Access this article online

Symposium on Pediatric Trauma Website: www.ijciis.org

DOI: 10.4103/2229-5151.100887
Quick Response Code:

Pre-hospital care of pediatric patients

with trauma
Terrence Seid, Ramesh Ramaiah, Andreas Grabinsky

ABSTRACT Department of Anesthesiology and Pain

Medicine, University of Washington/
Prehospital pediatric care is an important component in the treatment of the injured Harborview Medical Center,
child, as the prehospital responders are the first medical providers performing life Seattle, WA, USA
saving and directed medical care. Traumatic injuries are the leading cause of morbidity Address for Correspondence:
and mortality in the pediatric patient population. Nevertheless, for most prehospital Dr. Andreas Grabinsky,
provider it is a rare event to treat pediatric trauma patients and there is a still existing Department of Anesthesiology and Pain
gap between the quality of care for pediatric patients compared to adults. To improve Medicine, University of Washington/
Harborview Medical Center, #359724,
pediatric prehospital trauma care more provider need to be trained in identifying the 325 Ninth Avenue, Seattle,
specific differences between adult and pediatric patients. WA 98104, USA.
E-mail: grabi@u.washington.edu
Key Words: Education, emergency medical service, pediatric, prehospital, training, trauma

INTRODUCTION in the prehospital setting like acute exacerbation of

Prehospital care is an important link in the chain of
survival in trauma patients and medical emergencies.
There are many emergency medical service (EMS)
systems that established a survival benefit for patients
by early interventions performed by prehospital
providers. But almost all of these studies were
performed on the adult population. There is a paucity
of data about pediatric prehospital care outcomes.
This is primarily a result of the higher percentage of
adult emergencies and thus the higher number of adult
patients for whom the EMS providers are involved in
the early care. Another problem may lay in the fact
that pediatric emergency training is only a small part
of the training curriculum for prehospital providers,
and so prehospital pediatric care may not be performed
at the same high level as adult prehospital care. This
article focuses on the epidemiology of prehospital
pediatric injuries, the special considerations that apply
to pediatric patients, and the training and limitations
of the EMS provider. Caring for the injured child
requires a different skill set from those required for
adult providers, including attention to the unique
characteristics and needs of children. We will address
primarily pediatric trauma, as it is the major cause
of pediatric morbidity and mortality, but much of
the information, especially the described differences
from adults and the training of EMS providers, is also
applicable to other pediatric diseases encountered
asthma, and sepsis.
EPIDEMIOLOGY
Trauma is the most common cause of mortality and
morbidity for children in the US. Since most traumatic
injuries occur at a certain distance from dedicated
trauma or pediatric trauma center, most pediatric as
well as adult patients immediately after their trauma
rely on prehospital providers and regional EMS systems.
These EMS systems therefore play a pre-eminent role in
stabilization and transportation to centers with definitive
care facility for trauma patients.
In a secondary analysis of the Emergency Department
(ED) component of the 1997-2000 National Hospital
Ambulatory Medical Care Survey Shah, et al.[1] found
there were 110.9 million ED visits by children aged
<19 years between 1997 and 2000. Pediatric patients
constituted 27% of all ED visits from 1997-2000, and
7.9 million (7%) of these patients arrived via EMS.
Pediatric patients represented 13% of all EMS transports.
In their study, 62% of pediatric patients arriving at the
ED by EMS were transported as a result of injury or
poisoning. Compared with children arriving by other
means, children arriving by EMS more frequently
required care within 15 minutes after arrival (17% vs
40%), suggesting a higher acuity. Furthermore, EMS-
transported patients had an elevated acute illness level

