Emergency ambulance transport in those with Autistic Spectrum Condition

Cite this article as:
Vicki Marchant. Emergency ambulance transport in those with Autistic Spectrum Condition, Don't Forget the Bubbles, 2021. Available at:
https://doi.org/10.31440/DFTB.33246

A small bit of knowledge about Autistic Spectrum Condition (ASC) can make a huge difference in how an emergency situation evolves. ASC is also referred to as ASD – Autistic Spectrum Disorder – but there is a move away from using the term “disorder”, driven by autistic people themselves. Many see their autism as part of their character and identity, hence “autistic people” rather than “people with autism”, and prefer to think in terms of a condition rather than a disorder due to the negative connotations this carries.

Unlike the UK, Ireland does not have official clinical guidance for transporting those with ASC or communication difficulties to the ED. There are two ambulance services in Ireland: the Dublin Fire Brigade (DFB), who run 12 ambulances in the greater Dublin area, and the National Ambulance Service (NAS) who run the remainder of the ambulances in Dublin and the rest of the country. Neither has any formal training in the management of those with ASC. Although some personnel have knowledge of the intricacies of the condition this is mostly due to personal experience with friends or family members.

A call to a situation where the patient has ASC is usually a last resort. Family members don’t want to make the situation worse by calling in strangers and will have tried their best to de-escalate the situation themselves. If the call has been made, the situation has gone past their control and they are admitting they need help. The parents may feel they have failed their child and the attitude of the staff coming into the house can make a huge difference to all involved.

Sam is 15, he’s 5ft 10 and 20 stone. He trips going out the front door and twists his ankle. He starts screaming and tries to get up. He puts weight on his foot and it goes from under him, further aggravating the injury. Due to his size and his injury, he is unable to get up. His dad tries to help him but is unable to lift him. He is screaming very loudly and a crowd is gathering. His family call an ambulance which arrives after 15 minutes. You can hear his screams as you pull up. There is a large crowd gathered, watching and offering ‘helpful’ suggestions to his father who is sitting behind Sam gripping him very tightly. Sam is trying to headbutt his dad and writhing around in apparent agony. You can see his ankle is injured but you can’t get near enough to assess him without getting kicked. You have to shout loudly to make yourself heard and the crowd are enjoying the entertainment.

You feel you need a few more bodies here to help and escalate the call to a behavioural emergency scenario which warrants the police being called. Within a few minutes you have two police officers with you shouting at the dad, trying to get him to stop assaulting the boy. The dad tries to explain but can’t be heard over the noise Sam is making, which has somehow gotten louder. You, your colleague and the two police are standing over Sam trying to hold him down with the dad telling you to get away. The crowd are filming everything. Every time Sam kicks out, he injures his ankle more. The situation is completely out of control.

From a Different Perspective…..

Sam is 15, he’s 5ft 10 and 20 stone. He is autistic and non-verbal. He trips going out the front door and twists his ankle. He starts screaming and tries to get up. He puts weight on his foot and it goes from under him, further aggravating the injury. Due to his size and his injury, he is unable to get up. His dad tries to help him but is unable to lift him. He is screaming very loudly due to pain and frustration and a crowd is gathering. His family call an ambulance which arrives after 15 minutes. You can hear his screams as you pull up. There is a large crowd gathered, watching and offering ‘helpful’ suggestions to his father who is sitting behind Sam bear-hugging him very tightly. One of Sam’s coping mechanisms to deal with unusual situations is to headbutt whatever is around him, in this case the ground, so his dad is sitting behind him to try and stop this but also giving deep pressure to Sam which helps comfort him. You can see Sam’s ankle is injured and a quick survey of the situation shows you that Sam is aggravated by the noise in the crowd also.

You ask your partner to quietly move the crowd on and you slowly approach Sam and his dad but stay out of kicking distance. You introduce yourself to Sam and his dad in a calm, quiet voice and ask what you can do to help.  By asking this way you are acknowledging that the parent knows this child the best. You may be asked to go into the house and get an object to help calm the child: a blanket, a tablet or a favourite toy. In this case Sam’s dad asks you to go in and get his sleeping bag which he immediately puts over Sam’s head. Sam continues to sob but immediately stops kicking out. You are able to chat with Sam’s visibly shaken dad about what happened, and you can look at Sam’s injured ankle. You say what you are going to do and Sam’s dad says it in words Sam may understand. Although he protests a bit, you are able to assess his ankle and determine he needs ED assessment as it may be broken.

