EMSC Connects

March 2023; Vol.12, Issue 3

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Pedi Points

Tia Dickson, RN, BSN

Primary Children's Hospital

Spring skiing and run off season approaches.

Everyone has heard the stories. “There was an avalanche, he was dead and they brought him back” or “CPR for 2 hours after falling in a cold river but the child survived.” The media loves stories like this. Hypothermic patients can have a better chance of survival than other injured patients, children in particular. A child’s body surface area causes them to cool down more rapidly and therefore enter the stage of profound hypothermia sooner than an adult. A child’s organs are also more resilient to cold stress than an adult. Even so, successful stories of survival are, in fact, rare. But the better we understand recognition and process for these resuscitations, the better their chances.

I had the privilege of being a team member for two successful hypothermia resuscitations. They truly are medical miracles. Identifying patients who may benefit from this protocol and transporting quickly to an ECMO capable facility is an important part of the process. It's YOUR part.

Expert Input

Hypothermia, how best to help cold little ones

Julia Smith MSN, CPNP PCH General Trauma & Surgical Services

Excerpts from February 13 PETOS

Hypothermia is defined as a core body temperature less than 35 degrees Celsius.

Hypothermia on scene should impact your decision-making

A core temperature <32 degrees Celsius should alter typical decisions to withhold or terminate treatment. At these temperatures, suspended metabolism may protect against hypoxia. You should continue to resuscitate all children with moderate or severe hypothermia unless clearly lethal injuries are present. In pulseless patients with severe hypothermia (core temperature <28 degrees Celsius), providers must avoid the premature declaration of death on scene.

Do you have what you need to take a core temp in the field?

A timely and accurate core temperature helps with decision-making down the line.

  • Rectal thermometer: insert at least an inch for an accurate core temperature
  • Bladder probe
  • Esophageal probe
It is also helpful if you can provide the temperature of cold water in water rescue situations.

Recognition of hypothermia

Based on the story and circumstances of an incident, early recognition of potential hypothermia is key. Good outcomes are in patients who become cold quickly without hypoxia first; preserving organ function.

Environmental exposure

  • Avalanche ski/snowmobile
  • Cold water drowning (<68F/20C)
  • Cold water submersion
Any time the child is too cold for the history given
  • Child abuse (example: ice dunking punishments)
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Per our Utah EMS Protocol Guidelines we should NOT re-warm patients with a core temp <30 degree Celsius. In most hypothermia cases, the patient will be re-warmed.

Prevent heat loss
  • Remove any wet clothing
  • Move to a warm environment (your ambulance)
  • Apply dry, insulating layers to prevent further heat loss—don't forget the head


Non-invasive: To use in mild hypothermia with circulation intact

  • Apply heat packs externally to neck, groin, armpits
  • Administer warm IV fluids
  • Heated oxygen
  • Bair hugger devices
Invasive: For severe hypothermia with no circulation
  • Peritoneal/gastric/bladder/colonic lavage
  • ECMO

Arrhythmias can develop during the re-warming procedure; recognize and treat per PALS guidelines.


It is extremely important to notify the receiving hospital as early as possible in hypothermia cases. The optimal choice is to take them directly to an ECMO center.
  • Patients < 15 years old to Primary Children's Hospital (Lehi campus will not have ECMO capabilities until further notice)
  • Patients > 15 years old to University of Utah or Intermountain Medical Center

Primary Children's Algorithm for Hypothermia

Primary Children’s Hospital uses an algorithm to help determine a treatment pathway for the profoundly hypothermic patient. It is based on the core body temperature. The decision to place a child on ECMO is made by the physician based on information you provide from the scene. They take into account the mechanism of injury, core body temp, and absence of the exclusion criteria.

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What is ECMO? EMCO stands for extra corporeal membrane oxygenation. Extra corporeal means outside the body. A membrane oxygenator is a machine which acts as a lung to deliver oxygen into the child's blood. The ECMO circuit acts as an artificial heart and lung for the child. It is a life-saving treatment which allows the infant or child to rest while healing and it can gradually warm the hypothermic patient. As the patient warms, the hope is that the hypothermia preserved brain and organ function.
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Case Studies

17 month old MVC into pond. Unknown down time. Initial temp 28.8 CPR started on scene.

  • Transported to IMC
  • Transferred to PCH
  • Placed on ECMO
  • Unknown downtime and no determination of whether she became hypoxic before becoming hypothermic. Ideally should have come straight to PCH.
  • No recovery

3 year old drowning in a bathtub at home. On scene it was noted she was very cold. Initial temp 28.5. CPR was started on scene.

