Original article 1
Prehospital paediatric emergencies treated by an Australian helicopter emergency medical service Claire L. Barker and Andrew D. Weatherall Objectives The aim of this study was to describe the mechanism and severity of injuries in the paediatric population treated by an Australian helicopter emergency medical service and to examine the frequency and nature of interventions performed. This information is important for planning education and continuing professional development in prehospital medicine. Methods The study is a retrospective cohort analysis of 349 patients under the age of 16 treated by CareFlight in Sydney, Australia, between April 2007 and April 2012. Data collected included age, type of incident, medication and fluid administered, procedures performed, receiving hospital, 24 h and 30-day mortality and injuries sustained. Results Falls (33%), motor vehicle incidents (30%), sport injury (14%) and immersion injury (12%) were the most common mechanisms. A total of 27 children died within 30 days; nontrauma cases were proportionally overrepresented in the deaths. With respect to tasking, 59% cases involved a severely or significantly injured child. Among the children, 97% with a traumatic mechanism were transferred directly to a paediatric trauma centre. In addition, 81% of children had at least one
Background Prehospital helicopter emergency medical services (HEMS) provide rapid assessment and advanced emergency management at the scene of the incident before transfer to definitive care. Increasing numbers of studies in adults report reduced mortality in severely injured patients when managed by HEMS teams [1–3]. It is not yet clear whether this improvement is due to reduction in time between the incident and arrival of the team, the increased likelihood that the patient will be taken directly to a level 1 trauma centre or the higher level of clinical skill that often accompanies the helicopter. Treatment of life-threatening events at the scene of the incident rather than waiting until arrival at the hospital [cardiopulmonary resuscitation (CPR), advanced airway management or other invasive procedures and pharmacotherapy] has been shown to reduce mortality [4,5]. Children encountered by the emergency services sustain different injury patterns due to altered body proportions and suffer different types of medical emergencies [6]. Little is written about the benefits or otherwise of paediatric prehospital care other than in drowning where on-scene advanced life support improves outcome [7]. There are few descriptions of the prehospital intervenc 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins 0969-9546 !
intervention by the helicopter emergency medical services team at the incident scene, most commonly intravenous cannulation (61%), crystalloid bolus (29%), intubation (21%) and intravenous analgesia administration (15%). Conclusion Paediatric prehospital patients can be of high dependency, requiring urgent critical care procedures. Training in prehospital medicine should include paediatrics. It is essential that practitioners maintain skills in venous access, airway management and provision of adequate analgesia in children. European c 2013 Journal of Emergency Medicine 00:000–000 ! Wolters Kluwer Health | Lippincott Williams & Wilkins. European Journal of Emergency Medicine 2013, 00:000–000 Keywords: interventions, mechanism, outcomes, paediatric, prehospital CareFlight, Sydney, New South Wales, Australia Correspondence to Claire L. Barker, MBBS, CareFlight, Cnr Redbank Road and Barden Street, Northmead, Sydney, NSW 2152, Australia Tel: + 61 2 98435100; fax: + 61 2 98435155; e-mail:
[email protected] Received 3 December 2012 Accepted 25 April 2013
tions children receive from HEMS teams with those available originating from European groups. These show that only 5–10% of cases responded to by HEMS services involve paediatric patients, and a relatively low proportion require critical care [6,8]. However, severe and time critical paediatric emergencies do occur. Children who required intervention for traumatic injury were less likely to be intubated and have intravenous access established before arrival at hospital compared with adults [9]. In addition, difficult or failed intubation in the prehospital setting is more likely in children [9,10]. To date, there has been no description of the population of children receiving prehospital care by a HEMS service in Australia. The primary objective of this study was to describe the procedures performed on paediatric patients treated by the HEMS team and to evaluate how often the HEMS provided additional medical care not able to be provided by the emergency medical services (EMS) in this region. The secondary objective was to describe the mechanisms and severity of injuries in this group of patients and their short-term outcomes. This information will assist in planning education and resource allocation in paediatric prehospital medicine. DOI: 10.1097/MEJ.0b013e328362dffa
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