You are able to splint his ankle and, between the 3 of you, help Sam onto the chair and get him into the ambulance. His father asks if you can dim the lights and he runs back into the house and grabs a few bits including a tablet which he gives to Sam who is now trying to undo the seat belts. Sam calms immediately and even lets you do some obs when he’s distracted although he thoroughly dislikes the BP monitor and rips the cuff off. You pre-alert the hospital to ask if they can find a quiet space for Sam to wait to be seen and give them chance to review Sam’s care pathway, if he has one.

If you have no knowledge of ASC you will approach this scenario as an ordinary call and walk into chaos. You will see the father essentially holding this child down for no reason and you will act accordingly and put the safety of the child first.

The Autistic Spectrum

People with ASC vary from having very mild symptoms and being able to manage very well to someone like Sam who is completely non-verbal and also has an intellectual disability. The autistic spectrum isn’t a linear thing, with “high functioning” at one end and “low functioning” at the other. Think of it as a pie, made up of variable-sized slices – the social communication difficulties slice may be quite big, whilst the slices for inflexible thinking and anxiety may be fairly small. The whole pie is different for every autistic person. “Slices” vary, depending on the source used, but commonly also include sensory issues, routine, repetitive movements and intense focus or interests.

Autistic Symptoms and Coping Mechanisms

One of the most common symptoms of ASC is a dislike of change in routine, leading to use of personal coping mechanisms which can be seen as self-harm: head-butting walls, picking at skin etc. In this case, Sam was trying to headbutt the ground which would have caused him more injuries than just his ankle. As with some with ASC, Sam does not understand the consequences of doing this so could hurt himself badly before stopping.

Some autistic people have sensory processing difficulties. This can mean that the body misinterprets certain sensations – light touch may be uncomfortable, deep pressure may be comforting, loud or sudden noise may be very distressing. This is why Sam’s dad had a very tight hold on his upper arms. Other coping mechanisms in those with ASC may include talking about one subject, loudly and constantly, perhaps to distract themselves from something distressing, or sometimes if they feel they are not being engaged with. Some may not understand you may be talking to someone else about something more important, the situation is scary to them and this is their way to cope. Further symptoms may include a dislike of loud noises, bright lights, strangers or crowds.

You will be seeing these patients on an already bad day. Something unexpected has happened which has put them out of their comfort zone already, but it has happened to the extent that someone else has been called to their side. This can often be in a noisy environment with lots of people trying to help. Their senses are overloaded and they will need to employ all their coping mechanisms to try and manage.

You will not always know immediately that a person has ASC. They may tell you if they are able, or a family member/carer may say. If you feel the person’s reactions are out of proportion given the situation, consider whether they may be autistic.

Tips to Remember

Unfortunately, parents are used to getting unsolicited advice about how to best manage their children and a large number of people feel the symptoms of ASC are just a child being naughty with poor parenting. Parents may appear defensive at first but asking how you can help may calm them as they realise you are there to help rather than criticise.

Speak quietly and don’t crowd the patient. Don’t touch them without asking. Ask what you can do to help: do they have a toy/blanket/comforter with them that you can get? Is there anything that usually helps to make them feel more comfortable? If they are in the ambulance, can you turn the lights down and travel without the siren?

First and foremost, go into every situation with an open mind and ask what you can do to help. Not everything is as it looks and by being aware of this you can turn chaos into, well, less chaos.

Communicating clearly

Cite this article as:
Liz Herrieven. Communicating clearly, Don't Forget the Bubbles, 2021. Available at:
https://doi.org/10.31440/DFTB.32916

The Joint Royal Colleges Ambulance Liaison Committee (JRCALC) produces guidance for ambulance services across the UK. I was thrilled to be asked to contribute to this in the form of a new chapter on patients with communication difficulties. This post expands on that guidance, which was written to support pre-hospital clinicians in providing the best possible care to their patients who face challenges with communication. This may be due to a wide variety of underlying conditions, including learning disability, autism, hearing loss, dementia and dysphasia.

