Pre-hospital Emergency Care for Pediatric Patients - An Overview

Introduction:

Pre-hospital care is critical for injured children because it provides the first service for life-saving and medical care. Pediatric trauma, which occurs mostly due to falls or motor vehicle accidents, is one of the primary causes of mortality and morbidity. The emergency medical services of Children (EMS-C) program should focus on correcting pediatric deficiencies and should also set targets for training, research, and standardization of pre-hospital emergency care for pediatrics. The pre-hospital care should mainly focus on controlling the effects of trauma and maintaining the airway, breathing, and circulation.

What Are the Causes of Pre-hospital Emergency Care for Pediatric Patients?

For pediatric patients who are less than a year, the causes include:

• Congenital anomalies such as esophageal atresia (improper development of esophagus), total neural tube defects (defect of brain and spine), congenital diaphragmatic hernia (a defect in the sheet that separates the chest cavity from the abdominal cavity called the diaphragm), etcetera.

• Sudden infant death syndrome (SIDS, unexplained death of a baby).

• Maternal pregnancy complications.

• Bacterial sepsis (a condition in which, due to an infection, the body responds improperly).

• Neonatal hemorrhage.

• Respiratory distress.

• Seizure (abnormal electrical activity of the brain causing abnormal movements and behavior).

• Circulatory system disease.

• Dehydration.

• Unintentional injury.

• Short gestation.

• Defect in placenta cord membranes.

For pediatric patients of one to fourteen years, the causes include:

• Unintentional injury or traumatic injury is the primary cause of death. This occurs mostly due to falls and motor vehicle accidents.

• Homicide.

• Malignancy.

• Heart disease.

• Influenza and pneumonia (infection of the respiratory system).

• Septicemia (severe infection of the blood).

• Chronic low respiratory disease.

• Cerebrovascular disease.

• Benign neoplasm.

• Suicide (10 to 14 years)

What Is the Pre-hospital Emergency Care for Pediatric Patients?

Things to be considered in managing pediatric patients are:

1. The percentage of a child’s head is more than the total body mass when compared to an adult body.

2. They have flexible joint capsules and interspinous ligaments (ligaments that connect the spinous processes), which predispose to cervical spine injury (both soft and bone tissues). Therefore multiple organ injury occurs more.

3. The sutures and fontanelles are not closed up to the age of three years.

4. The underdeveloped abdominal muscles and the flexible rib cage does not provide enough protection to the internal organs. Therefore, children are more prone to internal injuries even without fractures because of flexible bones.

5. Maintaining a pediatric airway is a very important step in pediatric resuscitation. Cardiac arrest mostly occurs due to hypoxia (decreased oxygen supply to the body), unlike in adults, in whom cardiac arrest mostly occurs due to cardiac-related defects. Therefore, early and aggressive management of the airway is required.

6. Establishing a successful airway and laryngoscopy (diagnosis of the larynx) is a challenging task in children because of the following:

• A large tongue compared to the oropharynx (present behind the mouth below the soft palate) increases airway obstruction.

• Larynx is positioned more anteriorly and cephalic (forward and upward) compared to the adults.

• Shorter epiglottis (cartilage which is present behind the tongue and covers the food pipe while swallowing).

• Angled vocal cords, which cause passage of endotracheal tube into the anterior part of the larynx rather than into the trachea.

• A short neck and long head cause more difficulty in achieving an ideal position for laryngoscopy which is the sniffing position (extension of the head and flexion of the neck).

7. Children have a high rate of metabolism, and therefore their oxygen consumption is also high.

8. Hypothermia (decreased temperature) can occur due to a larger body surface area. Hypothermia can cause shivering, release of catecholamines (neurotransmitters such as adrenaline), and higher consumption of oxygen, leading to lactic acidosis (increased lactic acid). All these can affect the coagulation (clotting) system.

9. The principles including to maintaining the cardiovascular system are:

• The heart rate should be two to three times the respiratory rate.

• Systolic BP should be more than 60 mm Hg in the case of newborns, more than 70 mm Hg in the case of one month to ten years old, and more than 90 in the case of children above 10 years old.

10. Fluid resuscitation should be started early because of the vigorous vasoconstrictive (narrowing of blood vessels) response. The fluid bolus can be started from 20 mL/kg (milliliters per kilogram) of isotonic crystalloid, which can reach up to 60 ml/kg.

11. Warm intravenous fluids should be given to avoid hypothermia.

12. Large amounts of fluids should not be given, which can cause hypothermia and bleeding problems.

The invasive procedures are the same as in adult patients but are difficult to perform because of the anatomy and size. The Pre-hospital Emergency Care for Pediatric Patients includes:

• Intravenous (IV) access should be given for administration of fluids and medications. Pediatric patients require small intravenous catheters. The procedure may be difficult because of the uncooperative behavior of the child and small veins.

• In the case of severe hypovolemic patients (excess fluid loss), intraosseous (IO) access should be given.

• If intravenous (IV) access is not successful in 90 seconds or in three attempts, intraosseous (IO) access (placement of the needle in the medullary space through the cortex of bone) should be given.

• The airway should be managed with the help of small equipment and precise techniques.

• To visualize the vocal cords, padding is placed below the shoulder because of the large occiput (back of the head).

• A straight blade for a laryngoscope is used in small children (less than one year) rather than a curved blade.

• Glidescopes (video laryngoscopy devices) can be used in the management of airways.

• If oral intubation cannot be achieved, needle cricothyroidotomy, in which an over-the-needle catheter is passed through the cricothyroid membrane, is present in the front portion of the neck. But this can damage the cartilage and cause subglottic stenosis (narrowing of the airway).

• Cuffed ETT (endotracheal tube) can be used, which is passed to a depth of three times its size. This should be inflated with air to provide enough seals for ventilation.

• Analgesic drugs are given to pediatric patients, which relieve them from pain.

• Anticonvulsants such as Midazolam are used in case of seizures.

Conclusion:

The pre-hospital emergency management systems should have improved training and research. Traumatic injuries are the majority of cases that require pre-hospital emergency care. The staff should be highly skilled to manage airways and to provide IV placement.