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Prehospital Care of the Pediatric Trauma Patient


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An evidence based review of prehospital care of the pediatric trauma patient. This lecture was given to EMS personnel at the Medical University of South Carolina on 12/3/14.

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Prehospital Care of the Pediatric Trauma Patient

  1. 1. Prehospital Management of Pediatric Trauma EMS Outreach Conference 12.4.14 Dan Park, MD MUSC Pediatric Emergency Medicine Chris Streck, MD & Tanya Green, BSN, RN MUSC Pediatric Surgery
  2. 2. 1 2 3 4 5 EMS for kids: Numbers & History OBJECTIVES Quick review of pediatric anatomic considerations Discuss evidence regarding cervical spine immobilization Review essentials of airway management in prehospital care of kids Review essentials of traumatic brain injury management
  3. 3. EMS: Some numbers 50% of kids who die in the US die from the effects of injuries 27% Pediatric patients make up of all ED visits from 1997-2000 13% Pediatric patients represent of all EMS transports of pediatric trauma patients arrive via EMS 54% Shah MN et al. Prehosp Emerg Care 2008
  4. 4. 13% of all EMS transports are kids The acuity of pediatric EMS patients if often higher than that of adults
  5. 5. PREHOSPITAL CARE FOR CHILDREN TIMELINE Military triage and transport developed during WWII and Korean War translated to civilian population EMS Systems Act of 1973 created nationwide development of regional EMS systems Research showing half of pediatric deaths from trauma might be preventable In response to deficiencies in pediatric prehospital care government created EMS-C authorizing the use of federal funds for EMS services for kids Pediatric emergency medicine becomes a recognized specialty by the American Board of Medical specialties Great advances in closing the gap between pediatric and adult prehospital care but the discrepancy still exists and there is more work to be done Ramenofsky ML et al. J Trauma 1984, Seidel JS et al Pediatrics 1984, Seidel JS. Circulation 1986, Seidel JS. Pediatrics 1986, Bankole S et al. Pediatr Crit Care Med 2011
  6. 6. PREHOSPITAL CARE OF KIDS IS SUBOPTIMAL COMPARED TO ADULTS 1 Retrospective study compared prehospital care of 99 adult and 103 pediatric head injury patients with GCS <15 Compared IV access, endotracheal intubation, and fluid resuscitation Significantly more pediatric patients had problems with intubation, 27 children (69%) vs. 11 adults (21%) IV access was successfully established in 86% of adults compared to 66% of children at the scene 2 3 4 EMS providers need more training and practice with these challenging skills in kids Bankole S et al. Pediatr Crit Care Med 2011
  7. 7. Essential Components of an Integrated Pediatric Trauma System Pediatric trauma system System design $ Education Standards of care Research and development Quality assurance Funding Prevention Ramenofsky ML. J Pediatr Surg 1989 Integrating needs of children into existing EMS infrastructure involves high-quality prehospital care that uses pre-established protocols Protocols must be applied by skilled EMTs with assistance of online medical control until ultimate transport to an appropriate facility capable of providing definitive care
  8. 8. EVIDENCE BASED MEDICINE IN PREHOSPITAL CARE IS LACKING IOM report in 2006 highlighted evidence-based practices for prehospital care of pediatric trauma have not been adequately addressed: - Delaying transport to initiate treatment on-scene, the use of advanced life support (ALS) or basic life support (BLS) resources - Identifying high-risk pediatric trauma Institute of Medicine of the National Academies. 2006 patients - Optimally managing the airway - Obtaining IV or IO access - Immobilization of the cervical spine - Optimal management of traumatic brain injury - Assessment and management of pain
  10. 10. Head of infant makes up a larger percentage of total body mass compared to an adult Neck muscles don’t support this relatively larger head as effectively Simply by virtue of size, there is more force per square inch of body surface than adults Underdeveloped abdominal muscles afford little protection to internal organs making them vulnerable to multi-organ injury
  11. 11. Children have increased metabolism and therefore higher O2 consumption compared to an adult Because of their larger body surface area to size ratio, children are vulnerable to hypothermia in the setting of injury Vital to avoid hypothermia when caring for children
  13. 13. CASE 1 2 month old male Patient reportedly had been eating and choked, then dropped Exam on scene: Unresponsive, flaccid, Poor color, no respiratory effort Weak brachial pulse, HR 60 Chest compressions initiated Total scene time 13 mins Patient taken to ambulance, intubated, IV access obtained, Epi x 1 and fluid with ROSC (HR 120s) prior to hospital arrival Patient remained unresponsive and apneic upon arrival
  14. 14. CASE 1 ED Exam No purposeful movements, obtunded Pupils non-reactive bilaterally Agonal breathing noted, intubated Abdominal distension, absent bowel sounds Bruising to bilateral shoulders and bilateral thighs Abnormal primitive reflexes, abnormal muscle tone ED Care ETT exchanged to a 3.5 tube (was 2.5) PIV placed, fluid boluses (20 ml/kg x 2) Cervical collar placed IV antibiotics Seizure prophylaxis Labs, CT/X-rays
  15. 15. CASE 1 CT of Head Depressed skull fracture Bilateral subdural hematomas, epidural hematoma Subarachnoid hemorrhage, possible epidural components CT cervical spine No evidence of acute cervical spine trauma CT chest, abdomen, pelvis Healing right seventh and either posterior rib fractures Extensive groundglass opacity throughout both lungs which may represent hemorrhage, aspiration pneumonitis, or edema. More focal areas of consolidation in the right upper lobe and both lower lobes posteriorly.
