LEARNING OUTCOMES
After completing this module the paramedic will be able to:
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The challenges paediatric trauma presents to pre-hospital and emergency clinicians have remained constant over the years. There has been a nationally increased focus to improve the quality of trauma care in the UK, leading to the development of regional trauma networks in 2012. This focus includes children. This module will discuss the challenges and issues of dealing with paediatric trauma and how some of the problems encountered might be mitigated.
Familiarity and experience
Who are the paediatric trauma experts? Prior to establishing trauma networks, the entire burden of paediatric trauma divided amongst receiving units led to an average of just over one case of major trauma (ISS>15) per year presenting to each single unit (NHS Clinical Advisory Group, 2011). Figures from the Department of Transport show that in 2000 there were 5 011 seriously injured children and 191 deaths as a result of motor vehicle accidents; by 2011 this had fallen to 2 211 seriously injured and 61 killed (Department for Transport, 2013). Paediatric Intensive Care Audit Network (PICANet) data shows that trauma accounts for around just 2.8% of Paediatric Intensive Care Unit (PICU) admissions (Draper et al, 2012). These are happy numbers but the chances of any individual practitioner having regular exposure to significant paediatric trauma are slim. The fact remains that most primary responders will not have paediatric expertise and may only have very limited experience. This deficiency has the unwanted and probably entirely unnecessary effect of heightened anxiety when presented with a seriously injured child. This can lead to further impairment of clinical performance and decision making. There is very little confidence in dealing with seriously injured or unwell children.
Clinical skills
It is often apparent that skills acquired in a hospital environment are harder to display in the pre-hospital environment. These skills are yet again harder to perform when dealing with the paediatric patient. Everything becomes technically more challenging, compounding the difficulty of dealing with the patient effectively. Extended efforts to gain venous access at scene, for example, may result in delayed treatment and transport. The tenets of good pre-hospital care, such as relieving pain, providing emergency intervention and good packaging, all suddenly become a challenge to deliver.
The key step in the care of all emergency patients is recognition. Recognise the sick patient and you are halfway to making the correct management decisions. This is a lesson that is pushed endlessly on paediatric life support courses because health professionals know that lack of recognition leads to decompensation and the threat of the irretrievably sick child. Recognition requires theoretical learning and good assessment skills, which is reinforced with repetition in practice—exactly what is often lacking in paediatric trauma care. Your five days in the children's emergency department during training may seem and may indeed be a long way a way, if you even received them.
Pre-hospital decision making
Imagine the scenario: you are at a motor vehicle accident with an injured 3-year-old child. They are tachycardic, tachypnoeic, pale and very drowsy. You correctly identify that the child is hypovolaemic, critically injured and peri-arrest. The child needs oxygen, access and fluids as soon as possible. What do you do? Hold your nerve, apply oxygen, get access at scene and deliver some boluses of fluid before loading and transferring an improved child to trauma centre? Or do you scoop them up, drive like the wind to the nearest emergency department, attempting and failing to do all of that whilst in transit? Paediatric pre-hospital critical care is littered with opportunities to make it even harder to treat the child, such as by attempting to get access in transit. We are all taught that the outcome from paediatric cardiac arrest is dismal, but that it is almost always secondary to hypoxia and/or hypovolaemia. In this case the reversible cause is hypovolaemia and the best chance of correcting this will be 1–2 minutes more at scene whilst establishing vascular access to enable the delivery of fluids. The pre-hospital practitioner must give themself the best chance possible to improve their patient. Decision making must be rapid and accurate. Life-saving interventions, such as cardiopulmonary resuscitation, oxygenation and fluids must be of high quality. Twenty minutes of ineffective resuscitation in a mobile vehicle is of no benefit to the patient. This of course applies to all patients, but the pressure of the child in front of us clouds our decisions and urges speed and not necessarily thought.
Training
In a survey of UK ambulance services in 2010, four of the 13 respondents (31%) considered it ‘possible or highly likely’ that someone with no specific training could be the first to respond to a child in an emergency, and seven (54%) indicated that the likelihood that the first response to a child could be someone with no current qualification specific to paediatrics was ‘high’ (Houston and Pearson, 2010). The paper survey also highlighted that paramedics receive limited paediatric training and that large areas of the country have to have formal medical support available to those paramedics at any time of day (Houston and Pearson, 2010).
How often do you perform adult advanced life support (ALS)? When was your last adult ALS update? Now, ask that question with paediatrics in mind. Since leaving undergraduate training when did you last undertake paediatric training? Most of your patients are adults but many are children and a few of those are seriously injured or ill.