  • Transported directly to PCH
  • Placed on ECMO
  • Found to have a cervical ligamentous injury
  • Determined to be a case of child abuse (cold water punishment for potty-training)
  • Successful recovery

2 year old missing for 15 minutes, found face down, and pulseless in a cold water creek. CPR started on scene.

  • Transported directly to PCH
  • Placed on ECMO
  • Successful recovery. Parent provided an interview and reported "he was thriving."

Skill Refresher—Introducing EMS to ECMO

Introducing EMS to ECMO | JEMS

Skill refresher—ECMO: Educational Animation

ECMO: Educational Animation HD

Protocols in practice—Temperature and Environmental Emergencies

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Ask our doc

Do you have a question for our EMSC medical director, Sarah Becker, MD, PCH, ER attending physician about this newsletter topic or anything related to pediatrics? Email tdickson@utah.gov.

News from Utah EMSC

EMS survey for children

The deadline for our 2023 EMS survey is nearing. This survey, which is sent to 14,672 EMS agencies, closes March 31. Utah has a legacy of getting a 100% response rate on these surveys and that's our goal for 2023. We need your help. These are agencies we are still waiting for . . .


If you work for one of these agencies, please reach out and help us reach our goal! This list is current as of 3/13/2023
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Click here to start the survey

Zero Fatalities

Utah EMSC is participating in the upcoming zero fatalities conference which has an exclusive EMS track. We have scholarships for attendance. Save the dates April 24-27, 2023 and contact our program manager jaredwright@utah.gov if you'd like to go on our dime.

PECC development

The Out-of-Hospital Births committee is looking for EMS representation

The Utah Women and Newborns Quality Collaborative Out-of-hospital Birth committee has a document which describes best practices around transfers from out-of-hospital birth venues to hospitals. Our current guide covers best practices for midwives, doulas, receiving hospitals, and hospital systems. We have long wanted to include EMS in the document, but we have never had a group of people from the EMS world who could contribute and let us know if the practices we might suggest would work for EMS. Meetings are once a month, usually on a Tuesday at 3 pm. We really value the EMS perspective and so often wish we had someone who could bring it to our work!

If interested email tdickson@utah.gov

Introducing PECARN

The Pediatric Emergency Care Applied Research Network (PECARN) works to do high quality, national research into the best management of acute illness and injury in children across the entire care system for pediatrics, including prehospital and emergency department care. Their research teams have done several big multi-centered studies to help us better care for pediatric patients, and we would like to share results of their work in our newsletters. Although they are doing more EMS work in the future, in the past, most of their work has focused on emergency department patients. However, we think some of their results can help everyone understand how to better evaluate and care for pediatric patients.

From PECARN For Hospitals

One recently published study looks at young neonates, younger than 2 months of age, who have a fever. We worry a lot about fever in these young babies because they have higher rates of infections caused by bacteria than older children. Their immune systems haven't yet developed nor are there vaccines to protect them against bacterial illnesses. They can get sick very quickly with sometimes fever being their only early sign of a bad illness such as meningitis or a urinary tract infection of bacteremia (bacteria in the blood stream).

Their study builds on data and best practices that we already have for these young babies. Here is the summary:

  1. If a baby < 2 months of age gets a fever of more than 38.0 of 100.4, they need to be evaluated by a doctor, likely in an emergency room.
  2. Certain tests, such as a urine analysis, should be done on all of these babies. A urinary infection (UTI) is the most common cause of a bacterial infection in these young babies and about 10% of febrile neonates will have a UTI.
  3. A blood culture, white blood cell count, and inflammatory markers such as procalcitonin or CRP should be done on all babies <2 months of age, even if they have a UTI.
  4. Babies < 1 month of age need a lumbar puncture to make sure they don’t have meningitis even if they have a UTI; babies 1-2 months of age may need a lumbar puncture if the other labs are really abnormal.
  5. Any baby who looks really sick should have all these tests done, including a lumbar puncture for meningitis.
  6. There are good clinical guidelines to follow for febrile babies produced by the American Academy of Pediatric if your hospital ED doesn’t have a care pathway (see link). Intermountain hospitals should have a care algorithm built in their electronic medical record. https://emscimprovement.center/news/pecarn-in-well-appearing-febrile-infants-biomarkers-are-better/

Bottom line: young babies with fever should be taken seriously and evaluated by a physician quickly. Follow good evidence-based guidelines for testing and treatment.

