Most EDs ‘fail’ key tests in mock drills for pediatric trauma cases
Most EDs fail’ key tests in mock drills for pediatric trauma cases
EDs fall short in hypoglycemic shock, hypothermia, administering IV fluids
A recent North Carolina study showing hospital EDs failed to properly stabilize seriously injured children during trauma simulations is a sign of a larger national problem with EDs being ill-prepared to handle pediatric trauma patients, reports Elizabeth A. Hunt, MD, MPH, assistant professor of anesthesiology and critical care medicine at Johns Hopkins Children’s Center in Baltimore.
Hunt led research teams at Johns Hopkins and at Duke University Medical Center in Durham, NC, that staged "mock codes" using life-size child mannequins in 35 of North Carolina’s 106 hospital EDs. Among their more worrisome findings:
- Thirty-four of the 35 EDs failed to administer dextrose properly to a child in hypoglycemic shock.
- Thirty-four of 35 failed to correctly warm a hypothermic child.
- Thirty-one of the 35 failed to order proper administration of intravenous (IV) fluids.
- Personnel in 24 out of 35 did not attempt or did not succeed at accessing a child’s bloodstream through a bone (intraosseous needle) — a critical alternate avenue for rapidly delivering fluids and medicines to sick children whose veins may have constricted due to hypothermia or blood loss.
Not all of the findings, such as the poor use of intraosseous needle, were a surprise, Hunt says. "People don’t understand how valuable it is," she notes. "It’s very hard to get an IV in a sick child who is either cold or has lost a lot of blood. They also don’t know it’s an easy procedure."
Only 12 of the 35 hospitals prepared appropriate medications, monitoring equipment, and personnel needed to transport a child safely within the hospital. Of particular concern to Hunt was preparing patients for transport for a computed tomography (CT) scan. "It is well known in the literature that transporting patients is a dangerous and stressful time," she says. "They can sometimes lose their breathing tube or IV, or even have a cardiac arrest. This study gave us insight into that; a large proportion of the EDs figured out they should order a scan, but fewer realized they should have a monitor and a transport team ready, and an even smaller proportion did it." In all, she reports, 66% of the EDs failed that test.
Another interesting issue for her was cervical spine stabilization. "You don’t realize how many people do not have appropriate neck braces for various-sized children," Hunt observes. "It was interesting how the EDs had to make up ways of stabilizing the neck with towels or whatever, but not everybody had a plan."
Kids are different
This study raises the important issue of just how different children are from the adults most EDs are more used to seeing.
"When you’re dealing with a child, you actually have to think more in terms of doing math during resuscitation, whereas with adults, even if they are all different weights, you can assume you can use the same dosage of medication," Hunt explains. "But if a child is 2 or 16, you use different-sized endotracheal tubes, IVs, and different amounts of IV fluids."
Several EDs had a hard time estimating the weight of the child and did not always use some of the tools available to help guess their weight, she says. One of these is the Broselow-Luten tape. If you lay a child on a stretcher and put the color-coded tape at the top of their head, wherever the foot ends it will be in a certain color zone. "That is equated with a weight," Hunt explains. The tapes are inexpensive, she says, and many EDs have them available in the trauma bay.
The need for rapid vascular access is another key issue for children in trauma, Hunt says. "Their sugars become lower more frequently, so you also have to be aware of that," she adds. "They have small livers, smaller glucose stores, and have a higher metabolic weight; so they’re more likely to become hypoglycemic."
Kids are definitely not young adults, adds Naghma Khan, MD, medical director of the EDs at Children’s Healthcare of Atlanta and Egleston Hospital, both in Atlanta. "For example, a big issue is body surface area," she says. "Exposure to blunt trauma as a ratio [to total body surface] is much higher, so the same impact is dissipated better in adults."
The temperature in most EDs is set to be comfortable for staff — not patients — and this is a particularly important issue with children, she says. "If they get hypothermic, they have a lot more electrolyte imbalance, and more morbidity related to just being cold," Khan explains.
However, this problem is easily managed, she says. "When kids come in the door to our center, the first thing we do is make sure they are warm. We get the heating blankets out and remove any wet clothing."
In fact, in designing her new trauma center, Khan had the temperature set at 75° F, compared to the 66° that is typical in most EDs. "Actually, sweltering hot is the optimal temperature — close to 85°," she notes.
Finally, says Khan, "We are very liberal with fluids." Adults with fluid overflow are susceptible to congestive heart failure, but with kids, it’s the opposite problem, she notes. "In most kids, their hearts are fine, so they can maintain their blood pressure for a very long time," she explains. "We very often miss hypovolemic shock in these kids until it is too late."
Steps ED managers can take
There are several things ED managers can do to make their departments better prepared to handle young patients, says Hunt. First, make sure your people are aware of how their own equipment is organized, she says.
"One of the best ways to do that is through drills," she advises. "When you do that, you will quickly figure out, for example, that suction is so far across the room it won’t even work, or that you’re not stocked with a particular kind of equipment."
Khan also stresses the value of drills. "We do regular mock codes, using dummies or models," she shares. "We do it specifically for pediatrics patients." In addition to the dummies, the trauma director will dress up, "create" wounds, and walk into the ED and have the staff respond.
"We look for trauma to manage hypovolemic shock appropriately," says Khan. Another very important consideration, she notes, is pain management. "We have a huge initiative around pain management here," she says. "We tend to forget kids must be in a lot of pain."
In addition, come up with a method for quickly establishing a child’s weight and being able to figure out the right doses for children of different sizes, Hunt says. And of course, she adds, "Appreciate the value of intraosseous, and be sure to have the appropriate staff and equipment needed if transport becomes necessary."
You also want to have an outline of how you will manage these patients based on the resources at your facility, says Robert Schafermeyer, MD, FAAP, FACEP, an emergency physician at Carolinas Medical Center in Charlotte, NC, and past president of the American College of Emergency Physicians. For example, you need to know how you will handle transfers, how you will get a general surgeon, etc., he says. "At our facility, we have criteria for pulling together resources to get patients scanned quickly or ready for the OR. Having all of this ready in advance helps the staff do what they need to do."
Sources/Resource
For more information on treating pediatric trauma patients, contact:
- Elizabeth A. Hunt, MD, MPH, Assistant Professor of Anesthesiology and Critical Care Medicine, Johns Hopkins Children’s Center, Baltimore. E-mail: [email protected].
- Naghma Khan, MD, Emergency Department Medical Director, Children’s Healthcare of Atlanta and Egleston Hospital, Atlanta, GA. Phone: (404) 785-7127.
- Robert Schafermeyer, MD, FAAP, FACEP, Carolinas Medical Center, 1000 Blythe Blvd., Charlotte, NC 28203. Phone: (704) 355-3797.
For more information on the Broselow-Luten tape, see Luten R, Broselow J. Rainbow care: The Broselow-Luten system. Implications for pediatric patient safety. Ambul Outreach 1999; Fall:6-14. The tapes are five for $120 plus $9.50 for shipping and handling. To order the tapes, go to www.acep.org/bookstore. Then, in the "search" box, type: "Broselow Pediatric Emergency Tapes."
A recent North Carolina study showing hospital EDs failed to properly stabilize seriously injured children during trauma simulations is a sign of a larger national problem with EDs being ill-prepared to handle pediatric trauma patients, reports Elizabeth A. Hunt, MD, MPH, assistant professor of anesthesiology and critical care medicine at Johns Hopkins Childrens Center in Baltimore.Subscribe Now for Access
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