114 International Journal of Critical Illness and Injury Science | Vol. 2 | Issue 3 | Sep-Dec 2012
 Seid, et al.: Pre-hospital care of pediatric patients

demonstrated by a greater admission rate to non-ICU
(3.9% vs 14%) and ICU (0.12% vs 1.8%). These findings
reflect a significant number of pediatric trauma patients
and the higher acuity and urgency of pediatric patients
transported by EMS provider.
Information from the National Center for Health
Statistics at the Center for Disease Control (CDC) list
the top 10 causes of death by age group, and highlights
traumatic injury as a major source of mortality in pediatric
population. After the age of one year, unintentional injury
or trauma becomes the leading cause of death [Table 1].
2011, over a thousand children (age 0 to 19 years) die
from traffic related accidents [Table 2]. Firearm injuries
are the 5th leading cause of injury and show the highest
case fatality rate of all injury mechanisms, accounting for
805 fatalities in 2011. While firearm injuries are rare in
smaller children, there is a dramatic increase in teenage
children.[3]
As demonstrated by the chart, most trauma is unintentional
and likely to affect multiple organ systems (Fall, MVC)
[Table 3].

While falls are the highest number of incidents causing
pediatric trauma morbidity, it is closely followed my
motor vehicle accidents, which account for the highest
number of fatalities in pediatric patients. [2] Data from
the American College of Surgeons demonstrates that in
PEDIATRIC EMS SYSTEMS AND
PERFORMANCE
Emergency Medical Services have regional variety in
structure and providers. Modern EMS as it is practiced in

Table 1: Top 10 causes of death for pediatric patients by age group[2]

Top 10 Causes of Death by Age Group, United States-2008, number of deaths in parentheses
Rank Age group
<1 1 to 4 5 to 9 10. to 14
1 Congenital Anomalies (5,638) Unintenional Injury (1,469) Unintentional Injury (835) Unintenional Injury (1,024)
2 Short Gestation (4,754) Congenital anomalies (521) Malignancy (457) Malignancy (433)
3 SIDS (2,353) Homicide (421) Congenital Anomalies (170) Suicide (215)
4 Maternal Pregnancy Comp. Malignancy (394) Homicide (113) Homicide (207)
(1,765)
5 Unintentional Injury (1,315) Heart Disease (189) Heart Disease (97) Congenital Anomalies (161)
6 Placenta Cord Membranes Influenza and Pneumonia Benign Neoplasms (59) Heart Disease (132)
(1,080) (142)
7 Bacterial Sepsis (700) Septicemia (93) Chronic Low Respiratory Chronic Low Respiratory
Disease (55) Disease (64)
8 Respiratory Distress (630) Cerebrovascular (63) Cerebrovascular (41) Cerebrovascular (56)
9 Circulatory System Disease Chronic Low Respiratory Influenza and Pneumonia (40) Influenza and Pneumonia
(594) Disease (54) (49)
10 Neonatal Hemorrhage (556) Perinatal period (51) Septicemia (25) Septicemia (36)

Table 2: Incidence and case fatality rate[3]

Incidents and case fatality rate by mechanism of injury, patients <19 years old
Mechanism # of incidents Percent Fatalities Case fatality rate
Fall 46,312 31.51 100 0.22
Motor Vehicle Traffic 37,321 25.40 1,176 3.15
Struck by, against 15,945 10.85 68 0.43
Transport, other 10,853 7.39 129 1.19
Firearm 6,907 4.70 805 11.65
Cut/pierce 5,550 3.78 68 1.23
Pedal cyclist, other 5,250 3.57 11 0.21
Other specified and classifiable 4,873 3.32 249 5.11
Hot object/substance 4,229 2.88 5 0.12
Natural/environmental, Bites and stings 2,057 1.40 7 0.34
Unspecified 1,607 1.09 31 1.93
Fire/flame 1,578 1.07 28 1.77
Other specified, not elsewhere 870 0.59 5 0.57
classifiable
Pedestrian, other 765 0.52 21 2.75
Overexertion 682 0.46 0 0
Natural/environmental, Other 662 0.45 4 0.6
Machinery 558 0.38 4 0.72
Suffocation 156 0.33 42 8.61
Drowning/submersion 140 0.11 24 15.38
Poisoning 99 0.10 1 0.71
NK/NR 488 0.07 11 11.11
Total 146,953 99.97 2,790  

