Chest compressions in traumatic cardiac arrest

Cite this article as:
Karl Kavanagh and Nuala Quinn. Chest compressions in traumatic cardiac arrest, Don't Forget the Bubbles, 2021. Available at:
https://doi.org/10.31440/DFTB.31093

Traumatic cardiac arrest (TCA) is an infrequent event in paediatrics, and a cause of significant stress in the busy trauma resuscitation room. Outcomes are similar in both paediatric and adult arrests, with poor survival rates in both. There are now international guidelines on the management of traumatic cardiac arrest. A traumatic cardiac arrest (TCA) is traumatic not just for patients but also for staff and all those involved. The guidelines were published in 2016, however, the role of chest compressions is still a source of confusion for medical and nursing staff alike. Advanced Paediatric Life Support algorithms and supporting medical evidence have correctly engrained chest compressions into medical management of life threats. However, there is a paucity of studies examining trauma-induced hypovolaemic arrests to base the decision to change the “normal practice”. It is counter-intuitive for medical staff to not start compressions when an arrest is presented to you and withholding them inevitably leads to the question “Well, what can I do then?”.

Haemorrhage is one of the three common causes of early preventable death in trauma. This paper, from Sarah Watts et al, sought to determine whether compressions are beneficial and with what fluid the patient should be resuscitated with (if at all). Of course there are ethical and practical issues with a prospective randomised control study involving children as the subjects. Instead, this animal study is a helpful surrogate for analysis of the question surrounding the role of chest compressions in haemorrhage-induced traumatic cardiac arrest.

Disclaimer: not suitable for vegetarians!

Watts S, Smith JE, Gwyther R and Kirkman E. Closed chest compressions reduce survival in an animal model of haemorrhage-induced traumatic cardiac arrest. Resuscitation. 2019; 140:37-42. Doi: 10.1016/j.resuscitation.2019.04.048

PICO image

Population

39 pigs were enrolled and treated as per UK Animals (Scientific Procedures) Act 1986 ethics standards. The baseline data of all animals involved were within normal ranges and differences between them was not clinically significant. Each subjects’ vital signs were invasively monitored throughout the study.

Intervention

There were 5 phases through which all participants/subjects went.

  • Injury phase
  • Shock phase
  • TCA phase
  • Resuscitation phase
  • Post-resuscitation phase

Each subject was anaesthetised and the same injury was reproduced in each. Subjects were allowed to exsanguinate in a controlled pattern. Once terminal hypovolaemia was declared, three rounds of resuscitation were commenced. After resuscitation, subjects were categorised according to MAP and Study End was defined as 15 minutes after the end of the third resuscitation cycle.

Patients were blindly randomised into 5 different groups:

  1. Closed chest compressions(CCC)
  2. Whole blood (WB)
  3. 0.9% Saline (NaCl)
  4. WB+ CCC
  5. NaCl+ CCC

Outcome

The primary outcome was achievement of ROSC at study end.

Secondary outcomes were differences in survival and attainment and maintenance of ROSC during the resuscitation and post-resuscitation phases.

Results

To summarise the numerous results:

  1. All the subjects in compressions only group died.
  2. All the subjects that received whole blood only survived.
  3. Resuscitation with blood had improved outcomes over normal saline.
  4. Addition of compressions had a detrimental effect on fluid resuscitation.
  5. Subjects that received any combination of CCC showed a more significant metabolic acidosis, reflecting increased tissue ischaemia.
  6. In the group that received both CCC and WB, 5 of 8 subjects achieved partial ROSC (MAP 20-50mmHg). Once partial ROSC was ascertained, CCC’s ceased and fluid resuscitation alone was continued. This led to the subjects improving to such a degree that there was no longer a difference between this group and that resuscitated by WB alone from the beginning.
  7. All results can be attributed to the groups’ interventions as confounding variables were minimised and the initial injury reproduced in each case.

Discussion

While this is a small population study, it has become a sentinel paper as it demonstrates clear evidence that chest compressions in a TCA are detrimental and that our reflexive management of medical arrests is not transferable. We need to shift our focus to optimising fluid resuscitation. It shows a clinically relevant outcome that is internationally applicable. It is important to note that it was terminal hypovolaemia, not true cardiac arrest with no output, which was being measured. However terminal hypovolaemia is an imminent precursor of cardiac arrest.

Reflections from Nuala Quinn

I have listened to Dr Sarah Watts present this paper and listening to her reinforced my opinion that this paper is superb. It challenges the dogma and forces us to push beyond traditional management strategies in what is arguably the most stressful paediatric emergency: major trauma.

Closed chest compressions are a mainstay of medical management. They are firmly embedded in resuscitation culture and indeed have become a mainstay of civilian culture. When healthcare practitioners hear the word “arrest” they automatically move into the “chest compressions” mindset. However medical cardiac arrest and traumatic cardiac arrest are two completely different entities with ensuing separate management. Anecdotally it is difficult to separate the two and advising a team that no-one needs to do chest compressions in an arrest causes anxiety and confusion. This happened only recently in our department where advising one of our staff that we didn’t need to do chest compressions as a priority was met with “but it says in APLS so we need to do them”. 

So how do we get around this? In my mind we do this in two ways: 

Firstly, we use and promote the life-saving bundle of interventions for TCA and keep it as a completely separate entity. When leading a TCA, as the pre-brief I will usually start with This is a Traumatic Cardiac Arrest which will need the bundle of life-saving interventions before anything else”. I write the bundle of life-saving interventions on the adjacent whiteboard and assign specific people to them. I focus on the bundle, rather than ABCDE. Focusing the team on the bundle, rather than the “arrest” per se, helps to separate the medical arrest from the traumatic arrest. 

Nuala's priorities for traumatic cardiac arrests
Team priorities in a traumatic cardiac arrest

I follow the PERUKI guideline which can be found here. The bundle needs to be prioritised over chest compressions and defibrillation. For revision, here is the bundle:

Secondly, we use the evidence and this is where papers like Watts et al come in. Evidence is fluid, it changes all the time. It takes years for resuscitation courses and bodies to update manuals and so it is our responsibility to use emerging evidence and use it sensibly and progressively. Watts’ paper helps me to educate and challenge dogma, particularly with compressions and saline resuscitation. Again, anecdotally the practice of giving saline as the initial resuscitation fluid in trauma exists.  We seem to be hesitant to give blood immediately, with view that to try with saline first is better, to not waste blood. The literature is now abound with papers describing the deleterious effects of saline in trauma, particularly with regard to its dilutional effects and role in worsening trauma coagulopathy. Again, this paper supports the choice of whole blood over saline and is in keeping with the life-saving bundle.  This paper cements for me, the reasons for the importance of the life-saving bundle before anything else and should empower us to make better decisions in the trauma reception and resuscitation:

Should we just give a saline bolus first?

Should we just get someone to do chest compressions as they have no pulse?

