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Andria Tatem, MD
Department
Rupa Kapoor, MD, FAAP
Assistant Professor, Eastern Virginia Medical School, Norfolk, VA
Peer Reviewers
ABCDE
A: AIRWAY
ASSESSMENT
B: BREATHING
ASSESSMENT
Is the airway
patent?
NO YES
Is there
YES asymmetric chest NO
Consider: Is the cervical spine rise or breath
• Jaw thrust properly sounds?
• Adjunct airway immobilized?
Evaluate for Resolve any other
• Endotracheal
NO YES pneumothorax: breathing issues
tube intubation
Chest x-ray +/-
With cervical spine
needle
stabilization
decompression
(Class III) Continue to
(Class III)
Apply Continue to C: CIRCULATION
appropriate-sized B: BREATHING ASSESSMENT
cervical collar ASSESSMENT (page 11)
(Class III)
This clinical pathway is intended to supplement, rather than substitute for, professional judgment and may be changed depending upon a patient’s individual
needs. Failure to comply with this pathway does not represent a breach of the standard of care.
Copyright © 2018 EB Medicine. www.ebmedicine.net. No part of this publication may be reproduced in any format without written consent of EB Medicine.
ABCDE
Are distal Is the patient's
pulses palpable? GCS score
NO YES YES NO
≤ 8?
+/- ultrasound; Apply direct Has IV/IO access Continue to Consider TBI:
pericardiocentesis, pressure been established? E: EXPOSURE • Obtain head
if indicated (Class III) ASSESSMENT CT scan
YES NO
(Class III)
E: EXPOSURE
ASSESSMENT
NO YES YES NO
1. “The pulse oximeter showed a normal oxygen 4. “The patient vomited a couple of times after
level, so the patient had adequate airway and her head injury, but she was able to tolerate an
breathing. I’m surprised he had to be emer- oral challenge and seemed fine. I can't believe
gently intubated.” she became so altered.”
Inadequate airway management is a major Brain injury is the leading cause of morbidity
cause of morbidity and mortality in pediatric and mortality in injured children. TBI can be
trauma patients. Hypoxia is a late sign of airway missed early and can develop over hours,
or breathing problems in the pediatric patient. which is why anticipatory guidance and return
Early signs may be as subtle as tachypnea or precautions are essential for discharged patients.
hypoventilation. In hospitalized patients, recurrent neurologic
examinations are critical in patients with high-
2. “His blood pressure was normal. I was sur- risk mechanisms and in children with multiple
prised that he decompensated so rapidly.” injuries.
Hypotension is a late sign of hemodynamic
instability in the pediatric patient; tachycardia 5. “The nurse didn’t tell me that the patient's vi-
is the earliest sign. Complete assessment for tal signs were abnormal. If we had known the
trauma, which may involve hemorrhage in patient was bradycardic and hypertensive, we
large quantities (abdomen or femur), is critical. could have intervened sooner.”
Appropriate pain management and calming the Parameters for vital signs should be recognized
child are important to observe early tachycardia in the appropriate context and monitor alarms
as a sign of impending shock. Do not assume set accordingly. Often, emergency clinicians are
that tachycardia is due to pain or anxiety. looking for signs of shock, but in children with
head injuries, Cushing triad with hypertension
3. “The ultrasound of the abdomen was negative and bradycardia are opposite to the hypotension
for free fluid. I don’t know how the splenic and tachycardia of hypovolemic shock.
laceration was missed.” Abnormal vital signs are often dismissed in
The FAST examination is not sensitive in the face of anxiety or pain. Vital signs should
children. If intra-abdominal injury is suspected be continually reassessed as the child becomes
on examination or from laboratory results, CT more comfortable. It is also important to set
is a more sensitive test. parameters based on the child’s age—a normal
blood pressure for a teenager is hypertension in
a toddler.