The less we do something the more we need theoretical and practical training to mitigate the lack of actual clinical exposure. However, we often fail to identify learning and training needs in favour of focusing on training that is easier to deliver or personally less challenging to undertake. Paramedics themselves rather than their employers are responsible for their continuous professional development. They must ensure their development portfolio is varied, reflecting the paramedic's educational needs and the patients unmet needs.
Equipment
Key equipment may not be available or not appropriate, an example of this would be pelvic splint devices that don't fit younger children. This forces us to improvise and through no fault of the practitioner in all likelihood compromise clinical effectiveness. In the same study mentioned above, only 62% of respondents reported having pulse oximetry monitoring equipment suitable for use on children (Houston and Pearson, 2010).
The trauma networks
The commissioning of trauma networks has changed the way we make decisions in pre-hospital care. As of October 2016 there were five children's trauma centres in England. With some local variation in trauma decision-making tools, pre-hospital practioners may find themselves bypassing children's hospitals to take their patient to the designated trauma centre. This occurs in areas where children's hospitals are yet to be designated as a children's trauma centre. This leaves pre-hospital clinicians with instinctively uncomfortable decisions on destination. However compelled the clinician feels to scoop and run to the nearest children's hospital this may be entirely the wrong thing to do. A longer journey to the designated combined adult and children's trauma centre or even adult trauma centre may be in the child's best interest in many cases. The trauma network for children is thin in some areas where there are long transfers involved in accessing combined major trauma centres, let alone children's major trauma centres. It has to be said, however, that literature does not definitively support one model of paediatric care over another, be it paediatric trauma centre, adult with paediatric input or adult.
Solutions
So how do we overcome the challenges of providing good trauma care to children? There are several areas to address but firstly a statement of reassurance. Despite all the problems discussed above, paramedics and other pre-hospital clinicians are already capable of treating injured children, even if some perceive otherwise. There are two things an injured child needs: paediatric skills and trauma skills. Whilst individual paediatric skills may be light, this can be at least partly overcome by the volume of adult trauma experience held. The fact is that whilst the favorite statement ‘children are not little adults’ may ring in our ears following paediatric life support training, it may not be quite accurate for all paediatric patients. The physiology of the child is certainly seen into young adulthood, particularly in fit young adults where they are able to compensate in extremis, maintaining a blood pressure and organ perfusion. This is observed in young soldiers with huge battlefield injuries. Paramedics would probably not think twice about dealing with an injured 17-year-old, but the assessment and immediate management of that patient and a 10-year-old is practically the same. Children may not be little adults but young adults may well be big children; however, mentally we do not perceive the same difficulties with our young adult patients. Children sustain the same life-threatening injuries as adults and the life-saving interventions for those injuries are also the same. They may get the injuries in different patterns, but the skills used to identify them and then treat them are sufficiently similar that it should instill a degree of calm and confidence in the clinician who can merge the volume of general trauma experience with the focused paediatric skills acquired in training.
It is difficult to ask individuals to identify abnormal physiology and then treat children without the right training and equipment. In 2011, the NHS Clinical Advisory Group specifically referred to the requirement to improve equipment, skills and analgesia (NHS Clinical Advisory Group, 2011). Monitoring and resuscitation equipment should be appropriately sized and selected for children, e.g. pulse oximetry and splinting. Technical difficulties, such as vascular access and delivery of fluids, can be overcome with the availability of modern intraosseus devices (and the required training to use them) rather than hand needles. Extending paramedic training and guidelines would enable delivery of analgesia through the intranasal route. This has been performed safely and effectively for over 15 years in emergency departments to relieve pain and suffering in children without having to gain vascular access first.
Aside from policy, equipment and mental hurdles, the key to improving pre-hospital trauma care to children lies in training and support. Paramedics require regular update training including clinical placements. They should be current in life support training and should undergo regular simulation training to mitigate inevitable knowledge and skill fade. Vitally, however, they must honestly and accurately identify their individual training needs through portfolios and regular competency reviews to guide professional development. To support paramedics, the NHS Clinical Advisory Group recommend 24/7 access to telephone advice from a consultant with pre-hospital experience of paediatric major trauma.
Conclusions
Paediatric pre-hospital trauma care will continue to present a challenge to clinicians. Whilst paramedics should be confident in the application of skills already acquired there is still global improvement required and achievable through training, equipment and support improvement.