The answer here should always be no, and this paper is evidence to support that. The TCA algorithms are almost exactly the same, between adults and paediatrics and in institutions all over the world. This has really helped to standardize the management of TCA and have people trust the bundle, rather than revert back to what feels safe for them (compressions and saline in most instances). 

As to our case above, I wasn’t team-leading and with 10min to the patient’s arrival, didn’t want to push the issue, so the plan for compressions went ahead and the role was assigned. However, at the end of the trauma resuscitation, I realised that the chest compressions hadn’t actually been performed. So in that clinician’s subconscious, there was an understanding and mutual trust in the process of changing and progressing how we better manage traumatic cardiac arrest. Watts and PERUKI are leading the way. It is up to us to follow them.

Selected references

Watts S, Smith JE, Gwyther R and Kirkman E. Closed chest compressions reduce survival in an animal model of haemorrhage-induced traumatic cardiac arrest. Resuscitation. 2019; 140:37-42. Doi: 10.1016/j.resuscitation.2019.04.048

Rickard AC, Vassallo J, Nutbeam T, Lyttle MD, Maconochie IK, Enki DG, et al. Paediatric traumatic cardiac arrest: a Delphi study to establish consensus on definition and management. Emerg Med J. 2018;35(7):434-9.

Vassallo J, Nutbeam T, Rickard AC, Lyttle MD, Scholefield B, Maconochie IK, et al. Paediatric traumatic cardiac arrest: the development of an algorithm to guide recognition, management and decisions to terminate resuscitation. Emerg Med J. 2018;35(11):669-74.

(ANZCOR) AaNZCoR. Australian Resuscitation Council Guidelines 2016 [Available from: https://resus.org.au/guidelines/.]

Intraosseous access

Cite this article as:
Gavin Hoey and Owen Keane. Intraosseous access, Don't Forget the Bubbles, 2020. Available at:
https://doi.org/10.31440/DFTB.31005

It is 15.50 hrs on a Tuesday when the call comes in. A 3-year-old female is in cardiac arrest.

When it is an adult patient, we can manage this without even breaking stride…but as you begin to formulate your action plan, your brain now needs to focus on areas that you don’t tend to dwell on when it comes to a grown-up patient – How will I gain access? What are my medication doses? What are those novel airway features again? While we are more confident and experienced managing adult patients in cardiac arrest, it is important to remember that – Familiarity Breeds Contempt” – and this is different.

We are weaving in and out of rush hour traffic while deriving our WETFAG when we get updated information that an FBAO* may have led to this arrest.

*EM/prehospital speak for foreign body airway obstruction

My colleague and I discuss a plan of action:  we allocate roles, make a difficult airway plan, and agree to ensure that exceptional high-quality Basic Life Support is delivered in the first instance. We know that fundamentals matter most.

We discuss access options:

  • Intravenous (IV) – but will it be possible?
  • Intraosseous (IO) – we know that this is both possible and effective.

On arrival we find a 3-year-old old girl lying in a playroom. She is being tended to by a crew of firefighter-paramedics who have arrived just ahead of us.

I can see she is unresponsive but breathing. Her breathing does not look normal. She looks very unwell.

I get a handover from those on scene while Simon gets straight to work with airway assessment.

We voice our plan to the team:

  • Team role allocation reaffirmed.
  • Assess and manage the airway.
  • Assess and assist breathing.
  • Get access.
  • Complete a rapid A-E assessment to ensure we are not missing vital information.
  • Maximise team dynamics, performance, and optimise management of scene environment.

The decision to proceed with vascular access in paediatric patients is not an easy (or common) one to make for pre-hospital practitioners. Knowing that this patient was “Big Sick” makes the decision somewhat easier, but not so the challenge.  

When to IO?

Intraosseous (IO) is a rapid and effective method for accessing non-collapsible marrow veins without sacrificing pharmacokinetics.

Any delay in establishing vascular access can be potentially life threatening.

The Royal Children’s Hospital Melbourne states In decompensated shock IO access should be established if IV failed or is going to be longer than 90 seconds”.

The decision to gain IO access should be considered in the following scenarios

Selecting the site

How do we choose a site for placing an IO line and what can influence our decision?

Is the case medical or trauma? If it is a trauma, where are the injuries? Fractures at, or above, the insertion site can compromise the integrity of the underlying anatomic structures. Importantly, what sites are practical and accessible to me in this case right now?

Having never attempted IO access on a paediatric patient before, I stuck with what I had done most frequently in training and decided on “proximal tibia” as my site for IO insertion.

“In the pre-hospital environment, it is sometimes as important to know when not to do something as it is to know when to do something”

Justification for tibial IO access in this not-arrested patient was based on the following case elements for me:

  • IV access had failed.
  • I had a small child, obtunded and unresponsive, requiring airway and breathing support, tachycardic, tachypnoeic, and hypoxic. Big Sick.
  • Activities “up top” were busy, very busy – although the airway did not appear to have a FBAO, it did require my colleague to maintain a good seal. I did not feel positioning for humeral IO was viable at this moment.
  • This was a medical case with no apparent lower limb or pelvic trauma.

Of course, one must always consider contraindications before proceeding with IO access.

Contraindications

  • Fractures at (or above) the insertion site
  • Crush Injuries
  • Ipsilateral vascular injury
  • Illness or anomalies to the underlying bone e.g. osteomyelitis, osteogenesis imperfecta, osteoporosis.
  • Previous failed IO attempts at this location
  • Overlying skin infection
  • Pain associated with infusion may be considered a reason not to continue using the line if it cannot be controlled.

Landmarks

I considered all potential options for IO insertion before choosing the site most familiar to me– proximal tibia. Other possible sites included:

  • Distal tibia
  • Distal femur
  • Humeral head
Intraosseous insertion sites

Anatomical landmarks for the insertion site depend on whether you can palpate the tibial tuberosity or not. The tibial tuberosity does not develop until around 2 years of age. If you cannot feel the tibial tuberosity in the smaller child, palpate two fingerbreadths down from the inferior border of the patella, then one finger breath medial to this point. Where the tuberosity is palpable, just go one fingerbreadth medial to it.

Target flat bone and pinch the tibia (especially in the very young patient) to reduce bone mobility, and to prevent the skin rotating with the driver before starting needle insertion.

Surface anatomy for insertion around knee
Landmarks for proximal tibial insertion

This is a small child. While it might seem like there is no time to hesitate; training, planning, awareness, and observation are vital I recalled the phrase “Power and Pressure”. This was not going to require as much force as I usually use in adult IO insertion. “Let the driver do the work” and be careful not to overshoot through the bone.

Placing the needle over the landmark site at 90 degrees, I visualised the line I wanted to drill. After careful, but firm, passing of the needle through the skin, I pressed the trigger. After the first pop, I was careful not to overshoot. Anticipation here is key so avoid putting too much pressure on the driver. Similarly, be careful to avoid excessive recoil when you feel you have reached the medullary space as this can result in dislodgement of the needle.