  16. 16. CASE 1 MRI of brain done 2 days after admission and demonstrated Findings consistent with hypoxic ischemic injury Bilateral subdural hematomas of various ages An epidural hematoma overlies the left temporal lobe Acute subarachnoid hemorrhage within the bilateral sulci at the vertex MRI of cervical spine demonstrated Edema in the interspinous space spanning from C3-4 to C6-7, suggestive of injury to the interspinous ligaments Subcutaneous edema overlying the nuchal ligament with no evidence of ligamentous discontinuity
  17. 17. CASE 1 During hospitalization, neurologic exam slightly improved, pupils sluggishly reacted to light, with spontaneous eye opening, no tracking or blinking to threat. G-tube placed for feeds. Neurologically devastated: Hypertonicity in all extremities (spastic quadraplegia), no purposeful movements noted. Several days following admission, the father of the baby admitted to shaking the infant and has since been incarcerated Patient discharged home with mother with outpatient home health services.
  19. 19. CERVICAL SPINE INJURY Injury to the cervical spine is uncommon in children. The occurrence is less than 1% of children that are evaluated for trauma. There is a greater frequency of high cervical spine injury in children as compared with adults. Due to having a relatively larger head compared with the neck, the angular momentum is greater and the fulcrum is higher in the cervical spine, therefore, more injuries occur at the level of the occiput to C3. Kim et al. 2013
  20. 20. CERVICAL SPINE INJURY Forces applied to the upper neck are relatively greater than in the adult especially when the child is exposed to sudden acceleration and deceleration. Injuring the spine in the pediatric patient takes significantly less force than the adult spine. Therefore, a high index is suspicion should be maintained for a spinal injury in children. Collopy, Kivlehan, & Snyder, 2012
  21. 21. NEXUS and CANADIAN C-SPINE RULE NEXUS LOW-RISK CRITERIA (NLC) AND CANADIAN C-SPINE RULE (CCR) HELP HOSPITAL PROVIDERS DETERMINED WHICH STABLE TRAUMA PATIENTS CAN HAVE THEIR COLLARS REMOVED AND WHO NEEDS FURTHER IMAGING 1 CCR MORE SENSITIVE AND SPECIFIC THAN NLC 2 CCR would have missed 1 patient and NLC would have missed 15 patients with important injuries N=8283, 169 (2%) had clinically important cervical-spine injuries MAY NOT BE GENERALIZABLE TO PEDIATRIC TRAUMA 3 PATIENTS This was an adult study (>16 yo). Only 10% of the patients in the original NEXUS study were kids And the rate of cervical spine injury was so low (~1%) that it would be hard to safely apply the rule to children in the prehospital setting . Stiell IG et al. NEJM 2003
  22. 22. Canadian C-spine rule Dangerous Mechanism Fall from >3 ft or 5 stairs Axial load to head (diving) MVC >60 mph Rollover/ejection Collision involving a motorized recreational vehicle Bicycle collision Simple rear-end MVC excludes being pushed into oncoming traffic, being hit by a bus or large truck, or being hit by a high speed vehicle
  23. 23. Response of cervical spine to applied axial load A: With neck in neutral alignment, the vertebral column is extended. Force can be dissipated by spinal musculature and ligaments B: Neck in flexed position, spine straightens out and lines up with the axial force C: At impact, the straightened cervical spine undergoes rapid deformation and buckles under compressive load
  24. 24. “Backboards will soon be looked at much like MAST pants. Get used to it. Backboards make great spatulas, but at some point, that burger needs to get on a bun”
  25. 25. PREHOSPITAL VALIDATION OF CANADIAN C-SPINE RULE Enrolled 1,949 trauma patients in 7 regions, GCS 15, alert and stable Interpret rule and then immobilize all Sensitivity 100%, specificity 37.7% Would have avoided 731(38%) immobilizations Study found that paramedics can apply the Canadian C-Spine Rule reliably, without missing any important cervical spine injuries The adoption of the Canadian C-Spine Rule by paramedics could significantly reduce the number of out-of-hospital cervical spine immobilizations Vaillancourt C et al. Ann Emerg Med 2009
