Essex and Herts Air Ambulance Trust (EHAAT) is a publically funded charity that operates two doctor-paramedic pre-hospital care teams to provide support to land ambulance crews in two counties in the South East of England. The service is predominantly helicopter-based but operates a rapid response car outside daylight hours or in poor weather. The total population covered numbers approximately 1.8 million. The team responds to major trauma and medical emergencies, with the latter accounting for approximately 20% of all taskings. The paramedics who work for the service are all employed by the East of England Ambulance Service NHS Trust, and are seconded to EHAAT for a period of 24 months. A comprehensive selection process is undertaken and an extensive training programme covering aviation practice and extended clinical management is in place for successful candidates. In addition, EHAAT paramedics have been among the first to enrol and undergo enhanced skill training in anaesthetics and intensive care medicine as part of a postgraduate certificate in advanced paramedic practice in critical care. We believe that one of the strengths of the service provided by EHAAT lies in our paramedics acting as role models and ambassadors for both our service and the ambulance service in general.
Case study
The EHAAT doctor-paramedic team were dispatched to a 10-year-old girl who had been struck by a medium-sized van travelling at an unknown speed. Upon arrival of the first ambulance crew, the patient was found lying supine in the road. Clinical examination revealed that she was maintaining her own airway, had a fixed gaze and was making incomprehensible sounds. External haemorrhage was noted from an occipital scalp laceration. Additionally, the patient had a fractured left femur with gross angulation, resulting in the left foot resting over her right shoulder. The leg was returned to its normal anatomical alignment early in the initial assessment. Other suspected injuries included a head injury with reduced Glasgow Coma Score (GCS), an injury to the left side of the chest (leading to poor ventilation), a closed left humeral fracture and an additional right femoral fracture. During the initial management phase, the patient's level of consciousness was found to be deteriorating with clinical evidence of evolving respiratory compromise, leading the attending ambulance crew to expedite urgent transfer to the nearest trauma unit (TU) prior to the EHAAT teams arrival. As such, the EHAAT team proceeded directly to the TU. Upon arrival at the TU, the patient was emergently intubated and ventilated with improvement in her clinical condition; she required minimal fluid resuscitation. The cause of the respiratory compromise was identified as multiple rib fractures with an underlying lung injury. The EHAAT team facilitated further patient management including: fracture splinting, haemorrhage control and osmotherapy due to concerns as to the extent and severity of the patient's underlying brain injury. Following these further measures, the EHAAT team were able to expedite the rapid transfer of the patient to the regional major trauma centre (MTC).
Discussion
Due to the relative infrequency of major trauma in the paediatric population, along with the presence of family members during the resuscitation, management of trauma in this age group can be both emotive and highly challenging (Cowley and Durge, 2014). Therefore, it is vital that pre-hospital clinicians are well rehearsed in managing the injured child. Nonetheless, many of the principles used to treat adult trauma patients are the same as those used to treat children. Through comprehensive assessment, targeted resuscitation and considered triage to an appropriate paediatric trauma facility, pre-hospital care clinicians can help to improve outcomes in the paediatric trauma patient (Doran et al, 2012; Bouglé et al, 2013; Lyttle et al, 2013; Davenport, 2014). This article aims to provide a structured, evidence-based approach to the assessment and management of the injured child in the pre-hospital setting.
Assessment
In recent years, battlefield haemorrhage protocols have become transferrable to civilian trauma care due to an increase in knife and gun crime, leading to a paradigm shift within the way trauma care is assessed and managed. As with adult trauma patients, assessment should consist of a structured approach following the <C>ABCDE paradigm (Hodgetts et al, 2006).
(C) Catastrophic haemorrhage
The source of catastrophic haemorrhage should be rapidly sought and arrested using a device appropriate for the level of severity (discussed later). Only when this has been achieved should assessment follow the conventional paradigm.
(A) Airway considerations and cervical spine injury
Attention to the detail of basic airway management in children is crucial (D'Amore and Hewson, 2002). As discussed later in the article, the paediatric airway is more prone to obstruction than in adults (Walls et al, 2004). This obstruction leads to rapid desaturation and the potential for severe secondary hypoxic insults.