But am I in the right space?

Attempt to aspirate marrow from your line (though it might not always be present). Flushing saline through with little to no resistance is very reassuring. No Flush = No Flow!

The line needs to be secured in place and the extension tubing attached properly with no identifiable leak points. What we give through the line should generate a physiological response – if it does not, always consider if the line has become displaced.

The proximal tibial site may not always be an option, so we where else can we go?

Medial view of ankle
Landmarks for distal tibial insertion

Distal Tibia

Place one finger directly over the medial malleolus; move approximately 3 cm or 2 fingerbreadths proximal and palpate the anterior and posterior borders of the tibia to assure that your insertion site is on the flat center aspect of the bone. 

Distal femur surface anatomy
Landmarks for distal femoral site of insertion

Distal Femur

Midline, 2-3 cm above the external condyle or two fingerbreadths above the superior border of the patella. This is often an accessible site due to children having less muscle bulk. To ensure you avoid the growth plate, the leg should be outstretched when performing your landmarking’s above and aim about 15 degrees cephalad too.

Landmarks of the humeral head for IO insertion
Landmarks for insertion in the proximal humerus

Humeral Head:

The humeral head represents an excellent access point for large proximal vasculature (lies closer to the heart). Flow rates may be higher here too due to lower intramedullary pressures. The greater tuberosity secondary ossification centre doesn’t appear until about 5 years of age making palpation of this landmark more of a challenge in the younger child.  For this reason, it is more often used in older children, typically over 7 years of age or only in those in whom the anatomy can be readily identified.

You may need to consider using a longer needle here due to the larger amount of soft tissue over this axillary area.

The insertion site is located directly on the most prominent aspect of the greater tubercle. 1 cm above the surgical neck. The surgical neck is where the bone juts out slightly – you will find this by running a thumb up the anterior aspect of the humerus until you feel a prominence. This is the greater tuberosity. The insertion site is approximately 1cm above this.

It is important to position the arm correctly.

hand on belly or thumb to bum position for humeral IO
Positioning the arm for humeral IO

Humeral IO placement techniques:

  • Thumb to Bum – Move the patient’s hand (on the targeted arm) so that the patient’s thumb and dorsal aspect of hand rest against the hip (“thumb-to-bum”).
  • Palm to umbilicus – Move the patient’s hand (on the targeted arm) so that the palm rests over the umbilicus, while still maintaining the elbow close to the body.

Site versus flow

As mentioned above, the proximal humerus is very close to the heart and this, coupled with seemingly lower intramedullary pressures, lends itself to higher flow rates when compared to the lower limb sites.

Important to note, however, that any abduction or external rotation of the arm during resuscitative efforts (easy to picture this happening when moving your patient from scene to ambulance!) can lead to dislodgment of you IO. Nice and easy does it.

An awake IO?

The sound of the driver buzzing brings back dentist chair memories for all of us. No less so for your patient who, if conscious during the insertion, will be particularly anxious and upset. Anticipate this and control anxiety with reassurance, distraction, and parental explanation if you can.

Pain in the conscious patient with an IO in situ can be from the area around the insertion site as well as the volume expansion caused by infusion. A small volume of 2% lidocaine can be given through the line prior to commencing the infusion to help with pain – this is slowly infused over 120 seconds, left for 60 seconds, then flushed with 2-5ml of saline.

Always consider line dislodgment or compartment syndrome with gross discomfort and inspect/flush the line to ensure it is still functioning adequately.

Size of IO – credit to Tim Horeczko

What about the gear itself?

The EZ-IO 10 driver and needle Set is a semi-automatic intraosseous placement device commonly found in our EDs. All needle catheters are 15 gauge giving gravity flow rates of approximately 60-100ml/min. The use of pressure bags can greatly increase these rates. It is important to make sure you pre-flush the connector set to ensure no residual air can be injected after attachment.

Fail to Prepare, Prepare to Fail”. Practice really makes perfect and so frequent familiarisation sessions are encouraged to get used to both the IO equipment and identifying the various access sites and their relevant anatomy.

A recent study by Mori et al (2020) showed a high rate of successful placement at 92.7%. This paper also described the complications encountered with the use of EZ-IO in a paediatric population in a paediatric ED. The complication rate seems to be consistent across all needle sizes at around 21%. Complications (particularly the more commonly occurring extravasation and skin) are important considerations for PEM IO training programmes.

Potential complications

  • Extravasation or subperiosteal infusion – the highest reported complication in the Mori paper was 17% of all IO insertions. This occurs if you fail to enter the bone marrow or happen to go through the entire bone itself and overshoot the medullary canal. Dislodgement of a well-placed IO line during resuscitation can lead to this occurring too.
  • Dermal abrasion4% in Mori study. A more recently described complication of using the semi-automatic IO approach, these injuries can occur due to friction from the rotating plastic base surrounding the EZ-IO needle. While these all seemed to settle with conservative treatment it is important to watch out for this during insertion.
  • Compartment syndrome – rare…but the smaller the patient the higher the risk.
  • Fracture or physeal plate injury.
  • Osteomyelitis – very rare, reported as 0.6% (Rosetti et al).
  • Fat embolus

The use of POCUS to rapidly confirm intraosseous line placement and reduce the risk of misplacement with extravasation has been discussed in recent times. This paper by Tsung et al in 2009 comments on its feasibility and describes using colour Doppler signal with a saline flush to identify flow in the bone around the IO to confirm placement. Misplacement may also be identified if flow is seen in the soft tissues rather than bone.  

The Super Smallies

Achieving safe and reliable intraosseous access in the neonate or infant can be a big challenge as they have smaller medullary canal diameters. Higher risks of misplacement and extravasation also put this group at risk of compartment syndrome. Case reports of limb amputation secondary to iatrogenic compartment syndrome from IO misplacement are almost exclusively in neonates and small infants.

A case report by Suominen et al. in 2015 described proximal tibia mean medullary diameters on x-ray as 7mm in neonates, 10mm in 1-12-month infants, and 12mm in 3-4-year old children. The EZ-IO needle set for this group is 15mm in length and 12mm in length once the needle stylet is removed. This leaves a narrow margin of safety for the correct positioning and the avoidance of dislodgement of the IO needle.

With the measurements above, it makes sense that one would need to stop a few mm short to avoid throuugh-and-through insertion and subsequent extravasation. Stopping short like this could make the line more difficult to protect…Scott Wingart and Rebecca Engelman outline some neat tricks to “SEAL THE HECK OUT OF…” these delicate lines over here.