Study by Julia Magaña, MD and Nathan Kuppermann MD, MPH. Summarized by Hilary Hewes, MD

Read the article, watch a video with the authors, or follow @PECARNteam on Twitter for more author insights and the latest PECARN publications.

Virtual quarterly PECC meeting—save the date

Tuesday, May 16th, 10am-12pm

This is an online event.

You will receive an invitation with the link through email. If you are a PECC and don't receive this invitation contact our program manager, Jared Wright


Pediatric education from Utah EMSC

Pediatric education and trauma outreach series (Petos)

Monday, March 13th, 2-4pm

This is an online event.

Utah EMS for Children (EMSC), Primary Children's Hospital (PCH), and Utah Telehealth Network (UTN) offer the pediatric emergency and trauma outreach series (PETOS) to EMS providers.

This course provides one free CME from the Utah Department of Health and Human Services Office of Emergency Medical Services for EMTs and paramedics. The lectures are presented by physicians and pediatric experts from Primary Children’s Hospital. The format is informal; inviting questions and discussion.

Join us on Zoom each second Monday at 02:00 PM Mountain Time (US and Canada) Click the pic below!

Archived presentations can be viewed and also qualify for CME. Access at https://intermountainhealthcare.org/primary-childrens/classes-events/petos

To obtain a completion certificate

  • For "live" (virtual) participants: To receive a certificate of completion for attendance be sure to include your email address when the host requests it in the chat during the live presentation. Certificates are e-mailed out after verification of attendance and processing.
  • For archived viewing: After viewing archived presentations (link above) e-mail utah.petos@gmail.com with the date and title of presentation viewed. You will receive a three question quiz to verify participation. Once the quiz is returned, certificates are e-mailed out.

We try to have certificates out within a week but will occasionally have delays.

Looking for a PEPP class?

Pediatric education for the prehospital provider

Register online at www.peppsite.com. Look up classes in Utah and find the 1 that works for you. Once you find the class, go to jblearning.com, and look up pepp als in the search tool. Purchase the number ($21.95). Return to peppsite.org to register for the class and follow the prompts.

If you have any questions, please email Erik Andersen at erikandersen@utah.gov or text/call 435-597-7098. Continue to watch the website for additional classes.

Other pediatric education

University of Utah Winter Injury Prevention Learning Series

Tuesday, March 21st, 11:30am-1:30pm

This is an online event.

Register here

To view previous sessions for all these series visit this link

University of Utah Spring 2023 Pediatrics ECHO (multiple lectures per month (3/15, 3/22, 4/5, 4/12)

Wednesday, March 15th, 12pm

This is an online event.

For those new to pediatrics ECHO, you can earn CME for participating in a case-based learning session with experts in a variety of pediatric topics. Pediatrics ECHO offers a way to connect with other pediatric practitioners around Utah and beyond.

3/15/23 Primary Children’s Connector Service for Families

3/22/23 Autism 101: Surveillance and Screening

Register Here

EMS Focused Education

University of Utah's EMS Grand Rounds (Offered every 2nd Wednesday of even months)

Wednesday, April 12th, 2pm

This is an online event.

Click here to join

Virtual-Zoom Meeting Meeting

ID: 938 0162 7994 Passcode: 561313

Hospital Focused Education

Primary Children's Pediatric Grand Rounds (offered every Thursday, Sept-May)

Thursday, March 16th, 8am

This is an online event.

Offering both RN and MD CME

The Pediatric Grand Rounds weekly lecture series covers cutting-edge research and practical clinical applications, for hospital and community-based pediatricians, registered nurses, and other physicians and practitioners who care for children of any age.

The series is held every Thursday, 8 a.m. to 9 a.m. from September through May in the 3rd Floor Auditorium at Primary Children's Hospital. The lectures are also broadcast live to locations throughout Utah and nationwide.

Connect Live

Click here for the PGR PCH YouTube Channel to find the live broadcast. Archives (without continuing education credit) will be posted here within 1 week of the broadcast.

Save the date

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Emergency Medical Services for Children, Utah Office of EMS and Preparedness

The Emergency Medical Services for Children (EMSC) Program aims to ensure emergency medical care for the ill and injured child or adolescent is well integrated into an emergency medical service system. We work to ensure the system is backed by optimal resources and that the entire spectrum of emergency services (prevention, acute care, and rehabilitation) is provided to children and adolescents, regardless of where they live, attend school, or travel.