6. “The swelling of her lower leg was minimal 8. “The neck CT was negative. How could I pos-
when the girl first came in. I didn’t see any sibly have known that there was spinal cord
signs of compartment syndrome related to the injury?”
fracture when the child was in the ED, but the Although it is an uncommon injury, SCIWORA
orthopedic surgeon was called in for a fasci- is a high-risk injury of concern in young
otomy overnight while the patient was being children. Negative plain film or CT imaging
monitored in the PICU.” is not sufficient to clear a cervical spine in a
Definitive care for serious injuries is often pediatric patient with neurologic findings or
operative in nature, so subspecialists should be significant pain.
involved early on for pediatric trauma patients
with multiple injuries. Delayed management 9. “The transferring facility said the child was
of serious fractures can result in compartment stable, but now the transport team is saying
syndrome, especially in intubated or nonverbal that the child is not acting right. They are not
patients. Compartment syndrome can progress sure what is wrong.”
over time, making serial examinations for Transport personnel with pediatric training have
high-risk fractures mandatory. Early diagnosis a decreased incidence of adverse events during
and definitive treatment require frequent transport for children with head injuries. In long
reassessment when extremity injuries are transports or for multiply injured, complicated
present, particularly those known to predispose pediatric trauma cases, consider using transport
a patient to compartment syndrome. personnel with pediatric training.
7. “Splinting all the fractures was time consum- 10. “We discharged the patient who was in a motor
ing. Now I am waiting on laboratory results vehicle crash after observation in the ED. He
while trying to arrange appropriate follow-up. just returned with leg pain.”
Trauma patients take so long to disposition.” The most commonly missed injuries in pediatric
Activating a trauma team, when available, patients are fractures. Make sure to complete
improves time to disposition, especially in a thorough secondary survey, including
complicated, multiply injured patients. It also ambulation, to avoid missing small fractures
ensures the availability of adequate resources that may not present with obvious deformity
and proper follow-up. and swelling.
Current subscribers receive CME credit absolutely 4. A 2-year-old girl presents after a ceiling fan
free by completing the following test. Each issue fell on her head. During your examination, she
includes 4 AMA PRA Category 1 CreditsTM, 4 ACEP opened her eyes only to pain, she was moaning
Category I credits, 4 AAP Prescribed credits, or 4 but not saying any words, and she was with-
Take This Test Online!
AOA Category 2-A or 2-B credits. Online testing is drawing her extremities to pain. What is her
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your CME credits for this issue, scan the QR code a. 5
below with your smartphone or visit b. 6
www.ebmedicine.net/P0618. c. 7
d. 8
8. A 10-year-old boy sustained a crush injury to 10. A 3-year-old girl comes in after falling out of
his right arm. The following signs would all be a 3-story window. Her head and neck CT are
concerning for development of compartment negative, but she appears to be in pain when
syndrome EXCEPT: you try to take off the cervical collar. The next
a. Redness of the extremity most appropriate step in the management of
b. Excessive pain this patient is:
c. Decreased pulses a. Remove the collar, since the imaging was
d. Numbness and tingling negative.
b. Repeat the CT scan in 6 hours.
c. Perform serial neurologic examinations and
possible MRI for concern for SCIWORA.
d. Obtain a spine (neurosurgery or
orthopedics) consultation.
Accreditation: EB Medicine is accredited by the Accreditation Council for Continuing Medical Education
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September
Number 9
Volume 14,
thopedic Credit Designation: EB Medicine designates this enduring material for a maximum of 4 AMA PRA
Pediatric Or ence-Based
Author San Diego,
of California
Category 1 CreditsTM. Physicians should claim only the credit commensurate with the extent of their
MD, FAAP University
id
Jamie Lien, e; Associate Physician,
Injuries: Ev t in the
CA
Private Practic Hospital, San Diego,
n’s
Rady Childre
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Hospital; Assistl, Boston, MA ine,
Medical Schoo ency Medic
ACEP Accreditation: Pediatric Emergency Medicine Practice is also approved by the American College
Sanders,
MD rics and Emerg
Jennifer E. tment of Pediat New York, NY
sor, Depar Sinai,
Assistant Profes Medicine at Mount
Abstract
l of
Icahn Schoo
in children,
are common
of Emergency Physicians for 48 hours of ACEP Category I credit per annual subscription.
tives
mity injuries r 1 in 5 CME Objec
should be
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lower extre at just unde article, you edic injurie
Upper and ure estimated iology produce age- compl etion of this critical pediatric orthop
all risk of fract te emergent
Upon on and
phys Describe comm s to evalua
with an over atric bone anatomy and that are unique to chil- y 1.