International Journal of Critical Illness and Injury Science | Vol. 2 | Issue 3 | Sep-Dec 2012 115
 Seid, et al.: Pre-hospital care of pediatric patients

Table 3: Selected Mechanism of injury[3]

Selected mechanism of injury by age, 2011
Age Fall MVT Stuck by/against Transport other Firearm Cut/Pierce
<1 year 5,093 451 382 37 33 46
1 3,221 674 426 59 23 113
2 3,547 872 608 121 33 132
3 3,066 899 524 172 49 142
4 2,901 904 439 214 33 118
5 2,946 897 403 268 28 108
6 2,971 907 415 321 28 105
7 2,419 830 409 329 41 92
8 1,989 917 413 350 35 94
9 1,684 933 443 423 41 100
10 1,716 991 543 476 51 101
11 1,681 987 618 593 51 109
12 1,758 1,119 843 703 99 124
13 1,896 1,219 1,054 798 139 163
14 1,901 1,721 1,287 1,026 274 234
15 1,688 2,247 1,481 1,006 513 389
16 1,527 3,801 1,510 1,035 884 514
Total 42,004 20,369 11,798 7,931 2,355 2,684

the US today started in the 1950s and 1960s as advances
in military triage and transport developed during World
War II and the Korean War were later translated to the
civilian population. The EMS Systems Act of 1973 created
a grant program leading to the nationwide development
of regional EMS systems and was the stimulus for rapid
growth in prehospital care. Adult trauma care was the
primary focus and specialized pediatric emergency care
was a rarity at that time. In the early 1980’s, research by
Seidel, et al. and Ramenofsky, et al. demonstrated up to half
of pediatric deaths from trauma might be preventable, and
that children’s outcomes, compared to adults with similar
severity of injury tended to be worse.[4-6]
For example, a study of 88 general acute care hospitals
in Los Angeles County found nearly twice as many
deaths among children with serious traumatic injuries
compared to adults with similar injuries.[5] These studies
also revealed that prehospital personnel generally had
little training in pediatric care. And, the availability of age
appropriate equipment to manage children was lacking.[7]
In response to these noted deficiencies, the federal
government developed the Emergency Medical Services
- Children (EMS-C) program, a grant program for
states that focused on correcting pediatric deficiencies
within EMS systems, that is still in place today. In
the 1990’s pediatric emergency medicine became a
recognized specialty by the American Board of Medical
specialties, due to collaboration between the American
Board of Emergency Medicine and the American Board
of Pediatrics. And in 1993, the Institute of Medicine
published a report entitled Emergency Medical Services
for Children that set targets for research, training, and
standardization of prehospital and emergency care for
children. Since then, there have been great advances in
closing the gap between pediatric and adult care, but the
discrepancy still exists and research offer myriad reasons
why the difference persists.
A retrospective study published in 2011 by Bankole,
et al. compared the prehospital care of 99 adult and 103
pediatric head injury patients with GCS <15 on scene.
The metrics of comparison were intravenous access,
endotracheal intubation and fluid resuscitation. Their
results showed: A total of 91 patients, 52 adults (52.5%)
and 39 children (38.2%), needed endotracheal intubation
at the scene. Significantly more pediatric patients had
problems with intubation, 27 children (69.2%) vs.
11 adults (21.2%), P < 0.001. Intravenous access was
successfully established in 85.9% of adults compared to
65.7% in children at the scene (P <0.001). On arrival at
the trauma center, more children required intravenous
access, 80.4% compared with 63.6% for adults (P < 0.011).
More children (25.5%) required initial or additional
fluid bolus at the trauma center compared with adults
(9.1%, P < 0.003). The authors concluded that, based on
these metrics, prehospital pediatric care is suboptimal
compared to adults in controlling the essentials of trauma,
airway, breathing and circulation. In their discussion the
authors suggest that EMS providers receive insufficient
training and practice with these challenging skills and
that this may account for the discrepancy.[8]
In some European countries pediatric EMS includes EMS
units and ambulances with special pediatric equipment.
In addition these units are often staffed with personnel
who received specific training in pediatric care and in
some cases they are transporting a pediatric physician
to the scene of an pediatric emergency or during inter-
hospital transports.
PEDIATRIC AIRWAY
Like in adult patients, airway control is a priority in
pediatric resuscitation and often required in pediatric

