Study: Most EDs 'Fail' Pediatric Trauma Drills

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.?