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AAP Accreditation: This continuing medical education activity has been reviewed by the American
Determine edic condit
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tions for pediat
y nosis diffic 2.
pediatric orthopt treatment recommenda
specific injur e accurate
diag pathophysiolo
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emergencies
. Information”
This issue
revie common injur mendations cian CME
Academy of Pediatrics and is acceptable for a maximum of 48 AAP credits per year. These credits
, see “Physi
clinicians. , as well as ing this activity back page.
ific fractures s. Evidence-based recom opriate Prior to beginn on the
of child-spec mitie , including
appr a CME credit
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can be applied toward the AAP CME/CPD Award available to Fellows and Candidate Fellows of the
uppe ssed
ent of pedi are also discu This issue
for managem ies and treatment,
MHA
Wang, MD,
Vincent J. of Pediatr ics, Keck
stud
diagnostic Joshua Nagler,
MD, MHPEd cs and
r of Pediatri
Professor
School of
Medicine
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rn Californ
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Ilene Claudiu Department Professor of Medical Physician,
Professor, Center, Departm Chief and Attending FACEP
Associate Medicin e and e, Los Angeles, CA and Pediatrics, ncy ent USCF Benioff d, CA Zibners , MD, FAAP, ric
ncy Medicin c Emerge Departm Lara ant, Paediat
of Emerge School of FAAP, Director, Pediatri , University Hospital, Oaklan Honorary Consult e, St. Mary's
USC Keck Gerardi, MD, Children's
Pediatrics, s, CA Michael J. Medicine Division of Medicine- Medicin
Los Angele nt , MD Emergency l College Trust, or
Medicine, FACEP, Preside or of Emergency of Florida College Joshua Rocker of
FL Hospital Imperia
Pediatric Heat-Related
Morristown, Medicin
Hospital of Cincinnati,
OH School of
Children’s Pediatrics, e, Medical Center,
nda, MD, MS
Northwell Pharmacolo
Needs Assessment: The need for this educational activity was determined by a survey of medical staff,
of Clinical be, MD, PhD NY BCPS
Professor College of
Medicin Anupam KharbaCare Services Hyde Park, r, PharmD,
Sandip Godam and Patient Safety Aimee Mishle Medicine Pharma
cist,
Clinics of , MD
Albert Einstein Montefiore, Chief, Critical
August 2017
Chief Quality or of Pediatrics and of
Hospital at Hospitals and MN Steven Rogers University Emergency
including the editorial board of this publication; review of morbidity and mortality data from the CDC,
MD Physician, System, Kim, MD, Attending
Steven Bin, Professor, Tommy Y. Connecticut , CT r
Quality Edito
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Associate Clinical King's Daught Authors
Associate Professo e, University of Physician,
AHA, NCHS, and ACEP; and evaluation of prior activities for emergency physicians.
l, San Francisc Professor, ia; Assistant
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Clinical Professor l Montefiore
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FACEP ncy Medicin
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Emergency Medicine,Educati
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Professor ofatPediatric of Pediatrics,
Department; Poison Joseph Habbo or of Emerge
ncy of Educati Emergency
MD, FAAP Medicine, e, Bronx, NY
Target Audience: This enduring material is designed for emergency medicine physicians, physician
Infants, children, and adolescents
Emergency New York Assistant Profess ngone and Director, DirectorRiverside
ncy Medicin
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School Adam E. Vella, Riverside of Emerge
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of Medicinof California
are at increased risk for heat-related
Director, CentralGolisano Children's Medicine,
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Medicine,Medicine, Professor Community
Associate CA ics, and Medical Hospital, Editor
CME Department of
illness due to their inability to
Control Center, e, NY Medica l Centers,
New
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remove themselves from dangerous
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MD Aware
LLC Univers
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environments. Evidence shows York, NY; CEO, FACEP, Education, Icahn School Debora te Professor of Pediatr
Medicine, e of USC;
that morbidity and mortality
, MD, FAAP ko, MD, MSCR,
MD Emergency Associa
Goals: Upon completion of this activity, you should be able to: (1) demonstrate medical decision-making
Clinical Profess Angeles County Torrance, CA University Department ncyAssociate Emergency ens,
(ice-water immersion, cold packs)
Medicine,
Univers
l Center, Pediatric Emerge
of Emergency
l,
Departm
York-Pr
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and convection (moisture and
Emerge ncy
, Las Vegas
School of Medica Division Head,
BC Childre
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New
Flushing, NY
Carolinas Medical Center,
figures.