The systematic review by Scrivens et al in 2019 describe IO as an important consideration for timely access in neonatal resuscitation practice. They comment on the importance of incorporating IO insertion techniques into neonatology training. While a more recent study of IO access in neonatal resuscitation by Mileder et al reports lower success rates for insertion at 75%, clearly further studies are needed to scrutinise this access modality in neonates and whether it can be considered as a standard reliable and fast alternative to umbilical vein access in a time-critical scenario.

What are the take homes?

  • Have a vascular access plan before arriving at the scene for every paediatric patient – consider adding this to the end of you WETFLAG.
  • There are clinical scenarios outside of the patient in cardiac arrest where IO placement may be necessary – the decision to IO after failed IV should be rapid in the shocked child.
  • Familiarise yourself with the equipment, needle sizes and gauge, and be aware of the age-related anatomical considerations when landmarking sites for IO insertion.
  • Let the driver do the work – nice and easy does it!
  • Complications can occur and are not always rare – extravasation from dislodgement or misplacement, as well as skin abrasions, are well reported.
  • The smaller the patient, the higher the risk of through-and-through misplacement – these “super smallies” are at a greater risk of compartment syndrome. 
  • Keep it simple….“No Flush = No Flow!”. POCUS may be used to confirm satisfactory line placement too.

References

Arrow EZ-IO Intraosseous Vascular Access System. 2017 The Science and Fundamentals of Intraosseous Vascular Access. Available at: https://www.teleflex.com/usa/en/clinical-resources/ez-io/documents/EZ-IO_Science_Fundamentals_MC-003266-Rev1-1.pdf#search=’flow%20rates’

Ellemunter H, Simma B, Trawöger R, et al. Intraosseous lines in preterm and full-term neonates. Archives of Disease in Childhood – Fetal and Neonatal Edition 1999;80:F74-F75.

Santa Barbara County Emergency Medical Services Agency Intraosseous (IO) Vascular. https://countyofsb.org/uploadedFiles/phd/PROGRAMS/Emergency_Medical_Services/Policies_and_Procedures/Policy%20538A.pdf.

Royal Children’s Hospital Clinical Practice Guideline – Intraosseous Access. https://www.rch.org.au/clinicalguide/guideline_index/Intraosseous_access/

Advanced Paediatric Life Support, Australia & New Zealand: The Practical Approach, 5th Edition Published October 2012.

Weingart et al. How to place and secure an IO in a peds patient. https://emcrit.org/emcrit/how-to-secure-an-io-in-a-peds-patient

Wade, T. Intraosseous Access in Neonates, Infants and Children. 2019. https://www.tomwademd.net/intraosseous-access-in-neonates-infants-and-children/

Mori, T., Takei, H., Sasaoka, Y., Nomura, O. and Ihara, T. (2020), Semi‐automatic intraosseous device (EZ‐IO) in a paediatric emergency department. J Paediatr Child Health, 56: 1376-1381. doi:10.1111/jpc.14940. Available at: https://onlinelibrary.wiley.com/doi/10.1111/jpc.14940

Rosetti VA, Thompson BM, Miller J, Mateer JR, Aprahamian C. Intraosseous infusion: An alternative route of pediatric intravascular access. Ann. Emerg. Med. 1985; 14: 885–8.

Ngo AS, Oh JJ, Chen Y, Yong D, Ong ME. Intraosseous vascular access in adults using the EZ-IO in an emergency department. Int J Emerg Med. 2009;2(3):155-160. Published 2009 Aug 11. doi:10.1007/s12245-009-0116-9.Available at:https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2760700/

Tsung JW, Blaivas M, Stone MB. Feasibility of point-of-care colour Doppler ultrasound confirmation of intraosseous needle placement during resuscitation. Resuscitation. 2009 Jun;80(6):665-8. doi: 10.1016/j.resuscitation.2009.03.009. Epub 2009 Apr 22. PMID: 19395142. Available at: https://pubmed.ncbi.nlm.nih.gov/19395142/

Suominen PK, Nurmi E, Lauerma K. Intraosseous access in neonates and infants: risk of severe complications – a case report. Acta Anaesthesiol Scand. 2015 Nov;59(10):1389-93. doi: 10.1111/aas.12602. Epub 2015 Aug 24. PMID: 26300243.Available at: https://pubmed.ncbi.nlm.nih.gov/26300243.

Intraosseous (IO) – Salford Royal NHS Foundation Trust.  https://www.srft.nhs.uk/EasysiteWeb/getresource.axd?AssetID=45337&type=full&servicetype=Inline

Mileder LP, Urlesberger B, Schwaberger B. Use of Intraosseous Vascular Access During Neonatal Resuscitation at a Tertiary Center. Front Pediatr. 2020 Sep 18;8:571285. doi: 10.3389/fped.2020.571285. PMID: 33042930; PMCID: PMC7530188 Available at: https://pubmed.ncbi.nlm.nih.gov/33042930/.

Scrivens A, Reynolds PR, Emery FE, Roberts CT, Polglase GR, Hooper SB, Roehr CC. Use of Intraosseous Needles in Neonates: A Systematic Review. Neonatology. 2019;116(4):305-314. doi: 10.1159/000502212. Epub 2019 Oct 28. PMID: 31658465. Available at: https://www.karger.com/Article/FullText/502212.

Lefèvre Y, Journeau P, Angelliaume A, Bouty A, Dobremez E. Proximal humerus fractures in children and adolescents. Orthop Traumatol Surg Res. 2014 Feb;100(1 Suppl):S149-56. doi: 10.1016/j.otsr.2013.06.010. Epub 2014 Jan 4. PMID: 24394917. Available at: https://pubmed.ncbi.nlm.nih.gov/24394917/.

EMS Feedback

Cite this article as:
Andrew Patton and Andy O'Toole. EMS Feedback, Don't Forget the Bubbles, 2020. Available at:
https://doi.org/10.31440/DFTB.29849

Prehospital practitioners have an ever-expanding role in managing the acutely unwell and injured patient. Despite this large contribution to patient care, the majority of practitioners find it very challenging to followup or get feedback on their management of the patient.

The recent publication of the NEMSMA position paper regarding bi-directional information sharing between hospitals and EMS agencies sparked debate on Twitter about the challenges of EMS Feedback.

Gunderson, M.R., Florin, A., Price, M. and Reed, J., 2020. NEMSMA Position Statement and White Paper: Process and Outcomes Data Sharing between EMS and Receiving Hospitals. Prehospital Emergency Care, pp.1-7.

What was the paper about?

The NEMSMA Position statement and White Paper focuses on the bi-directional sharing of data between EMS agencies and receiving hospitals. The authors looked at the challenges EMS agencies face getting feedback data regarding patient outcomes, propose best practices for bi-directional data sharing and explore the current barriers to data exchange. 

The paper highlights the importance of receiving feedback and patient outcome data for quality assurance and improvement (QA/QI). Among other things, feedback is necessary for EMS providers to determine if clinical diagnoses in the field were correct, if pre-arrival notifications were effective and if the destination choice was appropriate. 