Communication is vital to all that we do – from the first contact with a patient, through history taking and examination, to initiating treatment and explaining procedures. We have to do our very best to get it right. This is perhaps even more important, and more difficult, in the pre-hospital field, where stress levels are high, the environment can be unpredictable and time is short. Clinicians meeting patients for the first time need to quickly assess the situation and also win trust and gain understanding.

Communication is a two-way thing. It sounds obvious, but it becomes even more important when patients find communication difficult. Not only do we have to try our best to make ourselves understood, but we also have to try our best to understand our patient.

It’s also important to remember that communication and understanding are two very different things. Someone may be able to communicate quite well but understand very little. Conversely, someone may not be able to communicate but may have a very good understanding, including things being said about or around them. Dysphasic or dysarthric patients may appear to be unable to understand when actually their difficulty is in expressing themselves.

So, how can we improve our communication?

Minimise fear and anxiety

Communicating and understanding become more challenging when there is fear and anxiety. The first step is to keep calm and reassure the patient. The specific nature of any communication difficulty needs to be recognised quickly then addressed. Patients with a learning disability may not understand what is happening so careful explanations may help. Some autistic patients may have difficulty interpreting information verbally or non-verbally, or they may have significant sensory processing difficulties which means that loud noises, bright lights and physical touch can be distressing or even painful. Deaf patients may be able to better understand if they can see the clinician’s mouth – difficult with PPE.

Make simple adjustments

Communication might be made easier with simple changes such as speaking slowly and clearly and avoiding jargon. And give time – time for your patient to respond. For some patients, including those with Down syndrome, it can take several seconds to respond – time to receive the auditory information, decode it, understand it, formulate an answer and produce that answer as the right set of noises. We’re all busy so that seven or eight seconds can feel like an age. It’s absolutely worth the wait, though.

Adapt the environment

Can we do anything to make the environment less distracting, quieter, less stimulating? Would it be better to assess the patient in familiar surroundings rather than in the ambulance? Can noisy, scary or flashing equipment be switched off, removed or covered? If the patient has to be moved can they bring something, or someone, familiar with them?

Pay attention to non-verbal communication

Would eye contact help? It often does, but for some autistic patients it can be distressing. Some people respond well to a reassuring touch (I’m a toucher and a hugger) but others find it really uncomfortable – check before extending that hand! Do we need to support our verbal communication with gesture or sign? Pictures or symbols might help to explain what we are saying, but if we don’t have any to hand then pointing to body parts or pieces of equipment can help. We absolutely need to pay attention to our non-verbal communication, body language, posture, facial expression and so on, and also watch for non-verbal cues from our patient. Those who know our patient best might be able to help with this – how would their loved one usually let someone know they were in pain, for example? Pain is often poorly assessed and managed in people with a learning disability (LeDeR – the Learning Disability Mortality Review Programme). We often hear about people having a “high pain threshold” and whilst it’s true that pain is perceived differently by different people, we can’t assume that someone does not feel pain just because they can’t verbalise it.

Play to your patient’s communication strengths

Some patients may have particular strengths and weaknesses when it comes to communication. People with Down syndrome often find it more difficult to understand and remember auditory information, due to a variety of issues including fluctuating hearing impairment and poor short term auditory memory. They may, however, find it much easier to remember and understand information presented in a visual format. Using gesture, sign language (such as Makaton), photos or symbols (such as PECS) may support the verbal information and make things much easier for both the patient and the clinician.

Family and carers can help to identify how best to communicate with the patient but consider other resources too – is there a hospital passport that can give you some clues? These are often used to list medications and past medical history, but their real beauty is in detailing likes, dislikes, behaviours associated with pain, interventions that might be difficult to tolerate, and so on. A care pathway can also give great clinical information and guide management.

Adapt your examination

Your standard examination might need to be altered a little. Give clear warnings before touching the patient, particularly if they have any visual impairment or a sensory processing disorder. Start with those parts of the examination that are less intrusive – watching and observing position, demeanour, breathing pattern, and movements can all give a huge amount of information before you even get your stethoscope out. Distraction might be useful for some patients but for others, including those who may have had previous bad experiences, it might not work. Family and carers may know how best to support your patient through the more distressing parts of the examination and any following interventions.

