of Medicine of the National Academies. 2006

- Delaying transport to initiate treatment

on-scene, the use of advanced life support

(ALS) or basic life support (BLS) resources

- Identifying high-risk pediatric trauma

patients

- Optimally managing the airway

- Obtaining IV or IO access

- Immobilization of the cervical spine

- Optimal management of traumatic brain

injury

- Assessment and management of pain

ANATOMIC CONCERNS

Head of infant makes up a larger percentage

of total body mass compared to an adult

Neck muscles don’t support this relatively

larger head as effectively

Simply by virtue of size, there is more force

per square inch of body surface than adults

Underdeveloped abdominal muscles afford

little protection to internal organs making

them vulnerable to multi-organ injury

\

Children have increased

metabolism and therefore

higher O2 consumption

compared to an adult

Because of their larger

body surface area to size

ratio, children are

vulnerable to hypothermia

in the setting of injury

Vital to avoid hypothermia

when caring for children

PREHOSPITAL CARE TIMETRIAGE & TRANSPORTAIRWAY MANAGEMENT

CERVICAL SPINE IMMOBILIZATIONTRAUMATIC BRAIN INJURY

CASE 1

2 month old male

Patient reportedly had been eating and choked, then dropped

Exam on scene:

Unresponsive, flaccid,

Poor color, no respiratory effort

Weak brachial pulse, HR 60

Chest compressions initiated

Total scene time 13 mins

Patient taken to ambulance, intubated, IV access obtained,

Epi x 1 and fluid with ROSC (HR 120s) prior to hospital arrival

Patient remained unresponsive and apneic upon arrival

CASE 1

ED Exam

No purposeful movements, obtunded

Pupils non-reactive bilaterally

Agonal breathing noted, intubated

Abdominal distension, absent bowel sounds

Bruising to bilateral shoulders and bilateral thighs

Abnormal primitive reflexes, abnormal muscle tone

ED Care

ETT exchanged to a 3.5 tube (was 2.5)

PIV placed, fluid boluses (20 ml/kg x 2)

Cervical collar placed

IV antibiotics

Seizure prophylaxis

Labs, CT/X-rays

CASE 1

CT of Head

Depressed skull fracture

Bilateral subdural hematomas, epidural hematoma

Subarachnoid hemorrhage, possible epidural components

CT cervical spineNo evidence of acute cervical spine trauma

CT chest, abdomen, pelvisHealing right seventh and either posterior rib fractures

Extensive groundglass opacity throughout both lungs which may

represent hemorrhage, aspiration pneumonitis, or edema.

More focal areas of consolidation in the right upper lobe and

both lower lobes posteriorly.

CASE 1

MRI of brain done 2 days after admission and demonstrated

Findings consistent with hypoxic ischemic injury

Bilateral subdural hematomas of various ages

An epidural hematoma overlies the left temporal lobe

Acute subarachnoid hemorrhage within the bilateral sulci at the vertex

MRI of cervical spine demonstrated

Edema in the interspinous space spanning from C3-4 to C6-7,

suggestive of injury to the interspinous ligaments

Subcutaneous edema overlying the nuchal ligament with

no evidence of ligamentous discontinuity

CASE 1

During hospitalization, neurologic exam slightly improved, pupils

sluggishly reacted to light, with spontaneous eye opening, no

tracking or blinking to threat. G-tube placed for feeds.

Neurologically devastated:

Hypertonicity in all extremities (spastic quadraplegia), no

purposeful movements noted.

Several days following admission, the father of the baby admitted

to shaking the infant and has since been incarcerated

Patient discharged home with mother with outpatient home health

services.

CERVICAL SPINEINJURY

CERVICAL SPINE INJURY

Injury to the cervical spine is uncommon in children.

The occurrence is less than 1% of children that are

evaluated for trauma.

There is a greater frequency of high cervical spine injury in

children as compared with adults.

