To ensure children receive the highest quality prehospital care available, the National Association of EMTs (NAEMT) developed the Emergency Pediatric Care (EPC) program. The EPC program prepares EMS providers to understand the challenges, prioritize the issues, treat the problems and properly care for pediatric patients. EPC courses instruct prehospital providers in the approach of sick and injured children, affords a practical understanding of respiratory, cardiovascular, medical and traumatic emergencies, and educates them in the treatment of children with special healthcare requirements (such as tracheostomy and central venous line management and gastric feeding tube maintenance). As part of its commitment to pediatric care, NAEMT is sponsoring this quarterly column dedicated to issues in prehospital pediatric care.
You are transporting a large-for-his-age, combative, and exceptionally strong 12-year-old who has overdosed on an unknown substance. You have him on the gurney with the straps across his distal femurs, abdomen and chest. Despite your efforts, he continues to work his arms free and is intent on hurting everyone within reach, so you are forced to physically hold the boy's wrist. Enhancing the restraining system with additional straps, wide tape, Elastoplast or commercially manufactured restraints on the forehead, chest, wrist and ankles may help, but there is no guarantee.
What can you do to maintain the safety of the child and yourself? How can you properly restrain him so you can attend to his treatable health needs? Caution must be taken, as failure to adequately assess and monitor the restrained patient is considered one of the major contributing factors leading to patient death. Physically restraining patients, especially pediatric patients, is "potentially dangerous and should be viewed as a last resort."1 Researchers from the SUNY Health Science Center found that in nearly 91% of all deaths due to physical restraints, the restraints were properly applied.2 One of the most common and serious complications is positional asphyxia. It must also be stated that consideration of restraining the child in the prone position increases the potential of aspiration and positional asphyxia.
So how do we safely and effectively restrain a hostile patient? How do you ensure both your safety and theirs during transport? Consider the following basic restraint procedures used by law enforcement:
- A strap across and above the knees
- A strap across the iliac crest
- A strap across the chest and under the armpits--not so tight that it causes respiratory restriction
- Soft restraints for both hands and both feet.
One study found that a simple bed sheet can be quickly and effectively used by wrapping the sheet around the patient.3
Supplemental taping or strapping can be placed across the apex of the forehead in such a way to maintain neutral spinal alignment, yet restrict movement and the potential for head trauma.
Padding may need to be added at the patient's sides to create a secure "cocoon" or "papoose" effect and to eliminate any lateral motion from a child fighting the restraints or physical forces of transport.
Once restraints have been applied, the child must be constantly monitored and reassessed. Regardless of whether a total or partial restraint system is utilized, the possibility of serious injury or death is increased. (Note: Pharmaceutical restraints are a specific treatment, require specific treatment protocols and are not within the scope of this discussion.)
You respond to the home of a three-year-old who reportedly had a seizure. Upon arrival, you are met at the curb by the father carrying a semi-limp child. You take the child, go to the back of the ambulance and place her on the stretcher. You place a strap across her abdomen, initiate standard treatments and transport her to the hospital.
In recent years, the EMS industry has become acutely aware of our failure to adequately protect two of our most vulnerable populations: ourselves and the patients we care for. Research has shown that when children are properly restrained in motor vehicles, the incidences of injury and death secondary to vehicle crashes are greatly reduced. Unfortunately, not all the children we transport receive the same levels of protection we advocate for in private vehicles. The good news is that this trend is being reversed.
In 1998, a team led by UCLA professor James Seidel, MD, surveyed every state to determine the number of EMS systems using pediatric transport restraints.4 The lack of standards sounded the alert that changes needed to be made. This prompted numerous studies demonstrating that using current safety restraints and designing new ones specific for use in ambulances will reduce injury and death for all occupants.
So what do we need to do to ensure we are transporting our pediatric patients safely?
We need to ensure that we properly immobilize any child with a potential spinal injury to protect them from further insult or injury. Remember, spinal immobilization begins with manual stabilization of the head and cervical spine and continues until the entire spinal column is secured. The child's large head attached by weak neck muscles produces a "cantaloupe supported by a wet noodle" type mechanism of injury. In parallel, the patient's airway, breathing, and ventilation status must be maintained. If any detrimental change is noted, corrective treatment must be taken immediately. Next apply a properly sized cervical collar and place the child on a backboard or similar device. Because of the child's age, her large occipital skull will cause her airway to be compromised; therefore placing padding from her shoulders to at least the buttocks will not only help achieve neutral spinal alignment, it will also place her airway in an anatomically correct position. Typically, one inch of padding suffices to accomplish the desired alignment.
After you ensure that airway, breathing, oxygenation and spinal precautions are adequate, place additional padding along the sides of the child to assure that when the straps are applied, she is snugly compressed within them. Failure to do so will allow the child to move within the straps or slide laterally and vertically during transport. Like the hostile boy in the opening scenario, straps should be placed just above the knees, across the iliac crest and across the chest under the armpits. Some anecdotal information recommends a "chest cross-strapping" technique. As long as the child is properly secured and maintained in an anatomically neutral position, either strapping method is acceptable. Keep in mind that the immobilization device must be properly secured to the gurney. Failure to do so may result in the restrained child becoming a projectile object which will increase the chance of injury to the patient and providers alike.
After the entire body is secured, manual C-spine stabilization can be converted to other stabilization methods. It cannot be emphasized enough that continuous assessment and monitoring must be done throughout the duration of care.
How do you immobilize a child who is in a car seat? Should he be left in the safety seat or removed? Unfortunately, there is no legitimate, published research that favors either option. Based on the evidence currently available, child safety seats are not considered a medical device and are not designed to withstand more than one crash. That being said, the assumptions imply that the child should be removed from the car seat and placed in an approved medical device or new child safety seat. Looking at what seems to have an extensive historical success rate, leaving the child in the car safety seat and using appropriate padding is preferred by prestigious groups like the Prehospital Trauma Life Support program and the American College of Surgeons. Regardless of which method you use, make sure the child is being provided the best care possible.
Finally, all providers should read the National Highway Traffic Safety Administration's The Do's and Don'ts of Transporting Children in an Ambulance fact sheet, available at http://bolivia.hrsa.gov/emsc/SearchpubID.aspx?id=EP000841&from=results. This simple document goes to the heart of common sense.
Robert K. Waddell, II, has been involved in EMS for over 30 years, working as a volunteer EMT in rural Wyoming, a paramedic in the Front Range of Colorado and the Colorado State EMS Training Coordinator. He was the first Director of EMS Systems for the U.S. Department of Health and Human Services EMS-C program at the EMS-C National Resource Center in Washington, DC. Currently, he is the International Chair for the NAEMT Emergency Pediatric Care (EPC) course.