In younger children, there are anatomical differences that clinicians should be aware of during the management of the airway. A key principle is that the large head-to-body ratio in younger children causes the head and neck to rest in a relatively flexed position due to occipital prominence (Macfarlane, 2005). Even in the traumatically injured child, attempts should be made to elevate the shoulders to ensure better airway alignment, while maintaining careful control of the cervical spine. This simple approach to achieving the correct positioning of the airway may be the only intervention required to successfully relieve the obstruction.
In addition to positional considerations, a child's airway is more susceptible to swelling or foreign body obstruction (Adewale, 2009). One millimetre of oedema or obstruction to a child's airway of 4 mm diameter, represents a 44% decrease in the cross-sectional area and a 200% increase in airway resistance (Walls et al, 2004). In the setting of trauma, oedema can be precipitated by direct injury to the upper airway or by thermal or chemical burns. Foreign body obstruction can be caused by the presence of a sweet or other item in the mouth at the time of the injury, by teeth, or by blood and vomitus. In the case of airway oedema, careful positioning and the use of adjuncts (as described below), alongside rapid conveyance to the nearest trauma unit is appropriate. Once identified, management of airway obstruction due to foreign bodies proceeds in line with published guidance (Biarent et al, 2010). Blood and other secretions can be removed with postural drainage or, in the potentially spinally injured child, by use of a portable suction machine such as the Laerdal Suction Unit (Laerdal Medical, 2014).
If simple positioning fails, a jaw thrust may be helpful, paying attention to manual in-line stabilisation of the cervical spine. Sometimes, wide mouth opening will separate the relatively large tongue from its resting position against the palate and relieve airway obstruction. In this situation, the insertion of an oropharangeal airway (OPA) prevents the tongue from re-obstructing the airway. It is essential that the OPA is correctly sized otherwise it may itself cause obstruction.
Cervical spine injury in children is uncommon despite the larger size of the head in comparison to their body (Cullen, 2012). Yet should an injury occur, it is more likely at the C1/C2/C3 junctions in the younger child (Brown et al, 2001), possibly due to the lack of ossification and underdeveloped ligamentous support, whereas older children are likely to suffer with lower cervical injuries (Platzer et al, 2007; Cullen, 2012). At these levels, the spinal cord injury could be catastrophic. Children with a significant mechanism injury, regardless of whether there are clinical signs of injury, should, if they tolerate it, have spinal precautions instigated.
The importance of maintaining good oxygenation through a patent airway is necessary to avoid hypoxic insult to the injured child. Simple manoeuvres such as positioning or a jaw thrust often will suffice, but ultimately a more definitive airway such as endotracheal intubation may be necessary, especially in the context of other injuries.
(B) Breathing
Until the age of 6 months children are predominately nasal breathers. The respiratory rate and pattern should be assessed and reassessed regularly as this will often be the first indicator of deterioration. Normal respiratory rates can be found in Table 1. Identification of abnormal chest signs can guide the priorities for treatment. A mnemonic for an assessment of breathing (FLAPS TWELVE) can be found in Table 2. Ensure the patient's chest is fully exposed.