LeDeR has also found that early warning scores were less likely to be calculated in people with a learning disability, and they were less likely to be acted on if abnormal. There are many likely reasons behind this, including clinicians being reluctant to cause distress to their patients. Things like blood pressure or oxygen saturation measurement can be very uncomfortable, particularly for those who may not understand what is being done or who may have sensory processing difficulties. Those patients still need to be assessed and treated appropriately. If a BP or sats, or any other part of your assessment for that matter, is likely to give important information then it should be done. There may, however, need to be some thought about how best to carry it out. Explanation, communication, visual information, distraction – what will help your patient tolerate the examination?

There is a common misconception that patients with chronic health problems always have an abnormal early warning score, so what’s the point? Any score, normal or abnormal, in a previously healthy patient or not, should be taken in context with the rest of the examination. It can be helpful to know what the patient is like (behaviour, level of alertness, comfort, interaction, early warning score) when well, to help to identify how ill they may be now. Again, family and carers can give vital information about this.

Be attuned to “soft signs”

“Soft signs” can help, too. These are things that family might notice long before health professionals. They are not specific to any particular illness or disease process, but give an indication that the patient isn’t well. For example, someone might be a little paler than usual, not want to get out of bed, not want to finish their favourite meal and not want to watch their favourite TV programme. A family member would know that these things mean their loved one is not themselves, and likely to be unwell. Healthcare professionals can learn a lot by listening out for soft signs.

Beware diagnostic overshadowing

It’s really important to watch out for diagnostic overshadowing. This happens when a patient has a pre-existing diagnosis, and any new symptoms are assumed to be down to this diagnosis. For example, an autistic person might present as being quite agitated, carrying out repetitive, stereotypical movements and it might be tempting for us to assume that this is all because they have autism. However, if we do that, we may miss the fact that they are in pain or feeling unwell. Again, we have to find out more about what our patient is like when they are well, to know how ill they may be now.

All of this boils down to making reasonable adjustments, which are required by law (Equality Act 2010). We can sum it up with the TEACH mnemonic:

Time: assessing someone with communication difficulties may take more time, but that time is absolutely worth it.

Environment: pick the best environment to assess your patient in. Keep things quiet and calm, remove distractions. Keep things familiar to the patient if you can, or let them have something familiar with them.

Assume: don’t assume anything about understanding – communication aids understanding, but someone who has difficulties with communication may still have very good understanding.

Communication: how can you best communicate with your patient? How can you help them make themselves understood? Would symbols or signs help? Pictures or gesture? Writing things down?

Help: what help does your patient need? What help do you need??

None of the interventions suggested are particularly tricky or difficult, but all have the potential to make a huge difference to our patients. For those working in UK ambulance services, the JRCALC guideline chapter will hopefully help as a prompt. For others, whether pre-hospital or not, I hope this blog helps a little.

https://www.jrcalc.org.uk

https://www.bristol.ac.uk/sps/leder/

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/.

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

Prehospital PEM Pearls

Cite this article as:
Dani Hall. Prehospital PEM Pearls, Don't Forget the Bubbles, 2020. Available at:
https://doi.org/10.31440/DFTB.24496

This post is dedicated to my prehospital friends and colleagues and is based on a talk I gave for University College Dublin. Stay safe out there.

Once upon a time there was a school called Hogwarts. And in that school were two friends, Ron and Hermione. They went on many adventures and, well, to cut a long story short, Ron and Hermione fell in love and got married. Although they both had good jobs with the Ministry of Magic, with Brexit looming Ron and Hermione decided to leave the UK and return to the country of Ron’s roots. They settled in a small country home on the west coast or Ireland. And it was there that their first baby was born.

Finlay, or Finn for short, is two weeks old and gorgeous, cute and super cuddly. His parents however, have just lived their worst nightmare. Finn was lying on the play mat when he suddenly went grey and ashen. Hermione picked him up but he was floppy and not breathing. She screamed for Ron who came running in and his initial thought was that Finn had died. He called 999 but before he’d ended the call, Finn had started breathing again and he was back to his normal self within 30 seconds. The paramedics arrive and check a blood sugar, which is 5.2, and his observations are normal. They wrap him up in a blanket and move him into the back of the ambulance. There they reflect on a paper they’d read recently on neonatal transport.

Duby et al, 2018. Safety Events in High-Risk Prehospital Neonatal Calls. Prehospital Emergency Care

This paper, published in 2018, looked retrospectively at all “lights and sirens” ambulance transports of neonates 30 days and younger over a four-year period in Oregon, Michigan.

