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.

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. 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. 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. 13% of all EMS
transports are
kids
The acuity of
pediatric EMS
patients if often
higher than that
of adults

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. 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. 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

9. 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. ANATOMIC CONCERNS

13. 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

16. 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

17. PREHOSPITAL CARE TIME
TRIAGE & TRANSPORT
AIRWAY MANAGEMENT
CERVICAL SPINE IMMOBILIZATION
TRAUMATIC BRAIN INJURY

18. 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

19. 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

20. 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.

23. 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

27. 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.

28. CERVICAL SPINE
INJURY

29. 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

30. 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

31. 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

33. 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

34. 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

40. “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”

41. 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

43. 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

44. SC DHEC EMS
Spinal Immobilization
Protocol

45. 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.

46. 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.
.

47. 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)

48. 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

49. TRAUMA
TRANSFER

50. 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

51. 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

52. 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

53. 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

54. 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

55. 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

56. 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

57. DEFINITION OF PEDIATRIC HYPOTENSION BY AGE
Badjatia N et al. Prehosp Emerg Care 2007

58. 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

59. 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

60. 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

64. Trauma Deaths
0 500 1000 1500 2000 2500 3000 3500
Motor Vehicle Related
Firearm
Auto-pedestrian
Transport, other
Fall
Deaths
Nance et al. 2014

65. FIREARMS MORTALITY
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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

66. TRAUMATIC
BRAIN INJURY

67. 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

68. AIRWAY
MANAGEMENT

69. 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.

70. 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

71. BVM vs. ETI
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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

72. 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

73. 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”

74. 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

75. 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

76. 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.

79. 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

80. 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