  26. 26. THOUGHTS ON THE IMMOBILIZATION CONTROVERSY 1 MAKE A DECISION, TRANSPORT TO BEST OF YOUR ABIILITIES, & EXPLAIN WHY YOU DID OR DIDN’T IMMOBILIZE 2 CHILDREN ARE CHALLENGING What are considered distracting injuries? Are fear and anxiety distractions? Can a child verbalize paresthesias? 3 MANY MORE CHILDREN WILL BE IMMOBILIZED THAN WILL BENEFIT FROM IT Young children are difficult to clinically clear from immobilization in the PED No validated criteria for selective immobilization in children When in doubt, err of the side of immobilizing
  27. 27. SC DHEC EMS Spinal Immobilization Protocol
  28. 28. CASE 2 7 mo male presents to OSH via EMS s/p fall from bed onto glass No PMH available OSH Exam: Unresponsive, unconscious Laceration to right neck not actively bleeding Tachycardic (170 – 190) Decreased breath sounds noted on left Vital Signs HR 184, BP 86/35, RR 22 Bilateral IO’s placed, PIV placed, 50 ml NS bolus given and patient intubated. During intubation, right neck laceration began to bleed, direct pressure applied with gauze and cervical collar.
  29. 29. CASE 2 1049 - Transport team arrived Patient taken to CT scan – head and cervical spine scans Blood products during transport requested by physician, team prepared to transport while awaiting blood. 1126 - Unit left scene for transport. HR remained 140’s – 150’s and BP remained systolic 90’s to low 100’s during transport. Patient received 20 ml of PRBC’s during transport per order of sending physician. .
  30. 30. CASE 2 1159 – Patient arrived in ED. Exam: Intubated, right breath sounds clear, left absent + bleeding from right neck, right femoral pulse weak Pupils 2 mm, non-reactive bilaterally HR 157, BP 125/99 ED Care 100 ml PRBC’s NS bolus Left chest tube (100 ml blood returned)
  31. 31. CASE 2 Patient taken emergently to OR Exploration of right neck penetrating traumatic wound Median sternotomy for exposure of vascular injury Repair of left innominate vein and ligation of left internal mammary artery Flexible esophagogastroscopy Postoperatively Patient did well but had phrenic nerve injury and hemidiaphragm Patient discharged on HD 14
  33. 33. TRAUMA TRANSFER Patient outcome is directly related to the elapsed time between injury and when the patient receives the properly delivered definitive care. When the need to transfer is recognized, transfer should be expedited and not delayed for diagnostic procedures or tests that will not change the immediate plan of care. American College of Surgeons strongly encourages rapid transport to a trauma center and minimization of on-scene time for trauma patients, and there is evidence to support improved outcomes with shorter on-scene times Sampalis JS et al. J Trauma 1993; American College of Surgeons 2012
  34. 34. TRAUMA TRANSFER A clinical decision rule placed these criteria in the following order to identify high-risk injured children: Need for assistance with ventilation via endotracheal intubation or bag-valve-mask GCS < 11 Pulse ox < 95% SBP more than 96 mmHg HR and RR did not prove to be important predictors in the model High SBP associated with poor outcomes may be plausible with traumatic brain injury Newgard CD et al. Prehosp Emerg Care 2009
  35. 35. ALS vs. BLS IN PREHOSPITAL SETTING HAS BEEN DEBATED The OPALS Major Trauma Study (n=2867) showed that system-wide implementation of full advanced life-support (endotracheal intubation and IV fluids and drug administration) programs did not decrease mortality or morbidity (primary outcome was survival to hospital discharge) for major trauma patients. Stiell IG et al. CMAJ 2008
  36. 36. ALS vs. BLS IN PREHOSPITAL SETTING HAS BEEN DEBATED Staffing an ALS unit compared to a BLS unit is estimated to cost an extra $94,928 per year per unit Also procedures performed by ALS units take additional time, which may delay ultimate transport to definitive care Right now, the evidence shows that there is no difference in mortality between ALS and BLS trauma care when provided by EMTs but there are significant difference in cost with possible benefit in situations of prolonged transport times Ornato JP et al Ann Emerg Med 1990