| <1 year | 30–40 breaths per minute |
| 1–2 years | 25–35 breaths per minute |
| 2–5 years | 25–35 breaths per minute |
| 5–11 years | 20–25 breaths per minute |
| >12 years | 15–20 breaths per minute |
| Feel | Feel the chest wall for crepitus, surgical emphysema, swelling or deformity. Is there equal expansion? Does the patient have a flail segment? |
| Look | Look at the patient's chest while crouching at their feet. Subtle changes are most evident from this angle. Look for hyper-expansion, paradoxical movement and bruising. |
| Auscultate | Lateral chest and anterior armpit. Note any decreased or absent air entry. Are there any added sounds? |
| Percuss | Should be performed if ambient noise allows. Often not possible. Hyper-resonance indicates air. Hypo-resonance indicates fluid. |
| Search | Search the lateral and posterior regions of the chest for blood and fractures as above. Assess the armpits for wounds. |
| Tracheal deviation | Tracheal deviation is a pre-terminal sign. Assess at the level of the sternal notch. |
| Wounds to the neck | Assess for swelling, bruising and bleeding around the neck. Anticipate airway compromise. |
| Empysema | Surgical emphysema can occur following a disruption of the surface of the lung and represents an air leak into the surrounding subcutaneous tissues. |
| Laryngeal disruption | Assess the larynx for stability and crepitus. High pitched or no voice? |
| Veins | Jugular venous distention is not normally seen in hypovolaemia, but if present, denotes obstruction within the thoracic cavity such as tension pneumothorax or cardiac tamponade. |
| Evaluate | Put your signs together. What injury does the patient have and what is your first priority? |
The reduced functional residual capacity and high metabolic rate in a child makes them much more susceptible to significant and rapid desaturation if the normal breathing mechanisms are disrupted by injury (Walls et al, 2004). All children who have sustained major trauma and require resuscitation should receive high flow oxygen via a tightly fitting facemask with a reservoir attached (Resuscitation Council UK, 2010). Ventilatory support with a facemask and self-inflating bag may be required if there is desaturation in a spontaneously breathing child attached to high flow oxygen with a patent airway. Always check that the oxygen supply is not empty, is turned on and that the oxygen tubing is not kinked.
The correctly sized facemask for a child covers both the nose and the mouth and forms a seal with no gaps. During assisted ventilation or airway support, it is important that the clinician's fingers rest only on the bony structures of the face rather than against the soft tissues. Even gentle pressure against the floor of the mouth risks worsening airway obstruction by allowing the tongue to press against the roof of the mouth (Holm-Knudsen and Rasmussen, 2009). With bag-valve-mask ventilation, the stomach can become insufflated to the extent that effective ventilation is impaired. Although it may lessen the seal of the facemask on the child's face, the insertion of a nasogastric or orogastric tube to deflate the stomach can improve ventilation in this situation. Using a two-handed, two operator, bag-valve-mask technique (Weiss and Lutes, 2008) has been shown to ensure optimal fitting of the mask and subsequent lung inflation while minimising gastric insufflation (Isono, 2008).
(C) Circulation
A healthy child's cardiac output is higher than an adult with a stroke volume of approximately 80–90 ml as opposed to 70 ml in a healthy adult (Macfarlane, 2005). A smaller total blood volume leaves little room for error in a patient who has sustained trauma. Estimating blood loss is challenging. Often, by the time the child begins to show clinical signs of shock, they will have already lost 25% of their circulating volume without any significant derangement of their central arterial pressure (Cullen, 2012). Inadequate tissue perfusion can manifest as irritability (due to hypoxia) resulting from hyper-or hypoventilation but also as peripheral and later central skin mottling and capillary refill prolongation. Searching for occult injuries and potential areas of blood loss is paramount in preventing a sudden, irreversible deterioration following a period of relative haemodynamic compensation. Tachycardia suggests shock; however, be suspicious of a normal heart rate in the presence of a significant injury mechanism. A bradycardic response is often documented as a pre-terminal sign (Cullen, 2012).
Significant blood loss can be seen in scalp lacerations and long bone fractures, so assessment should encompass identification of these injuries through the use of ‘blood on the floor and four more’. If there is no blood on the floor, i.e. no external haemorrhage and a patient is shocked, the clinician needs to search for blood loss in the four main compartments where bleeding can occur: chest, abdomen, pelvis and long bones (femurs). Capillary refill time should be measured centrally rather than peripherally. Age dependent observations can be found in Table 3.