During these four years, 26 neonates were blue lighted to hospital. Safety events, such as medication errors, airway management difficulties, resuscitation errors and clinical assessment and decision errors occurred in 19 babies. That’s almost three-quarters of all the transfers. Serious safety events, potentially causing permanent injury or harm, occurred in 10 babies, that’s more than a third of all neonatal blue light transfers. Specific examples included tenfold adrenaline dosing errors, failure to obtain IV or IO access and failure to adequately ventilate with bag-valve-mask devices.

This is pretty huge. Why were safety errors so common? The authors propose three reasons:

Firstly, very young babies blue-lighted by ambulance are more likely to be very sick, with life-threatening emergencies.

Secondly, neonates are the most dissimilar to adults. This is especially true for newborn babies, whose physiology is so significantly different from older children and adults because of the physiological transitions as they adapt to a life outside the uterus. The newborn life support algorithm is adapted specifically because of this, with 3 breaths to every chest compression instead of the 15 to 2 for children.

And thirdly, high-risk neonatal transfers are very infrequent. Mix low frequency yet high acuity illnesses with different physiologies, different disease processes, and dosing difficulties and you can see why the chance for error is high.

So, what can you do to mitigate these risks?

Practice, practice, and well… practice. For any presentation that’s low-frequency but high-acuity, falling back on a well-rehearsed algorithm helps with cognitive offload, minimizing the potential for error. Practicing neonatal resuscitation until you can do it with your eyes closed will help you get into the cognitive groove when it happens for real. Running skills and drills, like bagging a neonatal mannequin or putting IO needles into teeny tiny simulated legs (sticks are perfect) will help get over the adrenaline-induced block in the real thing. And practicing neonatal drug calculations, using apps to calculate those tiny medication doses, and then drawing up the neonatal sized drug volumes will 100% help improve safety.”

So, with that in mind, the paramedics review drug doses and treatment algorithms while transporting Finn to hospital. The journey, thankfully, is uneventful. But, they wonder, what had caused him to go so floppy and grey?

Finn had what we now call a BRUE – a brief, resolved, unexplained event.

Tieder et al, 2016. Brief Resolved Unexplained Events (formerly Apparent Life Threatening Events) and evaluation of lower risk infants. Pediatrics

This paper, published in 2016, provides evidence-based recommendations for low-risk babies who present with a BRUE. The key is in the words BRIEF and UNEXPLAINED. If the episode wasn’t brief (less than a minute) or unexplained then they didn’t have a BRUE. So forget about those babies who’ve had a funny episode whilst being snuffly for a few days (they’ve probably had an airway or respiratory episode) or the babies who went pale and floppy choked during a feed (they probably refluxed) or the babies with a fever (they could be septic).

The term BRUE has now replaced ALTE (previously known as Acute Life-Threatening Events, a pretty unhelpful term because it’s just so vague and so incredibly subjective) and also replaced that golden-oldie term, Near-Miss Sudden Infant Death Syndrome (a highly emotive and immensely unhelpful term) and looks like it has changed practice in at least some institutions.

In ED Finn looks like a healthy baby. He has a bottle of milk and looks like one of the cutest babies there ever was. Because he is so young, he has a set of bloods done, which are normal, and Hermione finally manages to catch a wee sample (after missing one onto the floor), which is also normal, and he is admitted for overnight observation. Finn remains well on the ward and is discharged the next morning.

6 months pass. Finn is doing brilliantly. But one morning he wakes up with a cough and two days later starts breathing really fast. He can’t manage a bottle and his little tummy is sucking in and out with every breath. In a panic Ron dials for an ambulance and soon help is at hand. The paramedics take one look at Finn and take a collective deep breath. He’s working pretty hard. They get him hooked up to the monitor: sats 89%, HR 190, RR 56. A quick listen to Finn’s chest reveals widespread wheeze and crackles. Wheeze. Right. Out comes the salbutamol. 2.5mg as per the clinical practice guideline.

Wait. Hold that thought. What are we treating here? Finn is wheezy. So he has bronchospasm, right? Wrong. Let’s stop for a second and think about wheeze in infants.

Wheeze in infants

Wheeze is a noise we hear when air passages are obstructed. We classically think of wheeze as being due to bronchospasm. And salbutamol relieves bronchospasm. But, and this is a big but for paediatrics, infants don’t get bronchospasm when they have a virus. So salbutamol doesn’t work.