The authors surmise that with confusing and complicated healthcare law, hospitals can be reluctant to “share information due to consequences of unintentional violations” of healthcare law, and fears of liability, many of which are misconceptions.

They report that…

“Many of the commonly held legal concerns preventing data exchange are misunderstandings and unfounded fears. While all regulations and laws need to be adequately addressed, legal issues should not preclude properly conducted sharing of electronic health records for quality improvement.”

Technology also creates a number of barriers to data sharing, in particular poor interoperability between EMS electronic patient care records (ePCR) and hospital electronic healthcare records (EHR). The absence of a universal patient identification value is another significant obstacle.   

The authors reference information blocking and market competition between hospitals as two of the big political and economic barriers which can be among the most challenging to overcome. 

They conclude by recommending a collaborative effort between EMS agencies and hospitals to develop and implement bilateral data exchange policies which would benefit all stakeholders. 

This paper focuses mainly on data sharing at an organisational level, it is very relevant to the difficulties faced by individual pre-hospital practitioners trying to follow-up on patients they treat at a local level. 

Why is this so important?

As discussed in the paper, feedback is an important part of quality improvement. For individual practitioners, feedback is a vital part of the learning cycle. Feedback is essential for us to learn from our mistakes, and to improve our practice.  To improve any performance, it is necessary to measure it. A practitioner that never follows up on a patient’s outcome will be left assuming that their treatment for the presenting complaint was accurate and warranted. They will likely continue to treat the same presentation in the same way in the future because their experience has never been challenged by facts that could have been discovered during patient follow up. 

Without feedback we could be unconsciously incompetent… We don’t know what we don’t know!

What’s the difficulty?

On an individual level, obtaining feedback and patient follow-up is challenging for EMS crews for a variety of reasons. In a local survey of 98 prehospital practitioners in Dublin, Ireland, only 21% of practitioners reported being able to follow-up interesting cases.

With dynamic deployment of EMS Resources, crews might transport a patient to a hospital and not return to that same hospital during their shift. If a crew does manage to find an opportunity to call back to the hospital, frequently the diagnostic work-up may be incomplete, and a working diagnosis still unclear. EDs are busy environments and, understandably, some practitioners may feel uncomfortable stopping a doctor or nurse to follow-up on a previous patient.

Calling back a few days later has its own complications; often there will be different staff working in the department who may not have been involved in the patient’s care. This method may work for the high-acuity resus presentations, but that ‘child with shortness of breath’ whose physical exam you were unsure of, or the child with a seizure who had a subtle weakness… the chances of the Emergency Department (ED) staff remembering their diagnosis or outcome is slim! 

Phoning the ED or ward is a route explored by many practitioners, but is fraught with increasing difficulty due to reluctance of staff to give out patient information over the phone fearing confidentiality issues. 

So how do we address this challenge?

Focusing specifically on providing feedback to individual pre-hospital practitioners, there are multiple potential ways to provide prehospital practitioners with follow-up information and feedback,  but you need to consider what system will work best for your individual department, ensuring patient confidentiality and data security.

The pre-hospital postbox

St. Vincent’s University Hospital is a tertiary referral hospital in Dublin, Ireland with approximately 60,000 annual attendances. Inspired by Linda Dykes and her team’s PHEM postbox at Ysbyty Gwynedd Emergency Department in Bangor, Wales, we set-up the Pre-Hospital Post Box in St. Vincent’s University Hospital Emergency Department in August 2017. 

We engaged local prehospital clinicians and ED consultants to develop an SOP. A postbox was built and mounted by the carpentry department. Using a template from Bangor, a feedback request form was developed.  Finally, the service was advertised in the emergency department, local Ambulance and Fire Stations and we were open for business. 

Prehospital clinicians seeking feedback on a case complete a form and place it in the post-box. The case notes are reviewed by an EM doctor and feedback is provided by phone call. 

To ensure patient confidentiality, feedback is only provided to practitioners directly involved with the patient care. A triple-check procedure is used to confirm this. The practitioner’s pin number on the request form is verified on the Pre-Hospital Emergency Care Council (PHECC) register and against the patient care record. The listed phone number is also verified through practitioners known to us or the local Ambulance Officer. 

Other hospitals use systems providing feedback via encrypted email accounts or posted letters.We elected to use a phone call system, the primary reason was the anecdotal reports that many of our pre-hospital staff don’t have easy access to work email accounts. We also anticipated that a phone call would be more likely to facilitate a case discussion and allow paramedics to ask questions that might arise during the discussion. 

Challenges with this system?

Providing feedback to prehospital practitioners is a very time-consuming and labour intensive job, particularly in hospital systems where the majority of clinical documentation is still paper-based. In our own system, where handwritten ED notes are scanned, radiology, labs and discharge letters are available on-line, and in-patient notes are handwritten physical charts – we’ve found the average time required to collate details for the feedback request is just 9 minutes, with a feedback phone call averaging 5 minutes per call.

To successfully upscale this would require a team of doctors or a rota based system with allocated non-clinical time to answer requests. Alternatively a digital solution allowing paramedics to access the data themselves, or facilitating the physician managing the case to reply directly would make it more feasible but may generate further challenges. 

The ideal, as discussed in the NEMSMA paper, would be an organisational process, with the automatic provision of discharge summaries and test results by hospitals to EMS agencies which would provide useful organisational data, and subsequent feedback to individual EMS practitioners.

GDPR / Data Protection Considerations

Patient confidentiality and data protection are of utmost importance in an EMS Feedback System. The system implemented needs to have robust mechanisms, such as our triple-check, to ensure that feedback is only provided to healthcare professionals directly involved in the patient’s care. 

It is also important that it is compliant with data protection legislation in your locality, such as General Data Protection Regulations (GDPR) introduced in Europe in 2018.  Our EMS feedback system is an important mechanism for us to review the care and treatment provided to patients and allows us to assist pre-hospital practitioners in evaluating and improving the safety of our pre-hospital services, which is provided for in the “HSE Privacy Notice – Patients & Service Users”

Providing EMS Feedback, in its current form, is a labour intensive process but we believe it is a worthwhile initiative. It is greatly appreciated by Pre-Hospital Practitioners and it enables them to enhance their diagnostic performance and develop their clinical practice.

If you’d like to find out more about how to set up a Pre-Hospital Post Box in your ED, have a look at these resources…

Attachments

References

Patton A, Menzies D. Feedback for pre-hospital practitioners: is there an appetite? Poster session presented at: 2017 Annual Scientific Meeting of the Irish Association for Emergency Medicine; 2017 Oct 19-20; Galway, Ireland.  

Gunderson MR ,Florin A , Price M & Reed J.(2020): NEMSMA Position Statement and White Paper: Process and Outcomes DataSharing between EMS and Receiving Hospitals, Prehospital Emergency Care, https://doi.org/10.1080/10903127.2020.1792017 

Croskerry P. The feedback sanction. Acad Emerg Med. 2000;7:1232-8.