  37. 37. PEDIATRIC SHOCK 1 Children can have up to a 30% reduction in circulated blood volume before you will see a decrease in their systolic blood pressure. 2 Pediatric patients have an increased physiologic reserve which allows for a normal systolic blood pressure even in the presence of shock. Other signs of blood loss in children include: Progressive weakening of peripheral pulses Narrowing of pulse pressure Mottling (which may show as clammy skin in infants and young children) Cool extremities compared with torso skin Decrease in LOC with a dulled response to pain 3 American College of Surgeons. 2012
  38. 38. PEDIATRIC SHOCK 4 5 Isotonic solution is the appropriate fluid for rapid repletion of circulating blood volume. The goal is to replace lost intravascular volume, therefore it could be necessary to infuse 3 boluses of 20 mL/kg Upon consideration of the third fluid bolus, the use of packed red blood cells should be considered, at 10 mL/kg If hemodynamic abnormalities following the first fluid bolus do not improve, this should raise the suspicion of continuing hemorrhage 6 American College of Surgeons. 2012
  39. 39. PEDIATRIC SHOCK 7 In severely hypovolemic patients it may be impossible to gain peripheral venous access and intraosseous access provides a suitable alternative. In critical situations if IV access is not successful in 3 attempts or 90 seconds, IO access should be considered. This route has been a well-validated and is a rapid route of access in both adults and children. LaRocco BG et al. Prehosp Emerg Care 2003, Sunde GA et al. Scan J Taruma Resusc Emerg Med 2010
  40. 40. DEFINITION OF PEDIATRIC HYPOTENSION BY AGE Badjatia N et al. Prehosp Emerg Care 2007
  41. 41. CASE 3 EMS arrived at scene at 1643 Total Scene Time: 13 minutes EMS found young male patient unresponsive with gunshot wound to the head Exam on scene: Unresponsive male receiving cervical spine maintenance and BVM ventilation GSW to right side of face near right eyelid, no exit wound Pupils fixed and dilated, blood noted from bilateral ears. Deformity to skull PIV placed Vital signs – HR 61, RR 20
  42. 42. CASE 3 EMS met by transport, care transferred Posturing noted, RSI Patient arrived to trauma bay at 1740 ED Exam GCS 6, pupils 5 mm, fixed and dilated, decorticate posturing noted Absent cough, gag and corneal reflexes Intubated ED Care Fluid bolus CT scan
  43. 43. CASE 3 Patient transferred to ICU, then taken to OR for emergent craniectomy Patient returned to ICU, ICP’s monitored, recorded between 30’s and 90’s HD 2 – sedation medications held HD 3 – brain death examinations began HD 4 – patient pronounced
  44. 44. Trauma Deaths 0 500 1000 1500 2000 2500 3000 3500 Motor Vehicle Related Firearm Auto-pedestrian Transport, other Fall Deaths Nance et al. 2014
  45. 45. FIREARMS MORTALITY Lorem Ipsum is simply dummy text of the printing and typesetting industry. Lorem Ipsum has been the industry's standard dummy text ever since. 10 9 8 7 6 5 4 3 2 1 0 Firearm Deaths/100,000 All Firearm Mortality (Ages 0-19 years) Nance et al. 2014
  47. 47. MINIMIZE SECONDARY INJURY BY MANAGING THE COMPRISED AIRWAY AND INTERVENING TO PREVENT HYPOTENSION Monitor BP with an appropriately sized cuff Give 20cc/kg boluses of isotonic fluids as needed to maintain normal BP for age 1 HYPOXEMIA and HYPOTENSION ARE VERY BAD in TBI Avoid hypoxemia by managing the airway by the most appropriate means (supplemental o2, BVM, ETI or other adjuncts) No evidence to support ETI or BVM in pediatric patients with TBI 2 CHILDREN WITH SUSPECTED TBI SHOULD HAVE CERVICAL SPINE IMMOBILIZED DUE TO RISK OF CONCURRENT INJURY 3 TRAUMATIC BRAIN INJURY SIGNS OF INCREASED ICP ARE REPRESENTED BY CUSHING’S TRIAD OF: HYPERTENSION, BRADYCARDIA, IRREGULAR BREATHING Maintain normal breathing rate. No evidence showing benefits of hyperventilation in children 4 Atabaki SM. Clin Pediatr Emerg Med 2006
  49. 49. AIRWAY MANAGEMENT FAILURE TO MANAGE THE AIRWAY PROPERLY IS THE LEADING CAUSE OF PREVENTABLE DEATH DUE TO TRAUMA 1 IN KIDS, THE CAUSE OF CARDIAC ARREST IS COMMONLY DUE TO HYPOXIA SECONDARY 2 TO RESPIRATORY ARREST For this reason, early and aggressive airway management is crucial IT’S A CHALLENGING SKILL WITH FEW TRAINING OPPORTUNITIES 3 Smaller size of the patient, airway, and equipment. In order to stay sharp you need practice and skill maintenance.