If you think of the respiratory system as being an upside-down tree, the trunk is the trachea, the first two branches are the right and left main bronchi, the next branches are the lobar and then segmental branches, and finally, you get to the twigs. The bronchioles. The classic wheeze that we see in children and adults is due to bronchospasm – that’s constriction of the bronchi. Beta-2 receptors on the smooth muscle cells of the bronchi respond to Salbutamol – give enough bronchodilator and the airways will relax. Goodbye wheeze. Children from about the age of 12 months can get something called “viral-induced wheeze” – bronchospasm triggered by a virus, much like a viral exacerbation of asthma. Because this is bronchospasm, salbutamol works.

However, babies don’t get viral-induced wheeze. They get bronchiolitis. When the teeny tiny twiggy bronchioles become inflamed, this is bronchiolitis – itis (inflammation) of the bronchioles. Bronchiolitis affects infants from birth until somewhere between their first and second birthdays and is the most common lower respiratory tract disorder in infants aged less than 12 months. Like viral-induced wheeze it’s also due to a virus (classically RSV but many other viruses can cause it too). The baby starts with a cough and a snuffly nose. The bronchioles gradually become inflamed and fill up with secretions. And these secretions obstruct the airway and voila – you hear wheeze and crackles when you listen to the lungs.

There’s no bronchospasm anywhere. So bronchodilators like salbutamol just won’t work.

And if you do give salbutamol to a little baby with bronchiolitis? Well… Salbutamol is a beta-2 agonist – it’s the beta-2 receptors on the bronchi that it acts on in viral-induced wheeze and asthma. But it also has a weak beta-1 effect causing tachycardia, dizziness, and nausea. So, now you have a baby with respiratory distress that’s not improved and now they’re tachycardic on top. Not ideal.

Generally, infants under 12 months have bronchiolitis, toddlers over 2 years have viral-induced wheeze, and the 1-2-year-olds may have either.

Of course nothing magic happens on a baby’s 1st birthday (even if you are a baby born to a wizard and witch) so there may be the odd 10 or 11 months old with viral-induced wheeze rather than bronchiolitis.

What can the paramedics do for Finn? He’s working pretty hard with his breathing. At 6 months old this is almost certainly bronchiolitis. And they now know salbutamol will only cause harm. Surely there’s something that can be done? 

OBrien et al on behalf of the Paediatric Research in Emergency Departments International Collaborative Network, 2018. Australasian Bronchiolitis Guideline. Journal of Paediatrics and Child Health

In 2018, the Australasian paediatric research network, PREDICT, published a systematic review of the literature on bronchiolitis and used it to produce the Australasian bronchiolitis guideline, currently the most up-to-date evidence-based guideline for managing infants with bronchiolitis. So, what did they find?

The evidence shows that there’s very little you can do in bronchiolitis other than supportive care.

Salbutamol, adrenaline and hypertonic saline nebulizers don’t work, steroids don’t work, antibiotics don’t work, and forget nasal suctioning… it doesn’t work. The only thing we can do is maintain oxygen saturations above 91%, support feeding and, as always, practice good hand hygiene. Oh well. We have a fab podcast guest featuring Fontanelle for all things bronchiolitis.

So, what happened to Finn? 

Finn’s sats were sitting at 89 to 90%, but with a little nasal cannula oxygen they picked up nicely to 93%. He couldn’t quite manage his bottles, so the nurses in ED popped in a nasogastric tube to support his feeding. Within 12 hours he was off oxygen and was settled enough for his first bottle. The very next morning he was looking grand so was discharged home, back to Galway.

Let’s jump ahead again to just after Finn’s third birthday. Finn loves watching his parents cast spells. He isn’t allowed to use his parents’ wands. But, like many inquisitive 3 year olds, he has a healthy disregard of rules and tries a little magic himself. Disaster strikes. There’s an explosion. It seems he’s inadvertently delivered an appendicitis mimic pain spell. Although soft and non-tender, his tummy is SO sore. Ron picks up the phone to dial 999 (which is now on speed dial). It’s not long before the paramedics arrive. There’s Ron wearily explains that the spell brings on a pain similar to appendicitis but without the need for surgery. The paramedics debate their options. The paracetamol and ibuprofen they’ve given Finn hasn’t taken the edge off. He’s too young for methoxyflurane or nitrous and although he looks like he needs an opiate, this isn’t trauma. Plus they’re worried about tipping him into respiratory depression. What should they do?

