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.
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.
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.
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 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
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:
- Reduce your cognitive load when it comes to any low-frequency but high-acuity events.
- Remember, wheeze in infants under a year is not the same as asthma.
- 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.
- 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.
- And finally, never forget, civility saves lives.