May 2021; Vol.10, Issue 5
First things first . . . happy EMS week May 16-22!
Tia Dickson, RN, BSN
Primary Children's Hospital
Spring and summer in the Beehive State means campouts, trips to the lake, and all around outdoor play. Two of the biggest risks for injury and fatality to children in these early summer months are burns and drowning. We have focused on these general topics in previous newsletters (burns and drowning) so in this issue we would like to dial down to a few specific issues that may arise. Summer brings an increase in gasoline and other chemical-related injuries while Utah's spring runoff claims the lives of children every year.
Burn injuries are among the most disfiguring and potentially serious bodily injuries. Childhood burns can cause long-term suffering and result in permanent physical and mental scars as well as lead to years of rehabilitation.
Childhood burns are known to result from accidental ignition of gasoline stored near a flame.
Dr. Christopher S. Kennedy and his associates at the Children's Mercy Hospital, together with the University of Missouri-Kansas City School of Medicine, reviewed cases seen in their emergency departments for burn injury risks associated with home storage of gasoline and outlined possible strategies to avoid related burn injury and death.
The study, published in the medical journal Pediatrics (1997;vol.99,p.e3), reported data about 25 childhood burn victims who were seen in Children's Mercy Hospital over a one year period.
The data showed 95% of the gas can burn victims were boys. The average age of the children was 2.7 years. The source of ignition of the gasoline was a pilot light in ALL cases (four gas dryers, 21 hot water heaters)!
Vapors were ignited in 56% of the cases and the gas can was described as closed in 64% of the incidents.
Eleven children died as a result of their burn injuries.
All 25 cases were associated with gasoline storage cans that were not structurally sound or child-proof.
The authors noted gasoline burn injuries account for nearly 15,000 emergency department visits annually in the United States. They recommend standardization of leak-proof (for both vapors and liquid) gas cans. Further, they recommend gasoline be stored in a shed or garage in a locked cabinet, and in a well-ventilated area. No pilot light or other flame source should be within 50 feet of the storage location.
Public awareness through the media and fire safety courses will also help decrease the risks of childhood burns caused by gasoline storage.
- Gasoline is clear colorless - amber volatile liquid. It is highly flammable as both liquid and vapor.
- Distant ignition and flashback are possible as it can accumulate a static charge.
- Gasoline can float on water and spread fire.
- In a CONFINED SPACE gas can accumulate in hazardous amounts especially in low-lying areas.
- Exposure may cause drowsiness and dizziness and may be fatal if swallowed and enters airways.
Inhalation: Take precautions to prevent a fire (e.g., remove sources of ignition). Take precautions to ensure your own safety before attempting rescue (e.g., wear appropriate protective equipment). Move victim to fresh air. Transport if the victim feels unwell.
Skin Contact: Quickly take off contaminated clothing, shoes, and leather goods (e.g., watchbands, belts). Quickly and gently blot or brush away excess chemical. Wash gently and thoroughly with lukewarm, gently flowing water and non-abrasive soap for five minutes. Call a poison center or a doctor if the victim feels unwell.
Eye Contact: Quickly and gently blot or brush chemical off the face. Immediately flush the contaminated eye(s) with lukewarm, gently flowing water for five minutes, while holding the eyelid(s) open.
Ingestion: Have victim rinse mouth with water.
Pre-hospital burn management
Remember that in a recent change to Utah's transfer agreements, children with a burn injury should be transported to Primary Children's Hospital for a trauma evaluation before going to a burn center.
- Prevent further tissue injury (stop the burning process)
- Manage the airway (intubate early)
- Manage pain
- Provide fluid resuscitation
- Determine and transport to the most appropriate destination
- Infection prevention (sterile techniques)
- Maintain body temperature
- Provide emotional and psychological support
- Evaluate for other injuries
Greg Nelsen, Pharm-D
One of the hardest treatment realities about burns is that they have a very high amount of pain. No matter how many pain meds are given, not all the pain will be taken away. The goal is to get the pain score to an acceptable level. Everyone will be tachycardic and hypertensive; this is a normal response to pain. Non-pharmacologic interventions will assist in controlling the pain such as distraction, gentle handling, and elevating extremities to near the level of the heart.
Occlusive ointments are also good to apply to burns. The application should be under the guidance from the burn center. The two most common ointments recommended by the burn specialists are silver sulfadiazine and bacitracin. Important pearls to remember are that silver sulfadiazine should not be used with anyone with a sulfa allergy and bacitracin should never be used on more than 30% of the BSA because limited data shows it is nephrotoxic.
Fluid management is also very important. Severe burn patients become very edematous and vascularly dehydrated. Proper fluid management becomes very critical. If the time from the burn is greater than 30 minutes, begins fluids using the Parkland Formula. Lactated Ringers is the preferred fluid. Call the Burn Center or medical control for guidance on the fluid management of the patient.