116 International Journal of Critical Illness and Injury Science | Vol. 2 | Issue 3 | Sep-Dec 2012
 Seid, et al.: Pre-hospital care of pediatric patients
trauma care. Unlike adults in whom cardiac problems are
the leading cause of cardiac arrest, the cause of childhood
cardiac arrest is commonly due to hypoxia secondary to
respiratory arrest.[9] For this reason early and aggressive
airway management is recommended. Due to the lack
of training opportunities, most prehospital providers
have only limited experience in managing the pediatric
airway.
The pediatric airway is anatomically different from an
adult’s. The large size of the infant’s tongue relative
to the oropharynx increases the likelihood of airway
obstruction and difficulties during laryngoscopy; the
larynx is anterior and more cephalic in the neck, the
epiglottis is shorter, omega shaped and angled over
the laryngeal inlet, so control with the laryngoscope
blade is more difficult; the vocal cords are angled, so a
“blindly” passed endotracheal tube may easily lodge
in the anterior commissure rather than slide into the
trachea; and the infant larynx is funnel shaped, the
narrowest portion occurring at the cricoid cartilage.
Further, children have a shorter neck and a larger head, so
ideally positioning a child for laryngoscopy (the sniffing
position) is challenging, especially when child is in full
spine precautions with a rigid cervical stabilization collar.
The large occiput tends to force the neck into flexion while
lying flat and the airway tends to buckle and obstruct.
For this reason, a towel or blanket may be put between
the shoulders to bring the child into a more anatomically
neutral position.
PEDIATRIC ANATOMY RELATED TO TRAUMA
The head of an infant constitutes a higher percentage
of total body mass compared to the adult and the neck
muscles do not support this relatively larger head as
effectively. Children have more flexible interspinous
ligaments and joint capsules, their vertebral bodies are
wedged anteriorly and tend to slide forward with flexion,
and their facet joints are flat. This predisposes them to
injuries of both the bones and soft tissues of the cervical
spine. Also, the skull of the infant is soft and the closure
of fontanelles and sutures is not completed until age 3.
The child’s body makes it susceptible to different injury
patterns than adults. Simply by virtue of their size,
there is more force per square inch of body surface than
adults. In children, the abdomen begins at the level of the
nipple and both the supple rib cage and underdeveloped
abdominal muscles afford little protection to internal
organs. This makes children vulnerable to injury, and as a
result multi-organ injury is more frequent. Since a child’s
bones are more flexible than adult’s, it is possible for a
child to have serious internal injuries without fracture.
International Journal of Critical Illness and Injury Science | Vol. 2 | Issue 3 | Sep-Dec 2012
PEDIATRIC METABOLISM
The pediatric metabolism shows certain differences to
adults and this needs to be accounted for when caring
for pediatric trauma patients, Healthy children have
already increased metabolism and therefore higher O2
consumption compared to adults. Because of the larger
body surface area to size ratio, hypothermia is a common
occurrence in injured children. It is very important to
avoid hypothermia as early as possible. Hypothermia
induces shivering and catecholamine release, causing and
even higher oxygen consumption that can result in lactic
acidosis. The hypothermia and resulting acidosis does
affect the coagulation system and can cause or exacerbate
coagulopathy resulting in further bleeding and can
lead into a vicious cycle of hypothermia, coagulopathy,
increased bleeding. Rapid (cold) fluid administration
can lead to further hypothermia. It is therefore crucial
to pay close attention to maintaining euthermia in the
prehospital setting.
PEDIATRIC CARDIOVASCULAR SYSTEM
In children, hypotension is defined as systolic blood
pressure below the fifth percentile for age or by clinical
signs of shock. These ranges can be difficult to remember,
especially if used infrequently. However, several standard