  50. 50. AIRWAY MANAGEMENT URGENT AIRWAY INTERVENTION NEEDED IN: Upper airway burns, severe facial or neck trauma, inability to protect airway (TBI, AMS), impending respiratory failure 4 PREHOSPITAL ETI OUTCOMES ARE MIXED 5 Some studies show increased mortality with RSI (Davis), some show decreased mortality (Domier). RISK OF INCREASED ON-SCENE TIME AND POTENTIAL COMPLICATIONS WITH ETI MUST BE WEIGHTED AGAINST THE BENEFIT OF RAPID TRANSPORT . 6
  51. 51. BVM vs. ETI PROSPECTIVE Lorem Ipsum TRIAL is simply dummy OF PEDIATRIC text of the printing and PATIENTS typesetting industry. IN AN Lorem URBAN Ipsum SETTING WHO 1 EITHER RECEIVED has BVM been the OR industry's E TI standard FOR dummy PREHOSPITAL text ever since. AIRWAY MANAGEMENT 830 patients aged 12 years or younger who required airway management in LA and Orange counties VERY INFREQUENTLY UTILIZED SKILL 2 ETI success was 57% in this study 12% of paramedics got experience in BVM per year; 1.6% of paramedics in ETI NO DIFFERENCE BETWEEN PREHOSPITAL BVM OR ETI FOR BOTH SURVIVAL 3 TO HOSPITAL DISCHARGE AND NEUROLOGICAL STATUS AT DISCHARGE This included subgroup analysis of various categories of trauma patients including submersion injury, head injury, and multiple trauma. The study DID NOT examine the potential effect of transport distance Gausche M et al. JAMA 2000
  52. 52. BVM Ventilation is a Crucial Skill to Learn and Master Mask size is important to mask seal Pull head into extension and open airway by pulling chin upward Seat the mask (apex) over the bridge of the nose first Then lower the mask over the chin
  53. 53. 3rd, 4th, 5th fingers are on mandible pulling it upward Move thumb into position at top of mask to maintain seal against bridge of nose Index finger falls naturally into place below the connection to ventilation bag Finger Positions Are Key: Thumb And Index Form A “C”, The Other Three Will Form An “E”
  54. 54. Pull Face Into the Mask Don’t think of this as pushing the mask onto the face (this can lead to head flexion and airway obstruction) Pull face into the mask (pulls head further into extension and opens the airway) Constantly reassess ventilation and adjust Look for chest movement, fogging of mask, & breath sounds
  55. 55. Positioning in Pediatric Intubation In all ages, if you follow these positioning principles, you will improve your view of the airway: 1. Align the ear to the sternal notch 2. Keep the face parallel to the ceiling (do NOT hyperextend the neck, as in the sniffing position) 3. In adults, the head usually needs to be raised while in infants (larger occiput), the torso usually needs to be raised to place the neck into normal anatomic position “Ear to Sternal Notch” has gained wide acceptance in the EM and anesthesia literature Levitan RM et al. Ann Emerg Med 2003
  56. 56. Straight Blade Can Be Useful in Young Children Due to anatomical differences many clinicians recommend use of a straight blade over a curved blade in small children, especially for children under one year of age as the straight blade allows for better control of the floppy and relatively large epiglottis.
