In his presentation “Myths and Lies of Pediatric Trauma” at the 2019 NAEMSP conference held in Austin, Tex., Bob Waddell II, EMT-P (ret.), reviewed clinical principles and practices commonly applied in healthcare settings despite little evidence existing to support them. He starts by establishing one crucial fact about pediatric care: Kids are not small adults. Below is his list of debunked myths:
Myth: The Golden Hour
Noting how those working in emergency medicine are “fixated on clocks,” Waddell says, “It’s a team effort, not a clock determination.”
The Golden Hour is considered the period starting from the time of injury until a surgeon has his hands on a patient. The problem, says Waddell, is that this time period very often takes longer than one hour.
The Golden Hour phrase was coined by the renowned trauma surgeon R Adams Cowley, who famously stated during a lecture, “The first hour after injury will largely determine the critically injured chances of survival.”
However, there is little evidence to support this claim. Waddell cites a study from the International Journal of the Careof the Injured that determined “with the exception of patients with non-traumatic cardiac arrest, no field-based population has consistently demonstrated a significant association between response interval and arrival.”
Myth: O2 saturation rates need to be at 100%
“If we set the oxygen too high, we’re part of the problem,” says Waddell.
According to an article “Improving Oxygen Therapy in Acute illness (IOTA) systematic review and meta-analysis” from the medical science journal The Lancet, the risk of in-hospital death increases by 25% when a patient has an SaO2 above 94-96%, which is actually considered ideal. Waddell says this is especially important to note in pediatric care, as the younger the patient is, the truer this statement is.
Myth: Tracheal deviation is a reliable indicator of tension pneumothorax
According to statistics published by the British Journal of Medicine, tracheal deviation/shift is not always an indication of a tension pneumothorax. And if a patient’s tracheal shift occurs above the jugular notch, the only thing that’s an indication of is a dead patient, says Waddell.
Myth: Pain medications alter assessments
When it comes to administering opioids to patients, Waddell advises the following to ED physicians: “Don’t hamstring your paramedics.” He says the medical community has had plenty of time to study the effects of painkillers on patient assessments, which have shown to be slim to none.
Morphine—first isolated in 1803–5
Fentanyl—first developed in 1960
Ketamine—first discovered in 1962
Myth: Backboards are an absolute
This shouldn’t come as a surprise to most EMS providers and physicians, as research has shown in recent years that backboards are often more harmful than helpful to the patient, causing issues like pressure ulcers and difficulty breathing—not to mention they haven’t been shown to be effective in providing true spinal immobilization.
Myth: Femur fractures kill
Waddell says in a 2005 study out of Colorado involving 1,139 patients with femur fractures, only 25 of them died, and not a single death was caused exclusively from the femur injury. Patients were more likely to die from other severe injuries resulting from a MOI significant enough to cause a femur fracture in the first place.
On a global scale, the ratio of patients who have died solely from a femur fracture is 26: 100,000.
Myth: Good patient care occurs within 8:59
Time is not a criterion of outcome, Waddell says, except in critical events like cardiac arrest, which only account for 3%–5% of calls.
Waddell says out of 84,000 patients transported per day in the United States, 2,400 are critical. For the remainder of those patient transports, time is basically irrelevant.
Quality patient care should be prioritized over fixed response times, he says.
Myth: Waddell’s Triad
In 1971, Dr. John Waddell of Toronto stated there was a predictable injury pattern in pedestrians struck by motor vehicles. These included: injury above the knee, injury to the hip and knee, and craniocerebral injury. The study that led to this conclusion only involved 10 participants, with their ages ranging from 21–74. Despite the fact that none of these participants were children, this concept somehow morphed into being the predicted injury pattern for EMS providers to assess in pediatric patients, as opposed to pedestrians. It then became a guide for assessing injuries caused by 1) the bumper (femur fractures), 2) the hood (chest injuries), and 3) the ground (head injuries), most of which stray from Waddell’s original statement on the location of injury patterns.
Bob Waddell encourages EMS providers to approach pedestrian/motor vehicle collisions (MVCs) differently. For example, what size vehicle are you dealing with? Also take into consideration the size of your patient—different-size people will be impacted differently in such a collision. Assessing a patient with the expectation that the injury pattern will follow the EMS version of Waddell’s Triad lends itself to tunnel vision and the potential of missing other significant injuries. In a pedestrian/MVC, the mechanism of injury is likely to also cause damage to parts of the body other than the head, chest, and femur.
“Multiple injuries occur in multiple locations,” Waddell says. “Assess your patient, think about the mechanism of injury and other life threats.” Even more important, he says, ensure you provide a quality report to the hospital as early as possible—while it’s easy to get distracted by the stress of managing a pediatric patient, you don’t want to call in 30 seconds prior to arrival and delay critical care.
Valerie Amato is assistant editor of EMS World. Reach her at firstname.lastname@example.org.