Due to having a relatively larger head compared with the

neck, the angular momentum is greater and the fulcrum is

higher in the cervical spine, therefore, more injuries occur at

the level of the occiput to C3.

Kim et al. 2013

CERVICAL SPINE INJURY

Forces applied to the upper neck are relatively

greater than in the adult especially when the child

is exposed to sudden acceleration and

deceleration.

Injuring the spine in the pediatric patient takes

significantly less force than the adult spine.

Therefore, a high index is suspicion should be

maintained for a spinal injury in children.

Collopy, Kivlehan, & Snyder, 2012

NEXUS and CANADIAN C-SPINE RULE

NEXUS LOW-RISK CRITERIA (NLC) AND CANADIAN C-SPINE RULE (CCR)

HELP HOSPITAL PROVIDERS DETERMINED WHICH STABLE TRAUMA

PATIENTS CAN HAVE THEIR COLLARS REMOVED AND WHO NEEDS

FURTHER IMAGING

1

CCR would have missed 1 patient and NLC would have missed 15 patients with important injuries

N=8283, 169 (2%) had clinically important cervical-spine injuries

CCR MORE SENSITIVE AND SPECIFIC THAN NLC2

This was an adult study (>16 yo). Only 10% of the patients in the original NEXUS study were kids And the rate of

cervical spine injury was so low (~1%) that it would be hard to safely apply the rule to children in the prehospital

setting .

MAY NOT BE GENERALIZABLE TO PEDIATRIC TRAUMA

PATIENTS3

Stiell IG et al. NEJM 2003

Canadian C-spine rule

Dangerous Mechanism

Fall from >3 ft or

5 stairs

Axial load to head

(diving)

MVC >60 mph

Rollover/ejection

Collision involving a

motorized recreational

vehicle

Bicycle collision

Simple rear-end MVC

excludes being pushed

into oncoming traffic,

being hit by a bus or

large truck, or being hit

by a high speed vehicle

Response of cervical spine to applied axial load

A: With neck in neutral alignment, the vertebral column is extended.

Force can be dissipated by spinal musculature and ligaments

B: Neck in flexed position, spine straightens out and lines up with the axial force

C: At impact, the straightened cervical spine undergoes rapid deformation and

buckles under compressive load

“Backboards will soon be looked at much like MAST pants. Get used to it.

Backboards make great spatulas, but at some point, that burger needs to get

on a bun”

Enrolled 1,949 trauma patients in 7 regions, GCS 15, alert and stable

Interpret rule and then immobilize all

Sensitivity 100%, specificity 37.7%

Would have avoided 731(38%) immobilizations

Study found that paramedics can apply the

Canadian C-Spine Rule reliably, without missing any important

cervical spine injuries

The adoption of the Canadian C-Spine Rule by paramedics could

significantly reduce the number of out-of-hospital cervical spine

immobilizations

PREHOSPITAL VALIDATION OF CANADIAN C-SPINE RULE

Vaillancourt C et al. Ann Emerg Med 2009

THOUGHTS ON THE IMMOBILIZATION CONTROVERSY

1 MAKE A DECISION,

TRANSPORT TO BEST OF YOUR ABIILITIES, &

EXPLAIN WHY YOU DID OR DIDN’T IMMOBILIZE

2 CHILDREN ARE CHALLENGING

What are considered distracting injuries?

Are fear and anxiety distractions?

Can a child verbalize paresthesias?

3 MANY MORE CHILDREN WILL BE IMMOBILIZED THAN WILL BENEFIT FROM IT

Young children are difficult to clinically clear from immobilization in the PED

No validated criteria for selective immobilization in children

When in doubt, err of the side of immobilizing

SC DHEC EMS

Spinal Immobilization

Protocol

CASE 2

7 mo male presents to OSH via EMS s/p fall from bed onto glass

No PMH available

OSH Exam:

Unresponsive, unconscious

Laceration to right neck not actively bleeding

Tachycardic (170 – 190)

Decreased breath sounds noted on left

Vital Signs HR 184, BP 86/35, RR 22

Bilateral IO’s placed, PIV placed, 50 ml NS bolus given and

patient intubated.