Jenkinson E, Hayman T, Bleetman A. Clinical feedback to ambulance crews: supporting professional development. Emerg Med J. 2009;26:309.

Patton A, Menzies D. Case feedback requests from pre-hospital practitioners – what do they want to know? Meeting Abstracts: London Trauma Conference, London Cardiac Arrest Symposium, London Pre-hospital Care Conference 2018. Scand J Trauma Resusc Emerg Med 27, 66 (2019). https://doi.org/10.1186/s13049-019-0639-x  

Patton A, Menzies D. Feedback for pre-hospital practitioners – a quality improvement initiative. Meeting Abstracts: London Trauma Conference, London Cardiac Arrest Symposium, London Pre-hospital Care Conference 2018. Scand J Trauma Resusc Emerg Med 27, 66 (2019). https://doi.org/10.1186/s13049-019-0639-x   

O’Sullivan J. HSE Privacy Notice – Patients & Service Users v1.2.  2020 Feb, Accessed on-line: https://www.hse.ie/eng/gdpr/hse-data-protection-policy/hse-privacynotice-service-users.pdf 


Picture of ambulance

The paediatric prehospital primer

Cite this article as:
Team DFTB. The paediatric prehospital primer, Don't Forget the Bubbles, 2020. Available at:
https://doi.org/10.31440/DFTB.28860

Here at Don’t Forget The Bubbles, we’re delighted to be collaborating with some incredible prehospital clinicians to bring you posts about providing excellent care to children before they get to hospital. While we work away behind the scenes to curate these posts, we wanted to bring some of our published archive together in our very first prehospital paediatric primer.

We hope you enjoy these posts. Keep an eye out for more of our prehospital posts and if you’d like to contribute to our growing prehospital library, please get in touch!

Prehospital analgesia: part 2

Cite this article as:
Joe Mooney + Dani Hall. Prehospital analgesia: part 2, Don't Forget the Bubbles, 2020. Available at:
https://doi.org/10.31440/DFTB.27501

You’re in the rapid response vehicle, having just handed over a 2 year old with a femoral fracture. As you clear the hospital, a call comes in: 8 year old, fall from slide, deformed left arm, conscious and breathing. When you arrive in the house you find him lying on the sofa, with bruising and deformity of his left elbow. The paracetamol and ibuprofen given by his mother has not controlled his pain*, so you take out a methoxyflurane inhaler and explain to him to suck in and blow out through ‘the whistle’. After a few breaths he begins to relax.

Methoxyflurane is a fluorinated hydrocarbon, used as an inhaled anaesthetic in the ’60s and early ’70s, until it fell out of favour after case reports describing renal failure at anaesthetic doses. But, when given in small doses, methoxyflurane has excellent analgesic properties, with no nephrotoxic side effects. It has been used extensively in Australia and New Zealand by prehospital clinicians as a self-administered analgesic for short-term pain relief in adults and children. After being licenced in 2015 in the UK and Ireland for the emergency relief of moderate to severe pain in conscious adults with trauma, methoxyflurane was included in the Irish prehospital CPG for EMTs, paramedics and advanced paramedics with permission under the seventh amendment to allow its use in children.

Added as a liquid to a Penthrox® inhaler, methoxyflurane vaporises, to be inhaled on demand. It has revolutionised prehospital pain control due to its quick onset and easy, pain free administration and, because of its light weight, crews can carry it over rough ground easily. Known as ‘the green whistle‘, each 3ml dose is quoted to last between 20 and 30 minutes, but in practice can sometimes last up to 45 minutes or an hour, depending on a child’s respiratory rate and depth and the way in which they self-administer. The Irish prehospital CPGs allow two inhalers to be administered in 24 hours to a patient, so when there’s an extended journey time, methoxyflurane inhalers used back-to-back can provide up to two hours of analgesia, which can be supplemented by the simple analgesics, paracetamol and ibuprofen, or morphine, fentanyl and ketamine, as needed.

But what’s the evidence for methoxyflurane in children?

Pop methoxyflurane in the PubMed search bar, and a lot comes up. It’s safe, it works, but there are surprisingly few randomised controlled trials (RCTs) that include children. A couple of observational studies are noteworthy. An Australian study in the prehospital setting, published in 2006 by Franz Babl and colleagues, describes an observational case series of 105 children, ranging in age from 15 months to 17 years, who received methoxyflurane while by being conveyed to hospital by ambulance. The children’s pain scores dropped from 7.9 to 4.5, with few side effects, although there was a tendency towards deep sedation in the under 5s. The following year Babl’s team published an ED-based observational case series of 14 children aged 6 to 13 years with extremity injuries who received methoxyflurane for painful procedures in the hospital setting. Although methoxyflurane was a useful analgesic agent, Babl’s team found it did not work as well as a procedural analgesic for fracture reduction.

The first double-blind RCT of methoxyflurane in children was published almost two decades ago by Chin et al in 2002. Forty-one children over the age of 5 with upper limb fractures were randomised to receive either methoxyflurane or placebo. Unsurprisingly, methoxyflurane resulted in a lower pain score at 10 minutes than placebo. Adverse events weren’t reported, but the apparent safety and efficacy of methoxyflurane demonstrated in this study paved the way the some bigger and better RCTs.

A better known, and more recent, RCT involving children was the STOP! trial, published in the EMJ in 2014. This randomised, double-blind placebo-controlled trial was conducted at six EDs in the UK. Three hundred patients, 90 between the ages of 12 and 17, with minor trauma (such as burns, fractures, dislocations and lacerations), were randomised to receive either methoxyflurane or saline via an inhaler. In a nifty way to keep the patients, doctors and nurses blinded to which drug was being administered, a drop of methoxyflurane was added to the outside of every inhaler so both drug devices smelled the same. Pain scores dropped significantly lower in the methoxyflurane group, with a median onset of action of 4 minutes. But what about those adolescents? Although 45 12 to 17 year olds were included in each group, their data wasn’t analysed separately, and children under the age of 12 were excluded from the study, so although we can probably assume methoxyflurane works well and is safe in adolescents, more trials would be helpful.

Segue to the Magpie trial, which is currently recruiting in the UK and Ireland via the PERUKI network. This international multi-centre randomised, double-blind placebo-controlled trial is specifically investigating the efficacy and safety of methoxyflurane in children and young people so that its UK license can be extended to include children. Like STOP!, participants are being randomised to either methoxyflurane or placebo (again saline) via an inhaler. To ensure younger children are well represented in the study data, the study team are aiming to recruit higher numbers of 6 to 11 year olds than adolescents, with a recruitment target of 220 children and adolescents in total. We’re awaiting the results eagerly…


*A top tip on top up dosing

This child had been given 500mg of paracetamol and 280mg of ibuprofen by his mother before the crew arrived. He was 8 years old, with an estimated weight of 31kg. Based on Irish CPGs allowing a paracetamol dose of 20mg/kg (620mg) and ibuprofen dose of 10mg/kg (310mg) he was underdosed. It’s important to top-up simple analgesics as part of your approach to pain relief in children.