Murphy et al, 2014. A qualitative study of the barriers to prehospital management of acute pain in children. Emergency Medicine Journal

The literature shows us that adults are more than twice as likely to receive prehospital opiate analgesia for acute moderate to severe pain when compared with children who describe similar pain scores, with younger children often associated with the poorest acute pain management.

In 2014 a group of Irish PEM clinicians published this paper after interviewing 16 advanced paramedics from Dublin and Cork to find out what barriers they felt existed to achieving optimal prehospital paediatric pain control. Some themes became apparent:

The Clinical Practice Guideline at the time was limited when it came to paediatric pain. The only pain assessment tools included were the pain ladder or the Wong-Baker faces scale. And although Wong-Baker is great for the verbal child, it’s really not right for the younger tots. The analgesic choices to hand were also pretty limited; intranasal fentanyl wasn’t approved for prehospital use so the APs were given the option of paracetamol and ibuprofen, nitrous oxide (which children under 5 can’t manage because the coordination of inhaling through a mouthpiece is just too tricky) or IV opiates. Vascular access in a moving target is tricky at the best of times; but throw in a tiny vein, a screaming child and an emotional parent and it’s not all that practical.

The fear of administering morphine to small children was also apparent. Add to the mix limited exposure to children in the prehospital setting, short transfer times to the emergency department, and worry of slowing the respiratory rate and you can see why decent analgesia was difficult prehospitally.

Introducing the FLACC score and intranasal fentanyl to the CPG has worked wonders, especially for the kids with broken, bendy forearm fractures or obviously deformed lower limb fractures. But this hasn’t broken down the final barrier – the interviews highlighted medical causes of pain as being less likely to be treated aggressively. Which poses the question – Can opiate analgesia mask medical causes of pain?

The myth about withholding analgesia in patients with a suspected acute abdomen for fear of ‘masking clinical signs’ continues to be held by some clinicians. But it’s exactly that. A myth.

If a child has an organic cause of their abdominal pain, giving analgesia won’t hide the signs.

When their pain is controlled they’ll be so much easier for you to assess: an elevated heart rate in a well-analgised child will be a reflection of their illness rather than their distress and will allow you to treat to the best of your ability.

Feeling reassured, the paramedics score Finn’s pain. He’s squirming in pain, sobbing and impossible to console. He scores a 7 so they give him a dose of intranasal fentanyl. That doesn’t do the trick and 10 minutes later his FLACC score is still high so they give him another dose. And then because his pain continues to escalate they put in a line and give him a dose of IV ketamine. That works wonders and by the time they arrive at the hospital he is nicely settled. After some fluids and rest in ED, Finn is ready to go home. And the wands are locked out a certain curious pre-schooler’s reach.

Seven years later and Finn is now 10. Like most 10 year old wizards-to-be he REALLY loves flying on his broom. He was zooming around, swerved to avoid a pigeon and crashed straight into a tree. He’s pretty badly injured and an advanced paramedic crew is dispatched. By the time they arrive Finn looks awful. He’s maintaining his airway but his respiratory rate is up at 50 and his sats are in the 80s with bruising to the right side of his chest. His heart rate is 170 with a blood pressure of only 95 systolic. His GCS is 15. The paramedics get to work. Manual inline stabilisation in place, they know his chest is the issue. No breath sounds on the right and the chest is dull to percuss. Coupled with Finn’s haemodynamic instability, this looks like a massive haemothorax. They remember a paper called the Rule of 4s.

Teague et al, 2019. Rule of 4s: safe and effective pleural decompression and chest drain insertion in severely injured children. Emergency Medicine Australasia

This paper describes an aide-memoire for the time-poor clinician.

The authors give a fantastic step by step guide talking through each of the points above, including a photo of how to find the site of the safe triangle (bounded by the lateral edge of pectoralis major, the anterior border of latissimus dorsi and base of the axilla, and fifth intercostal space at the level of the nipple), how to make an incision and then push and spread through the intercostal muscles using mosquito or artery forceps, or a finger, depending on the age of the child.

Don’t worry about not having a chest drain. The priority prehospital is the thoracostomy.