During intubation, right neck laceration began to bleed, direct

pressure applied with gauze and cervical collar.

CASE 2

1049 - Transport team arrived

Patient taken to CT scan – head and cervical spine scans

Blood products during transport requested by physician, team

prepared to transport while awaiting blood.

1126 - Unit left scene for transport.

HR remained 140’s – 150’s and BP remained systolic 90’s to low

100’s during transport.

Patient received 20 ml of PRBC’s during transport per order of

sending physician..

CASE 2

1159 – Patient arrived in ED.

Exam:

Intubated, right breath sounds clear, left absent

+ bleeding from right neck, right femoral pulse weak

Pupils 2 mm, non-reactive bilaterally

HR 157, BP 125/99

ED Care

100 ml PRBC’s

NS bolus

Left chest tube (100 ml blood returned)

CASE 2

Patient taken emergently to OR

Exploration of right neck penetrating traumatic wound

Median sternotomy for exposure of vascular injury

Repair of left innominate vein and

ligation of left internal mammary artery

Flexible esophagogastroscopy

Postoperatively

Patient did well but had phrenic nerve injury and

hemidiaphragm

Patient discharged on HD 14

TRAUMATRANSFER

TRAUMATRANSFER

Patient outcome is directly related to the elapsed time between

injury and when the patient receives the properly delivered

definitive care.

When the need to transfer is recognized, transfer should be

expedited and not delayed for diagnostic procedures or tests that

will not change the immediate plan of care.

American College of Surgeons strongly encourages rapid

transport to a trauma center and minimization of on-scene time for

trauma patients, and there is evidence to support

improved outcomes with shorter on-scene times

Sampalis JS et al. J Trauma 1993; American College of Surgeons 2012

TRAUMATRANSFER

A clinical decision rule placed these criteria in the following order to

identify high-risk injured children:

Need for assistance with ventilation via endotracheal intubation or

bag-valve-mask

GCS < 11

Pulse ox < 95%

SBP more than 96 mmHg

HR and RR did not prove to be important predictors in the model

High SBP associated with poor outcomes may be plausible with

traumatic brain injury

Newgard CD et al. Prehosp Emerg Care 2009

The OPALS Major Trauma Study (n=2867) showed that system-wide implementation

of full advanced life-support (endotracheal intubation and IV fluids and drug

administration) programs did not decrease mortality or morbidity (primary outcome

was survival to hospital discharge) for major trauma patients.

ALS vs. BLS IN PREHOSPITAL SETTING HAS BEEN DEBATED

Stiell IG et al. CMAJ 2008

Staffing an ALS unit compared to a BLS unit is estimated to cost

an extra $94,928 per year per unit

Also procedures performed by ALS units take additional time, which may delay

ultimate transport to definitive care

Right now, the evidence shows that there is no difference in mortality between ALS

and BLS trauma care when provided by EMTs but there are significant difference in

cost with possible benefit in situations of prolonged transport times

ALS vs. BLS IN PREHOSPITAL SETTING HAS BEEN DEBATED

Ornato JP et al Ann Emerg Med 1990

PEDIATRIC SHOCK

1

2 Pediatric patients have an increased physiologic reserve which allows for a

normal systolic blood pressure even in the presence of shock.

Children can have up to a 30% reduction in circulated blood volume

before you will see a decrease in their systolic blood pressure.

Other signs of blood loss in children include:Progressive weakening of peripheral pulses

Narrowing of pulse pressure

Mottling (which may show as clammy skin in infants and young children)

Cool extremities compared with torso skin

Decrease in LOC with a dulled response to pain

3

American College of Surgeons. 2012

PEDIATRIC SHOCK

4

5

Isotonic solution is the appropriate fluid for rapid repletion of circulating

blood volume. The goal is to replace lost intravascular volume,

therefore it could be necessary to infuse 3 boluses of 20 mL/kg

Upon consideration of the third fluid bolus, the use of packed red blood

cells should be considered, at 10 mL/kg

If hemodynamic abnormalities following the first fluid bolus do not

improve, this should raise the suspicion of continuing hemorrhage6

American College of Surgeons. 2012

PEDIATRIC SHOCK

7 In severely hypovolemic patients it may be impossible to gain

peripheral venous access and intraosseous access

provides a suitable alternative.