| <1 year | 110–160 beats per minute |
| 1–2 years | 100–150 beats per minute |
| 2–5 years | 95–140 beats per minute |
| 5–11 years | 80–120 beats per minute |
| >12 years | 60–100 beats per minute |
There is a paucity of knowledge surrounding cerebral blood flow and auto-regulation following paediatric head injury. Yet we know that the control of cerebral circulation is predominantly influenced by metabolism, the partial pressures of oxygen and carbon dioxide, blood viscosity and cerebral auto-regulation (Udomphorn et al, 2008). The change in cerebral blood flow occurs almost immediately with an increase or decrease of the partial pressure of carbon dioxide. Beyond the limits of normal auto-regulation, the brain depends upon adequate cerebral perfusion pressure (CPP=MAP-(ICP+CVP)) to ensure oxygenation and removal of waste products. In a child with a serious head injury, normal mechanisms of auto-regulation may be disrupted resulting in cerebral blood flow becoming proportional to mean arterial pressure. High intra-cranial pressure and low arterial blood pressure, have been found to impair brain auto-regulation (Czosnyka, et al, 2001). In adults, episodes of hypotension in the first 24 hours following head injury is significantly associated with poorer neurological outcome and increased hospital stay (Haddad and Arabi, 2012). This is also thought to occur in children (Kokoska et al, 1998).
(D) Disability
An initial assessment of the patient's consciousness level should be made using the AVPU scale, as well as examination of the pupil size, shape and symmetry in response to light. Observation and documentation of the movement of all four limbs independently should be undertaken, along with documentation of any pertinent negatives, such as: altered sensory or motor function. Any decrease in the child's level of consciousness warrants a formal calculation of their GCS. An accurate representation of the patient's GCS (Heather et al, 2013) (Table 4), and in particular their motor score, is used as a marker of higher brain functioning which is useful to guide neurosurgical intervention and assess prognosis (Choi, et al, 1988; Michaud et al, 1992). Any confusion or agitation in a child can represent a direct primary brain injury, hypoxia with subsequent secondary brain injury, or hypo-perfusion due to blood loss.
| Eyes opening | As per adult |
| Motor response | As per adult |
| Verbal response: Appropriate words or social smiles, fixes on and follows objects | 5 |
| Cries but is consolable | 4 |
| Persistently irritable | 3 |
| Restless, agitated | 2 |
| Silent | 1 |
(E) Exposure and Evaluation
A child's head makes up approximately 18% of their total body surface area. This exposure may lead to considerable heat loss when compared to the same region in adults. In order to compensate for this loss, newborns produce heat by non-shivering thermogenesis (increase in metabolic heat production above the basal rate through the breakdown of fat) and this is believed to be the main mechanism for heat production in children up to 1 year of age. During the child's first year, shivering thermogenesis becomes more effective and takes a more prominent role in thermoregulation. Clinicians should be assertive in maintaining normal body temperature and minimising heat loss in this patient group.
Management
Although the principles of resuscitation of children are similar to those in adults, knowledge of physiological variables and response to shock is required to ensure effective resuscitation. If catastrophic haemorrhage originates from a limb, a tourniquet should be applied proximal to the wound. Application of a tourniquet should generally occur over a single bone, i.e. the femur or humerus. It is prudent to note that wounds from the lower limbs may require more than one tourniquet to stem the bleeding. Junctional wounds at the neck, axilla or groin are not amenable to tourniquet application and so initiation of the haemorrhage control ladder with initial direct pressure is appropriate. In our case study, the child was reported to be maintaining her own airway. Oxygen was applied via a non-rebreather mask at a rate of 15 litres per minute. Ensuring that the oxygen mask is tightly fitting will aid in de-nitrogenation of the patients lungs and decrease the rate of desaturation should the external oxygen supply be terminated. Even in the absence of abnormal airway sounds it may be of benefit in a patient with a decreased GCS to apply a light jaw thrust (should the child tolerate it) in order to ensure that airway management is optimal.
Ventilation of a child with a BVM without an oropharygeal airway (OPA) in place may force air into the stomach rather than the lungs. Therefore, time taken to correctly size an OPA, with careful insertion under direct vision, ensures that the large tongue will not obstruct the upper airway and the soft palate is less likely to be damaged.