principals apply: (1) no child’s respiratory rate should be
>60 breaths/min for a sustained period; (2) normal heart
rate is roughly 2-3 times normal respiratory rate for age;
and (3) a simple guide for pediatric blood pressure (BP)
is that the lower limit of systolic BP should be <60 mm Hg
for neonates; <70 mm Hg for 1 month–1year olds; <70 mm
Hg + (2 ⋅ age) for 1-10 year olds; and <90 mm Hg for any
child older than 10 years [Table 4].[9]
It must be emphasized that, in children, blood pressure
is often maintained until late in shock because of their
vigorous sympathetic and vasoconstrictive response. So
appropriate fluid resuscitation must start early. Because
of their small blood volume, children can lose a small
amount of blood but a large percentage of their volume.
A rough estimate of blood volume can be made based
on the child’s weight. Blood volume is approximately
100 to 120 mL/kg for a preterm infant, 90 mL/kg for a
full-term infant, 80 mL/kg for a child 3 to 12 months old,
and 70 mL/ kg for a child older than 1 year (#5). The lower
limit of systolic blood pressure (5th percentile) for age
may be estimated by the formula: 70 mm Hg + (2× age in
years). Median (50th percentile) systolic blood pressure for
children older than 1 yr may be estimated by the formula:
90 + (2× age in years).[10] The initial fluid bolus should
be 20 mL/kg of isotonic crystalloid and the Pediatric
Advanced Life Support guidelines recommend up to
60 mL/kg for initial resuscitation. Clinical circumstances,
117
 Seid, et al.: Pre-hospital care of pediatric patients
Table 4: Normal vital signs according to age[8]
Normal vital signs according to age
Age Heart rate (bpm)
Premature 120-170
0-3 mo 100-150
3-6 mo 90-120
6-12 mo 80-120
1-3 yr 70-110
3-6 yr 65-110
6-12 yr 60-95
12+yr 55-85
such as the mechanism of injury or burn and vital signs
will dictate this. Because of the pediatric patients risk for
hypothermia, all intravenous fluid should be warmed.
While isotonic crystalloid solution offers a temporary
measure to maintain blood pressure, the administration
or large amounts crystalloids can cause further problems
in trauma patients by worsening bleeding, hypothermia
and coagulopathy. For this reason the crystalloids in the
prehospital trauma care should be used carefully. There
is a paucity of data about the optimal amount of fluid
resuscitation and optimal blood pressure in pediatric
trauma patients. Studies with adult trauma victims and
especially with the younger military trauma patients have
shown benefits of utilizing permissive hypotension and
restricted crystalloid fluid resuscitation.[11,12] While these
results cannot be entirely translated into the pediatric
trauma care, pediatric patients can tolerate lower blood
pressure than adult patients. With a lack of evidence of the
benefit of permissive hypotension in pediatric patients,
the current standard of care is primarily maintaining
tissue perfusion with crystalloid boluses until definitive
control of hemorrhage is available. [13] Interestingly, a
retrospective study by Vella, et al. examined 154 pediatric
trauma patients that presented to a level 1 trauma center
over one year and found that 70% of patients did not
receive a fluid because it was deemed not necessary by
the attending ER physician or trauma surgeon. Twenty
percent received one bolus of 20 ml/kg, 7% received
two boluses and 3% received three or more. The injury
severity score (ISS) was correlated to the amount of fluid
a child received. As the ISS is a number generated post-
hoc, the ISS cannot help guide fluid resuscitation during
the event, and the authors could not identify any other
variables to help guide resuscitation, however the study
is limited by its retrospective design. Also, 48% of the
patients did not have a second IV, as recommended by
current ATLS guidelines. No reasons for the single IV
are assessed, but the authors do call into question the
practice of a mandatory second IV because so few patients
received much volume resuscitation at all.[14]
In 2005, Boluyt, et al. conducted a meta-analysis to
develop a clinical practice guideline for all hypovolemic
pediatric patients, including septic, trauma, burn,
and other sources of hypovolemia like diarrhea. They