In critical situations if IV access is not successful in 3 attempts

or 90 seconds, IO access should be considered.

This route has been a well-validated and is a rapid route of

access in both adults and children.

LaRocco BG et al. Prehosp Emerg Care 2003, Sunde GA et al. Scan J Taruma Resusc Emerg Med 2010

DEFINITION OF PEDIATRIC HYPOTENSION BY AGE

Badjatia N et al. Prehosp Emerg Care 2007

CASE 3

EMS arrived at scene at 1643

Total Scene Time: 13 minutes

EMS found young male patient unresponsive with gunshot

wound to the head

Exam on scene:

Unresponsive male receiving cervical spine maintenance and

BVM ventilation

GSW to right side of face near right eyelid, no exit wound

Pupils fixed and dilated, blood noted from bilateral ears.

Deformity to skull

PIV placed

Vital signs – HR 61, RR 20

CASE 3

EMS met by transport, care transferred

Posturing noted, RSI

Patient arrived to trauma bay at 1740

ED Exam

GCS 6, pupils 5 mm, fixed and dilated,

decorticate posturing noted

Absent cough, gag and corneal reflexes

Intubated

ED Care

Fluid bolus

CT scan

CASE 3

Patient transferred to ICU, then taken to OR for

emergent craniectomy

Patient returned to ICU, ICP’s monitored, recorded

between 30’s and 90’s

HD 2 – sedation medications held

HD 3 – brain death examinations began

HD 4 – patient pronounced

Trauma Deaths

0 500 1000 1500 2000 2500 3000 3500

Fall

Transport, other

Auto-pedestrian

Firearm

Motor Vehicle Related

Deaths

Nance et al. 2014

FIREARMS MORTALITY

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0

1

2

3

4

5

6

7

8

9

10

Fire

arm

De

ath

s/1

00

,00

0

All Firearm Mortality(Ages 0-19 years)

Nance et al. 2014

TRAUMATIC BRAIN INJURY

MINIMIZE SECONDARY INJURY BY MANAGING THE COMPRISED AIRWAY AND INTERVENING TO

PREVENT HYPOTENSION

Monitor BP with an appropriately sized cuff

Give 20cc/kg boluses of isotonic fluids as needed to maintain normal BP for age1

HYPOXEMIA and HYPOTENSION ARE VERY BAD in TBI

Avoid hypoxemia by managing the airway by the most appropriate means (supplemental o2, BVM, ETI or other

adjuncts) No evidence to support ETI or BVM in pediatric patients with TBI2

CHILDREN WITH SUSPECTED TBI SHOULD HAVE CERVICAL SPINE IMMOBILIZED DUE TO RISK

OF CONCURRENT INJURY 3

TRAUMATIC BRAIN INJURY

SIGNS OF INCREASED ICP ARE REPRESENTED BY CUSHING’S TRIAD OF: HYPERTENSION,

BRADYCARDIA, IRREGULAR BREATHING

Maintain normal breathing rate. No evidence showing benefits of hyperventilation in children

4

Atabaki SM. Clin Pediatr Emerg Med 2006

AIRWAYMANAGEMENT

AIRWAY MANAGEMENT

For this reason, early and aggressive airway management is crucial

IN KIDS, THE CAUSE OF CARDIAC ARREST IS COMMONLY DUE TO

HYPOXIA SECONDARY TO RESPIRATORY ARREST2

FAILURE TO MANAGE THE AIRWAY PROPERLY IS THE LEADING

CAUSE OF PREVENTABLE DEATH DUE TO TRAUMA1

Smaller size of the patient, airway, and equipment. In order to stay sharp you need practice and skill

maintenance.

