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.