The supraglottic airway (i-gel or laryngeal mask airway) is a safe and effective device for airway management in the paediatric patient. However, due to the small oral cavity and relatively large tongue they may be difficult to insert. To complicate this, the floppy epiglottis may occasionally cause airway obstruction during adjunct insertion. A rotational placement technique (similar to the insertion of an oropharyngeal airway) has been documented as a method of overcoming this complication (Walls et al, 2004).
The use of the nasopharyngeal airway (NPA) in head injured patients has been a source of controversy among paramedics. Nonetheless, management of the patient's airway takes primacy over concerns related to inadvertent intracranial placement of the adjunct in this patient group. Therefore, a cautious attempt at insertion of an NPA is recommended in paediatric patients with a head injury. The hypoxia sustained through an unmanaged airway is likely to cause more harm than a carefully inserted airway adjunct. Optimal airway management in obtunded, self-ventilating patients who have signs of airway compromise, should consist of the placement of two NPAs and an OPA, the so-called tripod or silo, which should ensure maximal upper airway patency. Outside of definitive airway management with anaesthesia and endotracheal tube placement, this ensures optimal pre-hospital airway management.
The management of chest injuries by ambulance crews is generally supportive with relatively few patients requiring invasive management. In comparison to adults, a child's ribs are more elastic resulting in greater recoil during blunt traumatic injury (Cullen, 2012). Therefore, although they may not have clinically evident rib fractures, there may still be an underlying lung injury. Splinting a flail chest can be done manually in the absence of analgesia and can be performed by direct pressure using the patient's hand or the hand of a bystander, providing this does not detract from further assessment, rapid packaging and removal from scene. Alternatively, the patient can be positioned ‘bad lung down’ (i.e. inclined to the side of the flail segment) to facilitate ventilation of the uninjured, upward facing lung. Both of these options are temporising measures and use of the latter in patients with suspected or confirmed spinal injury would be controversial. In the context of chest injuries such as rib fractures or flail chest, the presence of pain inhibits normal ventilation. Therefore, adequate analgesia should be administered in order for the patient to take breath normally and achieve resting tidal volumes.
Tension pneumothorax, while being relatively uncommon, can be fatal. The clinical signs and technique for needle decompression should be familiar, allowing for immediate recall in emergency situations. The description and discussion of the management of tension pneumothorax was outlined in our previous article and, as such, is outside the remit of this paper. However, it is pertinent to emphasise that, in the multiply injured patient with signs of a chest injury, tension pneumothorax should be excluded as a cause of hypotension when other sources of blood loss have been discounted.
Successful resuscitation of the bleeding patient requires early recognition of potential bleeding sources and timely, definitive intervention. It is in the pre-hospital environment that paramedics can make a vast difference to outcomes in the bleeding patient. Fully exposing patients prior to assessment ensures that injuries are unlikely to be missed. Management of external haemorrhage should have a systematic approach, as detailed below.
Early splinting of the pelvis and long bones aims to minimise movement at the fracture site, decreasing pain, promoting haemostasis and limiting the potential space into which bleeding can occur (Lee and Porter, 2007). Should a traction splint not be available, manual traction of the limbs can be applied by a competent bystander or rescue worker. This frees up the clinician to undertake other high-level interventions. Manual traction should be maintained until a traction device can be applied.
There is a paucity of knowledge surrounding the effects of movement on haemostasis. Therefore, recommendations are largely consensus based (Moss et al, 2013). Elevation in blood pressure caused by pain or movement should be minimised. Packaging should be considered a haemorrhage control intervention in its own right and should involve concurrent application of the pelvic splint and scoop stretcher in order to avoid unnecessary patient movement. Hypothermia in the presence of trauma haemorrhage worsens clotting and effects outcome (Midwinter and Woolley, 2011; Davenport, 2014), therefore the EHAAT team aim to deliver a normothermic patient to the emergency department.