IT’S A CHALLENGING SKILL WITH FEW TRAINING OPPORTUNITIES3

AIRWAY MANAGEMENT

URGENT AIRWAY INTERVENTION NEEDED IN:Upper airway burns, severe facial or neck trauma, inability to protect airway (TBI, AMS),

impending respiratory failure4

Some studies show increased mortality with RSI (Davis), some show decreased mortality (Domier).

PREHOSPITAL ETI OUTCOMES ARE MIXED5

.

RISK OF INCREASED ON-SCENE TIME AND POTENTIAL

COMPLICATIONS WITH ETI MUST BE WEIGHTED AGAINST THE

BENEFIT OF RAPID TRANSPORT6

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830 patients aged 12 years or younger who required airway management in LA and Orange counties

PROSPECTIVE TRIAL OF PEDIATRIC PATIENTS IN AN URBAN SETTING WHO

EITHER RECEIVED BVM OR ETI FOR PREHOSPITAL AIRWAY MANAGEMENT1

ETI success was 57% in this study

12% of paramedics got experience in BVM per year; 1.6% of paramedics in ETI

VERY INFREQUENTLY UTILIZED SKILL2

This included subgroup analysis of various categories of trauma patients including submersion injury, head injury, and

multiple trauma. The study DID NOT examine the potential effect of transport distance

NO DIFFERENCE BETWEEN PREHOSPITAL BVM OR ETI FOR BOTH SURVIVAL

TO HOSPITAL DISCHARGE AND NEUROLOGICAL STATUS AT DISCHARGE3

Gausche M et al. JAMA 2000

Mask size is important

to mask seal

Pull head into

extension and open

airway by pulling chin

upward

Seat the mask (apex)

over the bridge of the

nose first

Then lower the mask

over the chin

BVM Ventilation is a Crucial Skill to

Learn and Master

3rd, 4th, 5th fingers are

on mandible pulling it

upward

Move thumb into

position at top of mask

to maintain seal

against bridge of nose

Index finger falls

naturally into place

below the connection

to ventilation bag

Finger Positions Are Key: Thumb And Index Form A

“C”, The Other Three Will Form An “E”

Don’t think of this as

pushing the mask onto

the face (this can lead

to head flexion and

airway obstruction)

Pull face into the mask

(pulls head further into

extension and opens

the airway)

Constantly reassess

ventilation and adjust

Look for chest

movement, fogging of

mask, & breath

sounds

Pull Face Into the Mask

Positioning in Pediatric Intubation

In all ages, if you follow these positioning principles, you

will improve your view of the airway:

1. Align the ear to the sternal notch

2. Keep the face parallel to the ceiling(do NOT hyperextend the neck, as in the sniffing position)

3. In adults, the head usually needs to be raised while in

infants (larger occiput), the torso usually needs to be

raised to place the neck into normal anatomic position

“Ear to Sternal Notch” has gained

wide acceptance in the EM and

anesthesia literature

Levitan RM et al. Ann Emerg Med 2003

Due to anatomical differences many clinicians recommend use of

a straight blade over a curved blade in small children, especially

for children under one year of age as the straight blade allows for

better control of the floppy and relatively large epiglottis.

Straight Blade Can Be Useful in Young Children

TAKE

HOME

POINTS

1

2

3

4

5

Care of injured children is

suboptimal to adults. EMS is an underfunded but crucial

component in the care of injured children.

More research is needed in all areas of

prehospital care

Kids are not little adults. They have

distinct anatomical & physiological

differences: Airway is more anterior and superior, larger

body surface area to size ratio makes them

vulnerable to hypothermia, larger occiput

puts them at risk of airway obstruction

When in doubt, immobilize.Spinal immobilization is controversial in

certain situations in adults. But kids are a

particularly challenging group. With a

concerning mechanism and a young child

err of the side of caution.