But what happened to the 8 year old?

You check CSMs (circulation, sensation and movement) before and after applying a splint and transfer him to the ambulance on a stretcher. His pain is very well controlled, and he asks his mother to take a photo for his friends. This sentence is hard for him to say and he gets the giggles. You transfer him uneventfully to hospital where he’s diagnosed with a supracondylar fracture.

Read more about assessing pain, prehospital analgesia in children and the evidence behind intranasal fentanyl in part 1 of the DFTB prehospital analgesia series.

References

Hartshorn, S., & Middleton, P. M. (2019). Efficacy and safety of inhaled low-dose methoxyflurane for acute paediatric pain: A systematic review. Trauma21(2), 94–102. https://doi.org/10.1177/1460408618798391

Babl FE, Jamison SR, Spicer M, Bernard S. Inhaled methoxyflurane as a prehospital analgesic in children. Emerg Med Australas. 2006;18(4):404-410. doi:10.1111/j.1742-6723.2006.00874.x

Babl FE, Barnett P, Palmer G, Oakley E and Davidson A. A pilot study of inhaled methoxyflurane for procedural analgesia in children. Pediatric Anesthesia. 2007;17:148-153. doi:10.1111/j.1460-9592.2006.02037.x

Chin, R, McCaskill, M, Browne, G A randomized controlled trial of inhaled methoxyflurance pain relief in children with upper limb fracture. J Paediatr Child Health 2002; 38: A13–A13.

Coffey F, Wright J, Hartshorn S, et al. STOP!: a randomised, double-blind, placebo-controlled study of the efficacy and safety of methoxyflurane for the treatment of acute pain. EMJ 2014;31:613-618

Hartshorn, S., Barrett, M.J., Lyttle, M.D. et al. Inhaled methoxyflurane (Penthrox®) versus placebo for injury-associated analgesia in children—the MAGPIE trial (MEOF-002): study protocol for a randomised controlled trial. Trials 20, 393 (2019). https://doi.org/10.1186/s13063-019-3511-4

Pre-hospital analgesia: Part 1

Cite this article as:
Joe Mooney + Dani Hall. Pre-hospital analgesia: Part 1, Don't Forget the Bubbles, 2020. Available at:
https://doi.org/10.31440/DFTB.26121

You’re on a shift in the Rapid Response Vehicle. The radio crackles to life; a two-year-old has pulled a chest of drawers onto himself. He’s conscious and breathing but his leg is badly injured. Lights and sirens on, you wonder what is going to greet you.

The prehospital challenge

Assessing children in the prehospital environment can be challenging. As a stranger arriving at a child’s house at a time when they’re feeling unwell, hurt, or scared, we can seem frightening. Attending multi-patient scenarios, such as a road traffic collision, where both child and parent are injured poses additional challenges. Separating a child from their parent to attend different adult and paediatric hospitals can be hugely traumatic for the child (and the carer )and although we try to get another adult to the scene to accompany the child to the hospital, this isn’t always possible.

In the prehospital setting, we don’t have the luxury of time. A quick decision needs to be made: is this child sick or not sick?

For many prehospital clinicians, children make up a very small proportion of their workload. Drawing up paediatric-drug doses and administering these medications to a scared child takes training and practice.

All of this can make a clinical assessment of a child difficult. Taking off the high-vis jacket, getting down to the child’s level, making a glove-balloon character and using bubbles can all help a child feel at ease.

The prehospital assessment toolbox

There are some validated tools in our box to help overcome these challenges. The Paediatric Assessment Triangle has been used by prehospital care providers at all levels for many years, allowing clinicians to form a hands-off, quick impression about whether the child is sick or not sick.

The triangle is made up of 3 elements: A, B, and C, a mnemonic familiar to clinicians around the world. But this ABC does not stand for airway, breathing, and circulation but instead translates to Appearance, work of Breathing and Circulation to the skin.

Appearance… Is the child interacting with caregivers and ambulance crew? Are they lethargic? Crying? Consolable? Limp in caregivers arms?

Work of Breathing… Are they using accessory muscles to help move air? Are they tripoding? Nasal Flaring? Are they breathing fast or slow? Can you hear a wheeze or stridor?

Circulation to the skin… Are they pale? Cyanotic? Mottled?

If all three parts of the triangle are normal the child is likely to be stable. If all three parts of the triangle are abnormal the patient is in cardio-respiratory failure.

Assessment of pain in the prehospital environment also poses different challenges to the assessment in the hospital, for the same reasons. We use the same age-appropriate pain scales as our hospital-based colleagues: FLACC, Wong-Baker and analog pain scale. Clinical practice analgesia guidelines help direct medication choice, from simple painkillers such as paracetamol and ibuprofen, to stronger analgesics like opiates and ketamine.

The ideal analgesic

The ideal properties of an analgesic are to provide effective pain relief rapidly, with painless administration. Gaining intravenous access in children can be challenging in the field, traumatic for children, and can delay administration of analgesics. It really can’t be stressed enough how important it is not to traumatise a child with cannulation when a good alternative is available. Intranasal fentanyl has had a huge impact on paediatric pain relief prehospitally. In the UK, diamorphine is sometimes used instead of fentanyl; both are potent intranasal opioids that are rapidly and efficiently absorbed from the nasal cavity, giving significant potential for pain management in children.

Arriving at the house, you can hear a child crying; he’s maintaining his airway and is conscious. You make a snapshot PAT assessment: he’s stable. But his thigh is swollen and it’s clear he’s fractured his femur. His parents have given him paracetamol and ibuprofen. This one’s beyond the call of bubbles, so you put them away and instead draw up 0.02mg of fentanyl and give it intranasally.

The intranasal route

Analgesia can be given orally, rectally, intravenously, intramuscularly, or intranasally. Oral medications are metabolized via the hepatic first-pass pathway, meaning they are absorbed from the gastrointestinal tract and delivered first to the liver by the portal vein before reaching the systemic circulation, resulting in a relatively slow onset of action. Intranasal medications, on the other hand, are absorbed directly into the systemic circulation, completely bypassing hepatic first-pass metabolism, so their bioavailability is higher and their onset of action is much faster. And because the nasal mucosa is highly vascularized, with more blood per cubic centimetre than muscle, brain or liver, with a surface area that’s massively increased by the three turbinates in each nostril (out pouches of bone inside the nostrils that create passageways that to warm and moisten the air that flows in through the nose), it is an ideal surface through which drugs with small molecular weights like fentanyl can be absorbed.