of Nevada moving air). The choice of method
NV Alson S. Inaba,
MD, FAAP e Medicine,
BC, Canada
Charlotte, NC
at tables and
used may depend on availability
Medicine,
Las Vegas,
MD, FACEP
, ncy Medicin
Pediatric Emerge ni Medical Center Vancouver, Prior to beginning this activity,
see “Physician closer look
for a Information”
of equipment, but there is evidence
Gausche-Hill, Kapiola icon CME
based on the strongest clinical evidence; (2) cost-effectively diagnose and treat the most critical ED
that can guide optimal use of
Marianne Specialist, Associate on the on
back the
& Children; Click page.
resources. This issue presents
FAAP, FAEMS r, Los Angeles for Women
based recommendations and Medical Directo Agency; Profess
or ofevidence-
best practices in heat-illness
County EMS
tion, including managing children resuscita-
presentations; and (3) describe the most common medicolegal pitfalls for each topic covered.
who are obese, have special
or take medications, and advocacy needs
for prevention strategies.
CME Objectives: Upon completion of this article, you should be able to: (1) Utilize a systematic approach
Ilene Claudius, MD and Professor of Pediatrics, University
Pediatrics, David Geffen School Joshua Nagler, MD, MHPEd
of of Hawaii John A. Burns School
Associate Professor, Department Medicine at UCLA; EMS Fellowship of Assistant Professor of Pediatrics Vincent J. Wang, MD, MHA
of Emergency Medicine and Director, Harbor-UCLA Medical Medicine, Honolulu, HI and Professor of Pediatrics, Keck
Emergency Medicine, Harvard
Pediatrics, USC Keck School Center, Department of Emergency Madeline Matar Joseph, Medical School of Medicine of the
of MD, FACEP, School; Fellowship Director,
for evaluation of trauma patients to reduce missed injuries in multiply injured children; (2) determine
Medicine, Los Angeles, CA Medicine, Los Angeles, CA FAAP Division University of Southern California;
of Emergency Medicine, Boston
Professor of Emergency Medicine Associate Division Head,
Editorial Board Michael J. Gerardi, MD, FAAP,
and Pediatrics, Chief and Medical
Children’s Hospital, Boston,
MA Division
of Emergency Medicine, Children's
FACEP, President James Naprawa, MD
Jeffrey R. Avner, MD, FAAP Associate Professor of Emergency Director, Pediatric Emergency Hospital Los Angeles, Los
Attending Physician, Emergency Angeles, CA
appropriate imaging modalities for identifying orthopedic and traumatic brain injuries in patients
Chairman, Department of Medicine, Icahn School of Medicine Division, University
Pediatrics, Maimonides Infants Medicine of Florida College of Medicine- Department USCF Benioff
Children’s Hospital of Brooklyn;
& at Mount Sinai; Director, Pediatric
Jacksonville, Jacksonville, Children's Hospital, Oakland, International Editor
Emergency Medicine, Goryeb FL CA
Professor of Clinical Pediatrics, Children's Hospital, Morristown Stephanie Kennebeck, MD Joshua Rocker, MD Lara Zibners, MD, FAAP, FACEP
Albert Einstein College of Medical Center, Morristown, Associate Chief, Division of Honorary Consultant, Paediatric
Medicine,
with multiple trauma; and (3) identify and manage traumatic brain injuries, orthopedic injuries, and
NJ Associate Professor, University
Children's Hospital at Montefiore, of Pediatric Emergency Medicine, Emergency Medicine, St. Mary's
Sandip Godambe, MD, PhD Cincinnati Department of Pediatrics,
Bronx, NY Cohen Children's Hospital Imperial College
Chief Quality and Patient Safety Cincinnati, OH Medical Center; Trust,
Steven Bin, MD Assistant Professor of Emergency London, UK; Nonclinical Instructor