However, time taken to cut clothes off the patient in a ‘Y’ shape vertically down the midline of the back and the legs will save time later in the packaging process and enable full exposure for thorough clinical assessment. Clothes that are left in-situ contribute to patient discomfort. Thus patients should be ‘skin to scoop’, immediately following completion of the primary survey. A patient roll of no more than 10–20 degrees can be employed to place the pelvic splint and insert the blades of the scoop stretcher. The log roll seldom offers useful information in the context of blunt trauma and can exacerbate spinal, pelvic and visceral injuries; thus it should be avoided.
| Direct compression | Standard ambulance dressings. |
| Indirect compression | Proximal compression of the artery supplying the limb. |
| Elevation/immobilisation | Elevation is appropriate if a fracture has been excluded. Immobilisation or splinting of a limb is often the best way of reducing the potential space to bleed into. |
| Haemostatic dressing | Many varieties are available, still requires direct pressure. |
| Tourniquet | If bleeding has not been stopped, now is the time to apply a tourniquet, noting the time of application. |
Recently there has been significant interest among medical professionals on educational social media as to best practice in immobilising the cervical spine. There is increasing recognition that benefit may be equivocal in certain cases, and that unwanted side effects are a more pressing concern. At the time of writing, the standard of care for spinal precautions when moving a patient from scene to hospital is ‘triple immobilisation’ with a correctly-fitting hard collar, headblocks and tape. Draft guidance published online from ILCOR (International Liaison Committee on Resuscitation) (Thomas, 2015), but not yet ratified, has removed the cervical collar from this protocol and it is anticipated that other major organisations will follow in their guidance. There are occasions in infants or very young children when their consciousness level is such that they would not tolerate being stripped of their clothing and strapped down. In this situation it is better for the child to either be held in their mothers arms or for them to remain in a position of comfort. The clinician should then secure the patient ‘as is’.
Wherever possible, vascular access should be attempted and if unable, intraosseous access should be gained (Greene et al, 2012). Due to a lack of available evidence to support the use of permissive hypotension in paediatric patients, fluid therapy at 5 ml/kg should be used and repeated as often as necessary to ensure cerebration and improve clinical signs prior to definitive haemorrhage control in hospital (AACE, 2013).
Tranexamic acid (TXA) is an anti-fibrinolytic drug that competitively inhibits the conversion of plasminogen to plasmin. TXA should be given en route to hospital as early as possible within the first 3 hours after initial injury, to be optimally effective (Roberts et al, 2013). The use of TXA in combination with blood products has been seen to improve coagulopathy and survival in military trauma victims (Morrison et al, 2012). At present, pre-hospital blood transfusion is not a capability the EHAAT team possesses.
In the context of head injury, the patient should be placed in a 20–30 degrees head up position (Ng et al, 2004), the cervical collar loosened to allow venous drainage (Karason et al, 2014) and optimal ventilation should be a priority to avoid secondary brain injury (Haddad and Arabi, 2012).
A pre-alert call through the local trauma network utilising a systematic handover of pertinent information will ensure an appropriate reception upon arrival at hospital.
The role of an enhanced care team
Land ambulance crews encounter anxious parents, relatives and bystanders in the course of their daily duties and are adept at managing both the clinical priorities of the patient as well as the emotional needs of those around them. Despite familiarity in dealing with anxious parents in the context of an unwell child, in injured children, assertive scene management, systematic assessment and appropriate management can be challenging for land-based crews due to relative inexperience of paediatric major trauma patients and lack of exposure. Our patient required early anaesthetic management for airway compromise and impending ventilatory failure, prompt fracture reduction and splinting with careful handling and packaging, followed by aeromedical transfer to the MTC. The requirement for multiple clinical and logistic interventions, coupled with the need for transport to appropriate disposition destinations, means that early involvement of enhanced care teams can be beneficial.
Conclusions
We have highlighted the need for an accurate and thorough primary assessment and early management in paediatric patients with time-critical injuries. While many injuries can be very well managed by land-ambulance paramedics, we have highlighted areas in which an extended care service, such as that provided by the EHAAT, can assist, particularly in terms of airway management, ventilatory support and triage to specialist centres.