Once absorbed into the nasal blood vessels, drugs drain to the right side of the heart via the superior vena cava, are pumped into the pulmonary circulations, and then back through the left side of the heart to the systemic circulations.

Some intranasal drugs have an even faster mechanism of action. It’s thought that fentanyl, and other drugs with very small particle sizes, can also transfer directly to the brain, via the olfactory and trigeminal nerves. This nerve superhighway means they can bypass the blood-brain barrier, and work even faster at their central receptors in the brain.

The intranasal analgesic cavalry

Fentanyl is a synthetic opioid; diamorphine is a morphine derivative. As fentanyl doesn’t cause histamine release, it results in less cardiorespiratory side effects than other opiates. Both fentanyl and diamorphine can be safely combined with oral morphine, meaning intravenous morphine top-ups are less likely to be required. When they’re given intranasally, their onset is within two to three minutes, with effects lasting up to half an hour. It’s easy to see how they’ve become a perfect choice for prehospital providers.

Ketamine, another analgesic in the prehospital analgesic armory, can also be given intranasally, although is not yet licensed via the intranasal route in children in the UK and Ireland. A few trials have compared intranasal ketamine and fentanyl and there have been some interesting results, posing the question as to whether sub-sedative doses of intranasal ketamine could be used as an alternative analgesic for children with limb trauma.

Published in Annals of Emergency Medicine in 2014, the double-blinded RCT, PICHFORK (Pain In Children Fentanyl OR Ketamine), was run in two large Australian paediatric EDs.  Children aged 3 to 13 years old with moderate to severe pain secondary to an isolated limb fracture were randomized in a double-blinded fashion to receive either 1.5 μg/kg intranasal fentanyl or 1mg/kg intranasal ketamine. 73 children were included in the analyses. Similar reductions in pain scores were seen at 30 and 60 minutes for both drugs. The ketamine group had higher patient satisfaction scores (83% compared to 72% for fentanyl) but more minor adverse events (78% compared to 40% of the fentanyl group). Published in 2017, a similar double-blinded RCT conducted in a level II trauma centre in America compared the two intranasal drugs at the same doses in 82 children aged 4 to 17. Like PICHFORK, their results showed more side effects in the intranasal ketamine group (2.2 times higher), but all were minor, with no respiratory adverse events. Analgesic effects at 20 minutes were similar in both groups. And finally, the PRIME (Pain Reduction With Intranasal Medications for Extremity Injuries) trial, a double-blinded RCT published in JAMA Pediatrics in 2019, showed similar results. 90 children, aged 8 to 17 years, presenting to a level I major trauma centre with limb trauma were randomized to receive either intranasal ketamine or fentanyl. Doses used were higher than those in standard clinical practice guidelines, with intranasal fentanyl dosed at 2μg/kg and intranasal ketamine at 1.5mg/kg. Like the other two trials, pain scores at 30 minutes were similar between both groups, while mild adverse events were found to higher in the ketamine group (with a relative risk of 2.5), although again all were transient.

So, is there a role for intranasal ketamine for children with isolated limb fractures in the prehospital or ED setting? None of these studies were powered to show a superiority of intranasal ketamine over fentanyl, but they do suggest that it’s non-inferior and a potential alternative. Although minor and transient, adverse events were higher in the ketamine groups, so it may not trump fentanyl as a first choice analgesic. But for children in whom an opiate is contraindicated, intranasal ketamine might be an alternative. More data will be needed before intranasal ketamine makes its way onto standard CPGs, but results from these trials are promising, with larger studies on the horizon.

After the intranasal fentanyl, the child settles. You apply traction to his leg, and with your colleagues’ help, you move him into an adult lower limb vacuum splint. This is a handy trick you’ve learned – the leg splint is just the right size to use as a whole body splint in small children, maintaining pelvic and spinal precautions. After moving to the back of the ambulance, he starts crying and is obviously in pain. You give him a second dose of 0.02mg fentanyl and phone medical support and discuss options with a senior clinician and get the go-ahead to give the third dose, en route to the hospital, if needed.

Ambulance control pre-alert the emergency department so they can prepare for an incoming paediatric trauma. The child’s mother sits next to the stretcher, holding his hand while you travel to the hospital. You explain to her what’s happened so far, what will you do if anything changes, and what might happen in the hospital. This calms her down. The child sleeps and that third dose of intranasal fentanyl is not required. As you pull onto the ambulance ramp he wakes. You hand him over to the waiting trauma team in resus; intravenous access is gained, IV morphine is given, and a Thomas Splint applied. After his primary survey is completed, an x-ray is taken, which confirms a femoral fracture.

The prehospital cannula

The question about intravenous access in the field is a tricky one. Inserting an IV line in a 2-year-old, particularly in the back of an ambulance, can be extremely difficult, and securing a cannula while travelling at speed requires the dexterity of a magician. If intranasal medication is working then there may not be the need for an IV line prehospitally. This always has to be balanced with the potential need for fluid resuscitation, or other intravenous drugs. Each case is a judgment call, based on the paediatric assessment triangle assessment and need for intravenous medications. But never forget, if a child’s in pain and the bubbles don’t work, don’t forget the fentanyl.

Selected reference

Reagan L, Chapman AR, Celnik A, et al. Nose and vein, speed and pain: comparing the use of intranasal diamorphine and intravenous morphine in a Scottish paediatric emergency department. Emerg Med J 2013; 30:49–52.

Graudins A, Meek R, Egerton-Warburton D, Oakley E, Seith R. The PICHFORK (Pain in Children Fentanyl or Ketamine) Trial: A Randomized Controlled Trial Comparing Intranasal Ketamine and Fentanyl for the Relief of Moderate to Severe Pain in Children With Limb Injuries. Ann Emerg Med [Internet]. 2015 Mar 1 [cited 2019 Jun 20];65(3):248-254.e1. Available from: https://www.sciencedirect.com/science/article/pii/S0196064414013638

Watts P, Smith A, Perelman M. Nasal delivery of fentanyl. Drug Deliv Transl Res [Internet]. 2013 Feb 1 [cited 2020 Jun 8];3(1):75–83. Available from: https://doi.org/10.1007/s13346-012-0078-y

Goldman RD. Intranasal drug delivery for children with acute illness. Curr Drug Ther 2006; 1:127–130.

Hadley G, Maconochie I, Jackson A. A survey of intranasal medication use in the paediatric emergency setting in England and Wales. Emerg Med J 2010; 27:553–554.

Mudd S. Intranasal fentanyl for pain management in children: a systematic review of the literature. J Pediatr Health Care 2011; 25:316–322

Finn M, Harris D. Intranasal fentanyl for analgesia in the paediatric emergency department. Emerg Med J 2010; 27:300–301.

Telfer P, Criddle J, Sandell J, et al. Intranasal diamorphine for acute sickle cell pain. Arch Dis Child 2009; 94:979–980