identified 12 studies addressing pediatric patients and
118 International Journal of Critical Illness and Injury Science | Vol. 2 | Issue 3 | Sep-Dec 2012
Blood pressure (mm Hg) Respiratory rate (breaths/min)
55-75/35-45 40-70
65-85/45-55 35-55
70-90/50-65 30-45
80-100/55-65 25-40
90-105/55-70 20-30
95-110/60-75 20-25
100-120/60-75 14-22
110-135/65-85 12-18
because of the paucity of evidence, they also included
studies from the adult population and this accounts for
the Grade A recommendation for the first conclusion.
Their recommendations were: 1. In neonates and
children with hypovolemia the first-choice fluid for initial
resuscitation is isotonic saline (Grade A): 2. When large
amounts of fluids are required (e.g. sepsis), it is possible
to use a synthetic colloid because of its longer duration
in the circulation (Grade C): 3. The initial fluid volume
should be 10-20 ml/kg and repeated doses should be
based on individual clinical response (Grade C).[15] Their
effort should be applauded as there is little research
available to guide fluid resuscitation in children.
PREHOSPITAL PEDIATRIC PROCEDURES
Pediatric patients require the same kind of invasive
procedures as adult patients, but due to the different
size and anatomy, many of these procedures are more
difficult to perform, and the lack of specific pediatric
training makes these procedure even more challenging.
Indications for peripheral IV access are identical to the
adult patient, but children require smaller intravenous
catheters and the procedure itself is more difficult
because of uncooperative pediatric patients the small
size of veins, especially in smaller children. In severely
hypovolemic patients it may be impossible to gain
peripheral venous access and intraosseous (IO) access
provides a suitable alternative. In critical situations, if IV
access is not successful in three attempts or 90 seconds, IO
access should be considered. The majority of prehospital
providers are not sufficiently trained to perform central
venous access, which leaves only the intraosseous access
as the only alternative to peripheral IV access. This route
has been a well-validated and is a rapid route of access
used by multi-disciplinary providers in both adult and
pediatric trauma patients in different settings.[16,17]
Airway management in pediatric patients is, in some
aspects, more challenging compared to adult airway
procedures. The biggest challenge is again the smaller
size of the patient, requiring smaller equipment and
different and more precise techniques. In addition there
are specific difference between the pediatric and adult
airway, which were described earlier. These anatomical
 Seid, et al.: Pre-hospital care of pediatric patients
differences result in some differences that already
start with the patient preparation for advanced airway
management. In the adult patient the sniffing position,
by elevating the head and preforming neck extension, has
been established as the best position to visualize the vocal
cords. For the infant patient with large occiput, padding
is often put underneath the infant’s shoulders to place
the neck into normal anatomic position as shown above.
The older the pediatric patient, the airway procedures
become similar to adult airway procedures. This may
be the main reason that airway procedures become less
likely to be successful by prehospital provider in the
younger pediatric patient.
Due to the anatomical differences many clinicians
recommend the 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 large epiglottis. Unfortunately
many prehospital providers are more comfortable using
a curved blade, since the curved blade is more commonly
used in adult patients and are therefore not familiar with
the specific advantages and disadvantages of straight
blades. Glidescopes are used in difficult airway and some
centers as a first choice to intubate in adults, however
the use in pediatrics is limited despite their availability.
If oral intubation is not possible, the preferred
surgical airway is needle cricothyrodotomy. Surgical
cricothyroidotomy is rarely indicated in infants or small
children and carries a likelihood of damaging the cricoid
cartilage causing secondary subglottic stenosis.