Officer, Professor of Pediatrics Anupam Kharbanda, MD, Medicine and Pediatrics, Hofstra of Emergency Medicine, Icahn
Associate Clinical Professor, and MS
Emergency Medicine, Attending Chief, Critical Care Services
investigational information about pharmaceutical products that is outside Food and Drug Administration
Melissa Langhan, MD, MHS Medicine, Pediatrics, and Medical
Assistant Professor of Emergency Associate Professor of Pediatrics Assistant Vice President, Montefiore
Hospital, Syracuse, NY and Education; Director, Undergraduate
Medicine, NYU/Langone and Emergency Medicine; Fellowship Network Performance Improvement;
Ari Cohen, MD, FAAP and Emergency Department Director, Montefiore Institute
Bellevue Medical Centers, Director, Director of Education, Simulation; Icahn School of
Chief of Pediatric Emergency New Medicine for Performance Improvement;
York, NY; CEO, MD Aware Pediatric Emergency Medicine, at Mount Sinai, New York, NY
approved labeling. Information presented as part of this activity is intended solely as continuing medical
Medicine, Massachusetts General LLC Yale Assistant Professor of Pediatrics,
Tim Horeczko, MD, MSCR, University School of Medicine,
Hospital; Instructor in Pediatrics, FACEP, New Adam E. Vella, MD, FAAP Albert Einstein College of
FAAP Haven, CT Medicine,
Harvard Medical School, Boston, Associate Professor of Emergency Bronx, NY
MA Associate Professor of Clinical Robert Luten, MD
Jay D. Fisher, MD, FAAP Medicine, Pediatrics, and Medical
Emergency Medicine, David Professor, Pediatrics and Education, Director Of Pediatric CME Editor
education and is not intended to promote off-label use of any pharmaceutical product.
Clinical Professor of Pediatric Geffen
and School of Medicine, UCLA Emergency Medicine, University Emergency Medicine, Icahn Deborah R. Liu, MD
Emergency Medicine, University ; Core of School
Faculty and Senior Physician, Florida, Jacksonville, FL of Medicine at Mount Sinai,
of Nevada, Las Vegas School Los New Associate Professor of Pediatrics,
of Angeles County-Harbor-UC York, NY
Medicine, Las Vegas, NV LA Garth Meckler, MD, MSHS Keck School of Medicine of
Medical Center, Torrance, USC;
CA Associate Professor of Pediatrics, David M. Walker, MD, FACEP, Division of Emergency Medicine,
Marianne Gausche-Hill, MD, FAAP
FACEP, Alson S. Inaba, MD, FAAP University of British Columbia; Director, Pediatric Emergency Children's Hospital Los Angeles,
FAAP, FAEMS Pediatric Emergency Medicine Los Angeles, CA
Faculty Disclosure: It is the policy of EB Medicine to ensure objectivity, balance, independence, transparency,
Division Head, Pediatric Emergency Medicine; Associate Director,
Medical Director, Los Angeles Specialist, Kapiolani Medical
Center Medicine, BC Children's Hospital, Department of Emergency
County EMS Agency; Professor for Women & Children; Associate Medicine,
of Vancouver, BC, Canada New York-Presbyterian/Queens,
Flushing, NY
and scientific rigor in all CME-sponsored educational activities. All faculty participating in the planning or
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In upcoming issues of must also make a meaningful disclosure to the audience of their discussions of unlabeled or unapproved
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CME activity were asked to complete a full disclosure statement. The information received is as follows: Dr.
Pediatric Emergency Tatem, Dr. Kapoor, Dr. Hughes, Dr. Zibners, Dr. Claudius, Dr. Horeczko, Dr. Mishler, and their related
parties report no significant financial interest or other relationship with the manufacturer(s) of any
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