Pre Hospital Paediatric Trauma care – how do we improve?

The introduction of regional trauma networks in 2012 shows that there has been a shift in thinking about how we deal with trauma in a pre-hospital setting. Of the trauma that we encounter such a small percentage involves paediatrics so our likely exposure to significant paediatric trauma is very small.

This does mean that responders may be inexperienced and this inevitably creates more anxiety. More anxiety means an impairment of clinical judgement and performance which creates more anxiety…..etc. etc. ad infinitum!

How many of us feel that added pressure when we attend to paediatrics? We might be theoretically well versed in what to do but the reality of getting that IV access, providing pain relief and doing emergency interventions, that are second nature when dealing with adult patients, may become extended efforts or worse still, unsuccessful.

Half the battle is recognising the sick child – as lack of recognition leads to decompenstation and then potentially an irretrievably sick child.  Going back to the limited paediatric training that we get, I’m sure we all remember that “children are not small adults” and physiological changes can occur rapidly with occult warning. Therefore, close and careful monitoring of the patient is essential and any changes should be interpreted in the context of the differing physiology of children.

So a good theoretical understanding and good assessment skills are required and then of course there is the need for repetition of practice…….which is where it comes unstuck, we just don’t get enough! The less we practice something the more the need for theoretical and practical training to try to overcome the huge lack of clinical exposure.

With such little exposure to paediatric trauma the experience that we acquire dealing with adults has to be translated to dealing with paeds. They both experience the same life-threatening injuries and although the injury pattern may well be different, the life-saving interventions are the same or sufficiently similar that it should instill a degree of confidence in the clinician.

In an ideal world we would be equipped with all the paediatric trauma equipment that we have for adults (the pelvic splints, the femur traction splints etc) . But this is not currently the reality and combined with the wrong, ill-fitting monitoring equipment makes identifying an ill child that much harder.

The 2011 recommendations from the NHS Clinical Advisory Group are that ambulances be equipped with paediatric monitoring and resuscitation equipment. They also advised that improvements need to be made in the skills and knowledge of the clinicians to treat the seriously injured child with triage criteria that are clear and simple. They go further and suggest that there is a need for a review of the delivery of analgesia to include the intranasal route and vascular access to include the use of up-to-date intraosseus devices, rather than the hand needle.

There seems to be quite a few hurdles in the pre-hospital management of trauma in paeds but given that we have little control over policy, equipment and geography what can we do to better prepare ourselves for these incidents? Most ambulance services currently rely on the individual to complete their own professional development which is a huge failing to their staff as regular update training and clinical placements would go a long way in reducing skill-fade and would certainly help with clinician confidence.

Hopefully the recommendations in the NHS Clinical Advisory Group’s report will be implemented soon as there is definitely scope for improvement in how we currently deal with children involved in trauma. What do you feel would help improve your practice?

For further info/reading:

http://www.ukpics.org.uk/documents/Management%20of%20Children%20wi~dvisory%20Group%20Report%201%20.pdf

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3500002/

http://www2.warwick.ac.uk/fac/med/research/hsri/emergencycare/prehospitalcare/jrcalcstakeholderwebsite/guidelines/trauma_emergencies_in_children_overview_2006.pdf

Pre Hospital Paediatric Trauma care – how do we improve?

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