Classic teaching mandated a cuffless ETT because the
funnel shaped larynx provided a natural cuff. However,
new prospective and cadaveric studies have challenged this
teaching and use of cuffed tubes in children is becoming
more common.[18] One can estimate the necessary size of
the endotracheal tube by the child’s fifth digit or by the
formula (age + 16)/4. The ETT should be passed under
direct vision just through the cords, or to a depth of three
times the ETT size (i.e. a 4.0 tube should be advanced
about 12 cm) and inflated with just enough air to provide
an adequate seal for ventilation without leak. The cuffed
ETT should be one-half size smaller than the uncuffed.
TRAINING AND EDUCATION
As shown in most of the studies presented in this article,
pediatric emergencies often represent only 10% or less the
calls to which EMS providers respond, which explains the
often unfamiliarity of medical providers with pediatric
patients. A study from Germany showed a pediatric
emergency rate of 3.5% and concluded from these patients
are often not treated adequately and recommended
intensified education about this patient group.[19]
International Journal of Critical Illness and Injury Science | Vol. 2 | Issue 3 | Sep-Dec 2012
Furthermore even this small percentage of EMS runs
does not represent a homogenous group, but range from
newborn to teenage children. There is a recognized gap
between adult and pediatric quality of care that has
persisted despite efforts to improve pediatric prehospital
care. Baker, et al. analyzed EMS run sheets over a 3-year
time period and compared the performance of PALS
trained versus non-PALS trained providers. There was
a significant difference in the ability to obtain vascular
access (100% vs 70%, P < 0.01) and intraosseous access
(100% vs 55%; P < 0.01), but no significant difference in
mortality (37% PALS vs 32% non-PALS). The authors
concluded that PALS training improves procedural skills
among EMS personnel and should be strongly considered
as part of EMS training.[20]
Studies have demonstrated that following completion
of Pediatric Advances Life Support (PALS) prehospital
providers show an initial increase in clinical knowledge,
assessed by a written test. But there is decay back to
baseline pre-course levels in as soon as 6 months. This
decay persisted at 12 months despite re-training with
mock resuscitation training refreshers.[21]
CONCLUSION
Prehospital EMS systems have undergone fundamental
changes over the decades and have shown improvement
in patient care and survival rates of patients. Most of these
changes and improvements addressed medical conditions
of the adult patients and the magnitude of these advances
cannot be seen in pediatric prehospital care. There are
still significant differences in the care of pediatric versus
adult emergency patients in the prehospital setting. The
majority of the publications and research are performed
with and for adult patients. Traumatic injuries are a
leading cause of morbidity and mortality in the pediatric
patient. Nevertheless, for most prehospital provider it is a
rare event to treat pediatric trauma patients and there is a
still existing gap between the quality of care of pediatric
patients compared to adults. Essential skills like airway
management and IV placement by prehospital providers
have a higher complication or failure rate in pediatric
patients versus adult patients. Pediatric prehospital
care is an important component in the treatment of the
injured child as it is for adult medical emergencies. The
prehospital responders are the first medical providers
performing life saving and directed medical care that
affects the patient’s morbidity and mortality.
To improve pediatric prehospital trauma care more
prehospital providers need to be trained to address
specific pediatric care and the differences between adult
and pediatric patients.
119
 Seid, et al.: Pre-hospital care of pediatric patients
REFERENCES
1. Shah M, Cushman J, Davis, C, Bazarian J, Auinger P, Friedman B. The
epidemiology of emergency medical services use by children: An analysis
of the National Hospital Ambulatory Medical Care Survey. Prehosp Emerg
Care 2008;12:269-76.