Relieving a tension pneumothorax or massive haemothorax will save a child’s life.

But how often is a child likely to need a thoracostomy in the prehospital setting?

Quinn et al, 2020. Thoracostomy in children with severe trauma: an overview of the paediatric experience in Victoria, Australia. Emergency Medicine Australasia

This paper was published by the same team earlier this year. Looking back at 31 months’ experience of the Royal Children’s Hospital and Victorian Ambulance service up until February 2019, the paper describes the clinical stories behind children who’d had a thoracostomy for trauma prehospitally or in the ED.

During this time 8 children had prehospital thoracostomies performed by paramedics at the scene, half unilateral and half bilateral. All the children had had blunt trauma, most commonly motor vehicle accidents, closely followed by cars hitting children on their bikes or as pedestrians.

The two indications for thoracostomy were hypoxia and/or hypotension. Two children with hypoxia were also in traumatic cardiac arrest.

Needle thoracocentesis was performed in 10 children. All 10 required subsequent thoracostomy to relieve their haemo or pneumothorax. So put away those needles and grab the scalpels.

When the thoracostomies were performed, all 14 children had evidence of decompression of clinically significant haemothorax and/or pneumothorax. And really importantly, in all the cases, the indication for thoracostomy resolved or showed sustained and notable improvement post-thoracostomy. 

Prehospital thoracostomies in children sound pretty scary but I’d really recommend listening to Darren Hodge, a flight paramedic in Australia, as he describes his experiences of performing the first ever finger thoracostomy in a child in Melbourne.

 

The Advanced Paramedics who attend Finn use the Rule of 4s.

Site: They find the 4th intercostal space in the triangle of safety between the anterior and midaxillary lines and make a 3cm incision.

Push: They use artery forceps to push and dissect through the intercostal muscles and once into the pleural cavity they opened the forcep jaws to widen the hole.

Sweep: They make a big sweep with the forceps to clear a path for air and blood to exit.

Thoracostomy done, blood gushes out. Finn’s vitals improve significantly: his respiratory rate drops to 40, his sats improve to 96 and his BP picks up. They give him a bolus of fluid, package him up and get him to hospital. After some blood in the ED and a definitive chest drain he stabilises. He’s home a week later. The thoracostomy saved his life.

We’re time travelling one last time but thankfully this time, no injuries or illnesses come to pass. Finn, aged 15, is a model student, and although he’s inherited his father’s auburn locks and propensity for mischief, he has his mother’s brains. He’s a brave and kindhearted boy, and those qualities are incredibly important in a wizard. He writes an essay for about a paper he’s recently read.

Riskin et al, 2015. The impact of rudeness on medical team performance: a randomized trial. Pediatrics

Things go wrong in healthcare when clinicians are exposed to rude behaviour and this neat RCT illustrates it beautifully. 24 neonatal intensive care teams participated in a training simulation involving a very sick preterm infant with a surgical abdomen. The teams were told that a foreign expert on team reflexivity in medicine would observe them. The teams were then randomly assigned to either exposure to rudeness (in which the expert’s comments included mildly rude statements completely unrelated to the teams’ performance) or no rudeness (the expert just gave neutral comments).

When the videos of the simulations were watched back, and team scores were given for diagnosis and performance, they found that the teams who’d been exposed to rudeness had significantly lower scores than the other teams. It was clear that the teams just couldn’t perform as well when exposed to incivility. It is part of the evidence base on the amazing Civility Saves Lives website, which has loads of incredible resources for clinicians about the importance of civility.

Civility saves lives.

Finn wins first prize for his essay and graduates top of his class. Kindness remains his passion and he makes the hard decision to leave the beautiful island of Ireland. He flies to London where he works for the Ministry of Magic, deep underground in Whitehall.

 

    • To recap those prehospital PEM pearls:

      1. Reduce your cognitive load when it comes to any low-frequency but high-acuity events.
      2. Remember, wheeze in infants under a year is not the same as asthma.
      3. Don’t be afraid to give opiate analgesia to children, particularly in the non-trauma setting. It will never mask true pathology and will definitely help your clinical assessment.
      4. Having a robust system in place, like the Rule of 4s, will help when you’re faced with a highly emotive situation like life-threatening chest trauma.
      5. And finally, never forget, civility saves lives.