  57. 57. TAKE HOME POINTS 1 2 3 4 5 Care of injured children is suboptimal to adults. EMS is an underfunded but crucial component in the care of injured children. More research is needed in all areas of prehospital care Kids are not little adults. They have distinct anatomical & physiological differences: Airway is more anterior and superior, larger body surface area to size ratio makes them vulnerable to hypothermia, larger occiput puts them at risk of airway obstruction When in doubt, immobilize. Spinal immobilization is controversial in certain situations in adults. But kids are a particularly challenging group. With a concerning mechanism and a young child err of the side of caution. Prevent hypoxemia and hypotension in traumatic brain injury. Immobilize these kids. Minimize on-scene time. No difference between out-of-hospital BVM or ETI in terms of survival. Crucial to get good at bagging. If ETI is needed, remember ear to sternal notch and miller blade in young kids
  58. 58. References American College of Surgeons. Advanced Trauma Life Support (9th ed.). Chicago. 2012 1 Bankole S et al. Pediatr Crit Care Med 2011 4 Atabaki SM. Prehospital Evaluation and Management of Traumatic Brain Injury in Children. Clin Pediatr Emerg Med 2006 2 Collopy KT, et al. (2012). Pediatric Spinal Cord Injuries. EMS World 2012; 41(8). 5 Badjatia N et al. Guidelines for prehospital management of traumatic brain injury, 2nd edition. Prehosp Emerg Care. 2008;12 Suppl 1:S1-S52 . 3 Haut ER et al. Spine immobilization in penetrating trauma: more harm than good? J Trauma 2010 Jan;68(1):115- 20 6 Gausche M et al. Effect of out-of-hospital pediatric endotracheal intubation on survival and neurological outcome: a controlled clinical trial. JAMA 2000 7 Hoffman JR et al. Validity of a set of clinical criteria to rule out injury to the cervical spine in patients with blunt trauma. National Emergency X-Radiography Utilization Study Group. N Engl J Med 2000 Jul 13;343(2):94-9. 8 Kim EG et al. Variability of prehospital spinal immobilization in children at risk for cervical spine injury. Pediatric Emergency Care, 2013; 29(4), 413-418 9 Nance, M. Baseball, Hot Dogs, Apple Pie and the Glock 9mm Semi-automatic Handgun: Growing Up in America. 2014 12 Levitan RM et al. Head-elevated laryngoscopy position: improving laryngeal exposure during laryngoscopy by increasing head elevation. Ann Emerg Med 2003 10 Newgard CD et al. The availability and use of out-of-hospital physiologic information to identify high-risk injured children in a multisite, population-based cohort. Prehosp Emerg Care 2009;13:420-31. 13 LaRocco BG et al. Intraosseous infusion Prehosp Emerg Care 2003, 11 Ornato JP et al. The need for ALS in urban and suburban EMS system. Ann Emerg Med 1990 14 Ramenofsky ML et al. Maximum survival in pediatric trauma: the ideal system. J Trauma 1984 Sep;24(9):818- 23 15 Sampalis JS et al. Impact of on-site care, prehospital time, and level of in-hospital care on survival in severely injured patients. J Trauma 1993 16 Seidel JS et al Emergency medical services and the pediatric patient: are the needs being met? Pediatrics 1984, 17 Shah MN et al. Prehospital management of pediatric trauma. Prehosp Emerg Care 2008; 11(1) 20 Seidel JS. A needs assessment of advanced life support and emergency medical services in the pediatric patient: state of the art. Circulation 1986, 18 Stiell IG et al. The OPALS major trauma study: impact of advanced life-support on survival and morbidity. CMAJ 2008 21 Seidel JS. Emergency medical services and the pediatric patient: are the needs being met? II. Training and equipping emergency medical services providers for pediatric emergencies. Pediatrics 1986, 19 Sunde GA et al. Emergency intraosseous access in a helicopter emergency medical service: a retrospective study. Scan J Taruma Resusc Emerg Med 2010 23 Vaillancourt C et al. The Out-of- Hospital Validation of the Canadian C-Spine Rule by Paramedics. Ann of Emerg Med Nov 2009;54(5):663-671 24 Stiell IG et al. The Canadian C-Spine Rule versus the NEXUS Low-Risk Criteria in Patients with Trauma. NEJM 2003; 349: 2510-2518 22