2. 10 Leading Causes of Death by Age Group, 2008, National Vital Statistics
System, National Center for Health Statistics, CDC. Available from: http://
www.cdc.gov [Last accessed on 05/25/20012].
3. National Trauma Databank 2011 -Pediatric Report`-, American College
of Surgeons, editor: Nance ML 2011.
4. Ramenofsky ML, Luterman A, Quindlen E, Riddick L, Curreri PW.
Maximum survival in pediatric trauma: The ideal system. J Trauma
1984;24:818-23.
5. Seidel JS, Hornbein M, Yoshiyama K, Kuznets D, Finklestein JZ, St
Geme JW Jr. Emergency medical services and the pediatric patient: Are
the needs being met? Pediatrics 1984;73:769-72.
6. Seidel JS. A needs assessment of advanced life support and emergency medical
services in the pediatric patient: State of the art. Circulation 1986;74:129-33.
7. 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;78:808-12.
8. Bankole S, Asuncion A, Ross S, Aghai Z, Nollah L, Echols H, et al. First
responder performance in pediatric trauma: A comparison with an adult
cohort. Pediatr Crit Care Med 2011;12:e166-70.
9. Nelson Textbook of Pediatrics, 19th ed, Kliegman RM: Elsevier Health
Sciences; 2011.
10. Adelson PD, Bratton SL, Carney NA, Chesnut RM, du Coudray HE,
Goldstein B, et al. Guidelines for the acute medical management of severe
traumatic brain injury in infants, children, and adolescents. Chapter 4.
Resuscitation of blood pressure and oxygenation and prehospital brain-
specific therapies for the severe pediatric traumatic brain injury patient.
Pediatr Crit Care Med 2003;4(Suppl 3):S12-8.
11. Dutton RP, Mackenzie CF, Scalea TM. Hypotensive resuscitation
during active hemorrhage: Impact on in-hospital mortality. J Trauma
2002;52;1141-6.
12. Morrison CA, Carrick MM, Norman MA, Scott BG, Welsh FJ, Tsai P, et al.
120 International Journal of Critical Illness and Injury Science | Vol. 2 | Issue 3 | Sep-Dec 2012
Hypotensive resuscitation strategy reduces transfusion requirements and
severe postoperative coagulopathy in trauma patients with hemorrhagic
shock: Preliminary results of a randomized controlled trial. J Trauma
2011;70:652-63.
13. Simpson JN, Teach SJ. Pediatric rapid fluid resuscitation. Curr Opin
Pediatr 2011;23:286-92.
14. Vella AE, Wang VJ, McElderry C. Predictors of fluid resuscitation in
pediatric trauma patients. J Emerg Med 2006;31:151-5.
15. Boluyt N, Bollen CW, Bos AP, Kok JH, Offringa M. Fluid resuscitation
in neonatal and pediatric hypovolemic shock: A Dutch Pediatric
Society evidence-based clinical practice guideline. Intensive Care Med
2006;32:995-1003.
16. LaRocco BG, Wang HE. Intraosseous infusion. Prehosp Emerg Care
2003;7:280-5.
17. Sunde GA, Heradstveit BE, Vikens BH, Heltne JK. Emergency intraosseous
access in a helicopter emergency medical service: A retrospective study.
Scand J Trauma Resusc Emerg Med 2010;18:52.
18. Weiss M, Dullenkopf J, Fischer E, Keller C, Gerber AC; European
Paediatric Endotracheal Intubation Study Group. Prospective randomized
controlled multi-centre trial of cuffed or uncuffed endotracheal tubes in
small children. Br J Anaesth 2009;103:867-73.
19. Möller JC, Ballnus S, Kohl M, Göpel W, Barthel M, Krüger U, et al.
Evaluation of the performance of general physicians in pediatric
emergencies: Obstructive airway diseases, seizures, and trauma. Pediatr
Emerg Care 2002;18:424-8.
20. Baker TW, King W, Soto W, Asher C, Stolfi A, Rowin ME. The efficacy of
pediatric advanced life support training in emergency medical service
providers. Pediatr Emerg Care 2009;25:508-12.
21. Su E, Schmidt TA, Mann NC, Zechnich AD. A randomized controlled
trial to assess decay in aquired knowledge among paramedics
completing a pediatric resuscitation course. Acad Emerg Med
2000;7:779-86.
Cite this article as: Seid T, Ramaiah R, Grabinsky A. Pre-hospital care
of pediatric patients with trauma. Int J Crit Illn Inj Sci 2012;2:114-20.
Source of Support: Nil, Conflict of Interest: No.
Copyright of International Journal of Critical Illness & Injury Science is the property of Medknow Publications
& Media Pvt. Ltd. and its content may not be copied or emailed to multiple sites or posted to a listserv without
the copyright holder's express written permission. However, users may print, download, or email articles for
individual use.