Prevent hypoxemia and

hypotension in traumatic brain

injury. Immobilize these kids.

Minimize on-scene time.

No difference between out-of-

hospital BVM or ETI in terms of

survival. Crucial to get good at bagging.

If ETI is needed, remember ear to sternal

notch and miller blade in young kids

ReferencesAmerican College of Surgeons.

Advanced Trauma Life Support (9th

ed.). Chicago. 2012

1

Bankole S et al. Pediatr Crit Care Med

2011 4

Atabaki SM. Prehospital Evaluation

and Management of Traumatic Brain

Injury in Children. Clin Pediatr Emerg

Med 2006

2

Collopy KT, et al. (2012). Pediatric

Spinal Cord Injuries. EMS World

2012; 41(8).

5

Badjatia N et al. Guidelines for

prehospital management of traumatic

brain injury, 2nd edition. Prehosp

Emerg Care. 2008;12 Suppl 1:S1-S52

.

3

Haut ER et al. Spine immobilization in

penetrating trauma: more harm than

good? J Trauma 2010 Jan;68(1):115-

20

6

Gausche M et al. Effect of out-of-

hospital pediatric endotracheal

intubation on survival and neurological

outcome: a controlled clinical trial.

JAMA 2000

7

Hoffman JR et al. Validity of a set of

clinical criteria to rule out injury to the

cervical spine in patients with blunt

trauma. National Emergency X-

Radiography Utilization Study Group. N

Engl J Med 2000 Jul 13;343(2):94-9.

8

Kim EG et al. Variability of prehospital

spinal immobilization in children at risk

for cervical spine injury. Pediatric

Emergency Care, 2013; 29(4), 413-418

9

Nance, M. Baseball, Hot Dogs, Apple

Pie and the Glock 9mm Semi-automatic

Handgun: Growing Up in America.

2014

12

Levitan RM et al. Head-elevated

laryngoscopy position: improving

laryngeal exposure during

laryngoscopy by increasing head

elevation. Ann Emerg Med 2003

10

Newgard CD et al. The availability and

use of out-of-hospital physiologic

information to identify high-risk injured

children in a multisite, population-based

cohort. Prehosp Emerg Care

2009;13:420-31.

13

LaRocco BG et al.

Intraosseous infusion

Prehosp Emerg Care 2003,

11

Ornato JP et al. The need for ALS in

urban and suburban EMS system. Ann

Emerg Med 1990

14

Ramenofsky ML et al. Maximum

survival in pediatric trauma: the ideal

system. J Trauma 1984 Sep;24(9):818-

23

15

Sampalis JS et al. Impact of on-site

care, prehospital time, and level of in-

hospital care on survival in severely

injured patients. J Trauma 1993

16

Seidel JS et al Emergency medical

services and the pediatric patient:

are the needs being met?

Pediatrics 1984,

17

Shah MN et al. Prehospital

management of pediatric trauma.

Prehosp Emerg Care 2008; 11(1)

20

Seidel JS. A needs assessment of

advanced life support and

emergency medical services in the

pediatric patient: state of the art.

Circulation 1986,

18

Stiell IG et al. The OPALS major

trauma study: impact of advanced life-

support on survival and morbidity.

CMAJ 2008

21

Seidel JS. Emergency medical

services and the pediatric patient: are

the needs being met? II. Training and

equipping emergency medical

services providers for pediatric

emergencies. Pediatrics 1986,

19

Sunde GA et al. Emergency

intraosseous access in a helicopter

emergency medical service: a

retrospective study. Scan J Taruma

Resusc Emerg Med 2010

23

Vaillancourt C et al. The Out-of-

Hospital Validation of the Canadian

C-Spine Rule by Paramedics. Ann of

Emerg Med Nov 2009;54(5):663-671

24

Stiell IG et al. The Canadian C-Spine

Rule versus the NEXUS Low-Risk

Criteria in Patients with Trauma.

NEJM 2003; 349: 2510-2518

22