Antibiotics should not be given empirically for burns, even though many people find it tempting. Remember, burns are not dirty wounds! The exception is an old wound that is now infected. Skin and soft tissue care plans should be followed with cultures to narrow antibiotic coverage.
Know Your Resources - Youth Firesetter Prevention Program & Resources
If a child you care about has played with matches, lighters, fireworks, candles, set a fire, or shown a curiosity of fire that worries you, please contact your local fire department and ask if they participate in the Youth Firesetter Intervention Program. (Click here for Juvenile Firesetting Contacts). These contacts can change, so contact your local department and ask about their prevention efforts.
The Youth Firesetter Intervention Program provides a simple risk assessment to help understand their situation. It also provides fire safety education for the child and other family members. Everything is confidential and intended to help you keep your family safe from fire. This is not a punitive program; no information will be shared with law enforcement. The goal is to help families learn about the dangers of fire setting and provide assistance and support to families with fire setting concerns.
Until your appointment, you can make sure you have at least one smoke alarm on each level of the house and outside the sleeping areas. Test each one to make sure they are working. Look through the house and remove or secure all fire starting tools including matches, lighters, and barbecue lighters. The child can help you do these things to keep your family safe.
Most programs work with children 5–17 years of age. If a child is facing charges, the fire department may wait until the case is settled because attendance in an Intervention Program is often ordered as part of the deferment, parole, or sentencing.
Fire setting can be a symptom of another challenge a child is facing. If the child is at high risk of continuing their dangerous behavior with fire, you will likely be encouraged to seek the assistance of a mental health professional to address the underlying cause of their behavior. If your insurance does not cover the costs, your local health department can often find assistance.
For Fire Departments
The Office of State Fire Marshal provides basic training and resource materials to initiate a Firesetter Prevention Program or assist in the assessment and education of a child. Below are the materials you will need. Our office is also available to provide this training to your department in a four-hour block, at no charge. If you would like to set up this training for one or several people contact:
Public Education Specialist
Phone: 801-256-2370 or email@example.com
For reports on a state and national level, or to track the data of your department’s Youth Firesetting instances, visit: https://www.yfires.com/
The Doc Spot
Chantal Mendes, MD and Jonathan Eisenberg, MD
Cold Water Drowning
As the weather warms, the flowers bloom, and the snow melts, families are drawn to the outdoors to enjoy the rushing rivers and alpine lakes of Utah. With this rewarming and subsequent snow melt comes high, swift moving water that is very cold.
- Drowning is the leading cause of accidental injury death in children ages 1-4
- Drowning is one of the top three leading causes of accidental injury death in children of all ages >1 year
- Children younger than age 14 account for one out of every five drowning deaths
With the dangers of drowning and associated morbidity well known, it is important at this time of year to quickly review medical care involved in the drowning child. As a terminology note, the medical community is trying to do away with the “dry/wet” or “near” drowning terminology. As well, salt vs. fresh water distinctions have not been found to be of importance.
For the prehospital provider, there are straightforward care protocols and some interesting nuances and pearls to consider. Most importantly, submersion time (cold or warm water) is the most important prognostic factor. The longer the period of hypoxia generally can be extrapolated to worse outcomes. Airway and breathing in the pediatric drowning victim become especially paramount as they previously had normal cardiac function in most cases and have had a hypoxic event leading to bradycardic arrest.
While resuscitating the patient, keep in mind that C-spine immobilization should be a consideration. History and mechanism of injury should be used to determine the need for C-spine care but significant spinal injury is rare and unnecessary immobilization should not undermine respiratory support. The airway should be cleared in the case of obvious obstruction such as vomitus. Oxygen should be administered with FiO2 of 100%. If there is continued respiratory failure, intubation or non-invasive ventilatory support should be utilized—higher positive pressures may be needed due to pulmonary edema in prolonged down time. The underlying pathophysiology of drowning does lead to V/Q mismatch, decreased lung compliance, and intrapulmonary shunting—with subsequent hypoxemia and organ dysfunction. In the pulseless child, CPR should be initiated. Compression only CPR is not the standard of care in this patient given likely hypoxia induced cardiac arrest. The pulses should be palpated longer than normal (~1min) due to hypothermia and potentially significant sinus bradycardia.
ABC’s take precedence overall. If possible, obtaining a blood glucose or electrolyte panel is also important—both to correct low sugars and to report to the health care facility what the potassium is to determine the suitability for ECMO in a critically ill hypothermic patient (in conjunction with core temp). Large amounts of water need to be aspirated for electrolyte changes to take place (22ml/kg) but hypoxia and acidosis can cause shifts.
The data on children and therapeutic hypothermia is still indeterminate based on recent studies for both traumatic brain injury and neuro outcomes and cardiac arrest secondary to drowning. Unless directed by medical control, proceed with rewarming the patient. There is a slight difference between rapidly induced hypothermia—in that it may confer a degree of “cerebral sparing” by reducing metabolic demand before hypoxic damage sets in.
