Prehospital Management of Pediatric TraumaEMS 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 reviewof pediatricanatomic

considerations

OBJECTIVESDiscuss

evidenceregardingcervical spine

immobilization

Review essentials of airway

management in prehospital

care of kids

Reviewessentials

of traumatic braininjury

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

1950-1960

1973 1980s1984 1990s Today

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

1 Retrospective 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 IMMOBILIZATION

TRAUMATIC BRAIN INJURY

CASE 12 month old male

Patient reportedly had been eating and choked, then dropped

Exam on scene: Unresponsive, flaccid,Poor color, no respiratory effortWeak 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 1ED Exam

No purposeful movements, obtundedPupils non-reactive bilaterally

Agonal breathing noted, intubatedAbdominal distension, absent bowel sounds

Bruising to bilateral shoulders and bilateral thighsAbnormal primitive reflexes, abnormal muscle tone

ED CareETT exchanged to a 3.5 tube (was 2.5)PIV placed, fluid boluses (20 ml/kg x 2)

Cervical collar placedIV antibiotics

Seizure prophylaxisLabs, CT/X-rays

CASE 1

CT of HeadDepressed skull fracture

Bilateral subdural hematomas, epidural hematomaSubarachnoid 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 injuryBilateral subdural hematomas of various ages

An epidural hematoma overlies the left temporal lobeAcute 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 INJURYInjury 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 INJURYForces 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 injuriesN=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 ruleDangerous 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 allSensitivity 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 CHALLENGINGWhat 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 ITYoung children are difficult to clinically clear from immobilization in the PEDNo validated criteria for selective immobilization in childrenWhen in doubt, err of the side of immobilizing

SC DHEC EMS Spinal

ImmobilizationProtocol

CASE 27 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 bleedingTachycardic (170 – 190)

Decreased breath sounds noted on leftVital 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 weakPupils 2 mm, non-reactive bilaterally

HR 157, BP 125/99

ED Care100 ml PRBC’s

NS bolusLeft chest tube (100 ml blood returned)

CASE 2

Patient taken emergently to ORExploration of right neck penetrating traumatic wound

Median sternotomy for exposure of vascular injuryRepair of left innominate vein and

ligation of left internal mammary arteryFlexible esophagogastroscopy

Postoperatively Patient did well but had phrenic nerve injury and

hemidiaphragm

Patient discharged on HD 14

TRAUMATRANSFER

TRAUMATRANSFERPatient 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

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

Cool extremities compared with torso skinDecrease 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 hemorrhage

6

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 ventilationGSW to right side of face near right eyelid, no exit woundPupils 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 ExamGCS 6, pupils 5 mm, fixed and dilated,

decorticate posturing notedAbsent cough, gag and corneal reflexes

Intubated

ED CareFluid 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

Fall

Transport, other

Auto-pedestrian

Firearm

Motor Vehicle Related

0 500 1000 1500 2000 2500 3000 3500Deaths

Nance et al. 2014

FIREARMS MORTALITY

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Hawaii

Massach

usetts

Maine

Vermont

New Yo

rkIowa

Minnesota

Ohio

Nebras

ka

Delaware

Colorado

Texas

Indiana

North Caro

lina

Pennsyl

vania

Georgi

aIdah

o

South Caro

lina

Oklahoma

Tenness

eeIllin

ois

Arizona

Marylan

d

Montana

New M

exico

Alaska

0

1

2

3

4

5

6

7

8

9

10

All Firearm Mortality (Ages 0-19 years)

Fire

arm

Dea

ths/

100,

000

Nance et al. 2014

TRAUMATIC BRAIN INJURY

MINIMIZE SECONDARY INJURY BY MANAGING THE COMPRISED AIRWAY AND INTERVENING TO PREVENT HYPOTENSIONMonitor BP with an appropriately sized cuffGive 20cc/kg boluses of isotonic fluids as needed to maintain normal BP for age

1

HYPOXEMIA and HYPOTENSION ARE VERY BAD in TBIAvoid 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 TBI

2

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 BREATHINGMaintain 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 failure

4

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 TRANSPORT

6

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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 study12% 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 notch2. 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 obstructionWhen 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