Take home points:
- ABC’s are most important
- Examine the environment for signs of injury, alcohol, or foul play
- Support the airway until definitive care with whatever means is available
- Correct glucose if low
- Rewarm the patient unless directed by medical control
Crompton EM, et al. Meta-Analysis of Therapeutic Hypothermia for Traumatic Brain Injury in Adult and Pediatric Patients. Crit Care Med. 2017 Apr;45(4):575-583. doi: 10.1097/CCM.0000000000002205. PMID: 27941370.
Moler FW, et al; Therapeutic Hypothermia After Pediatric Cardiac Arrest Out-of-Hospital Trial Investigators. Targeted Temperature Management After Pediatric Cardiac Arrest Due To Drowning: Outcomes and Complications. Pediatr Crit Care Med. 2016 Aug;17(8):712-20. doi: 10.1097/PCC.0000000000000763. PMID: 27362855; PMCID: PMC5123789.
Protocols in Practice - Drowning or Submersion
Pediatric Skills Refresher - Burn body surface area
News from Utah EMSC
Utah Chooses Handtevy for All EMS Agencies in the State
More Children’s Lives Will Be Saved as Utah Partners with Handtevy for All EMS Agencies in the State!
Utah Emergency Services for Childrens will be providing Handtevy Mobile to all Emergency Medical Services (EMS) agencies in the state.
"Handtevy Mobile gave us the fastest dosing solution with the best accuracy. We know seconds are precious and believe Handtevy gives our EMS agencies an edge in saving lives." Brett Cross, Bureau of EMS and Preparedness.
Want to access to yours? It has already been purchased for you! Contact your EMSC Program Manager Mark Herrera firstname.lastname@example.org
Agencies, Have you designated your PECC yet?
The Latest on Covid-19 and kids
As healthcare providers, please encourage your community members to be vaccinated. We are in a race between vaccination and variant proliferation.
The 2021 National Pediatric Readiness Project for hospitals launched May 1st
What is the National Pediatric Readiness Project (NPRP)?
The National Pediatric Readiness Project is a multi-phase quality improvement initiative to ensure all U.S. emergency departments have the essential guidelines and resources in place to provide effective emergency care to children.
What is the 2021 NPRP Assessment?
The NPRP Assessment is a national assessment of America’s EDs to determine progress in pediatric readiness, identify existing gaps, promote quality improvement (QI) efforts in hospital EDs around the country, develop national collaboratives to address common and critical gaps, and identify best practices.
Why is participation in the 2021 NPRP assessment important for ED managers?
The NPRP assessment helps ED personnel be better prepared to provide quality care for patients of all ages by evaluating the QI process of EDs over time.
- Hospitals with high ED readiness scores demonstrate a 4-fold lower rate of mortality for children with critical illness than those with lower readiness scores; thus, improving pediatric readiness improves outcomes for children and their families.
ED nurse managers, we need you!
Ask Our Doc
Have you met the PCH EMS Liaison?
You have the right close the loop on care you provided. For follow up on patients brought to Primary Children's Hospital contact the PCH EMS Liaison Lynsey Cooper at Lynsey.Cooper@imail.org
We are still looking for PECCs to represent every agency in Utah, care to join us?
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 one 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 ($18.95). Return to peppsite.org to register for the class and follow the prompts.
If you have any questions, please email Erik Andersen at email@example.com or text/call 435-597-7098. Continue to watch the website for additional classes.
Pediatric Education and Trauma Outreach Series (Petos)
Monday, May 10th, 2-4pm
This is an online event.
Utah EMS for Children (EMSC), Primary Children's Hospital (PCH) and Utah Telehealth Network (UTN) have partnered to offer the Pediatric Emergency and Trauma Outreach Series (PETOS) to EMS providers.
This course provides 1 free CME from the Utah Department of Health Bureau of EMS and Preparedness 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 2nd Monday at 02:00 PM Mountain Time (US and Canada)
Join Zoom Meeting
Meeting ID: 981 9375 7707
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 firstname.lastname@example.org with the date and title of presentation viewed, you will receive a three question quiz to verify participation and once the quiz is returned, certificates are e-mailed out.
We try to have certificates out within a week but will occasionally have delays.
University of Utah's EMS Grand Rounds (Offered every 2nd Wednesday of even months)
Wednesday, June 9th, 2pm
This is an online event.
Virtual-Zoom Meeting Meeting
ID: 938 0162 7994 Passcode: 561313
Emergency Medical Services for Children, Utah Bureau of EMS and Preparedness
The Emergency Medical Services for Children (EMSC) Program aims to ensure that emergency medical care for the ill and injured child or adolescent is well integrated into an emergency medical service system. We work to ensure that 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, no matter where they live, attend school, or travel.