2 European Journal of Emergency Medicine 2013, Vol 00 No 00
Methods This study is a retrospective cohort analysis of all patients under the age of 16 on the day of the incident assessed or treated by CareFlight in Sydney, Australia, during a 5-year period between April 2007 and April 2012. Ethical approval from the Sydney Children’s Hospital Network Human Research Ethics Committee was obtained before commencement of the study. The prehospital service operates in the greater Sydney area with a radius of operation of 100 km from the base located near the demographic centre of the city. Children under 16 years of age represented 15% of the caseload. The service responds by helicopter between the hours of 09:30 and 21:30 to prehospital emergencies. The team consists of a specialist grade anaesthetist, intensivist or emergency physician as well as a paramedic. Before 14 March 2011, the service was dispatched by either of the two parallel tasking processes. The ambulance service utilized a paramedic designated as the Rapid Launch Trauma Coordinator (RLTC) to screen emergency calls for appropriate cases using a keyword-based dispatch protocol; on-scene ambulance crews could also request HEMS support through the RLTC. The HEMS also had direct access to the ambulance service computer-assisted dispatch system through a web link and screened emergency calls in parallel in order to activate the helicopter. Basic tasking criteria (Table 1) and physician judgment based on the available information was used by HEMS to determine whether to dispatch the helicopter (for details of the system see Garner et al. [11]). After 14 March 2011, the helicopter was activated only by the RLTC. Data collected included age, type of incident, medication and fluid administered, procedures performed, receiving hospital, mode of transport, helicopter flight time, 24 h and 30-day mortality, length of hospital stay and injuries sustained. Medical procedures, namely, fluid and drug administration were classified as either EMS procedures, within the scope of practice of either the EMS or the HEMS team, or as HEMS-only procedures owing to the extra skills, equipment or medication. HEMS-only procedures were rapid sequence intubation, hypertonic saline administration, blood transfusion, thoracostomy, Table 1
peripheral nerve block and intravenous ketamine, fentanyl and midazolam administration. Either the physician or the HEMS paramedic performed the HEMS procedures. Intubation during cardiac arrest, cannulation, intraosseous insertion and intranasal fentanyl administration are considered EMS procedures in the area studied. Outcomes were classified as severe, significant or nonsignificant. Presence of a severe illness or injury was defined as an injury severity score of greater than 15, death within 24 h, intensive care admission or surgery within 4 h of injury (modified from reference [12]). Significant illness or injury was defined as surgery within 48 h, computed tomography or radiograph abnormalities or hospital stay greater than 24 h. Data sources for prehospital information were written paramedic and medical notes completed at the accident scene and an electronic data management system that was completed immediately on return to base. Hospital written notes were used to identify mortality data and length of stay, and the pilot log was used to identify flight timings. Data were transferred into an Excel (Microsoft, Redmond, Washington, USA) datasheet. To compare the probability that significant or severe injury will occur with a particular mechanism of injury, the odds ratio (OR) with a 95% confidence interval (CI) was calculated. Fall was categorized as the mechanism of injury reference group, as it was the most common incident type. Occasions when the team was activated but cancelled by the EMS before patient contact have not been included in this study.
Results A total of 349 children with a mean age of 7.2 years (range 1 day–15.9 years) were examined and treated. Among them, 279 (80%) children had a trauma-related injury. Falls (33%), motor vehicle incidents (30%) and sport injury (14%) were the most common mechanisms of traumatic injury (Table 2). As expected, because of the proportionally large head size in children, head and neck were the most common anatomical injury sites (Table 3). Immersion injury (12%) was the most common nontraumatic mechanism. A total of 138 (40%) children were transported to hospital by a helicopter, three were not transported, the remainder travelled by road ambulance, with the majority (73%) accompanied by the medical team. The mean flight time from base to the incident scene was 11.9 min
Paediatric helicopter emergency medical services tasking Paediatric indents according to type
criteria
Table 2
Severe paediatric trauma patients (< 16 years), regardless of GCS
Incident types
include all those with severe: Head injury Truncal trauma Limb injury Penetrating injury Near drownings Burns, especially airway burns Multicasualty incidents in which a child is likely to be involved
Fall Pedestrian vs. motor vehicle Other motor vehicle incidentsa Sport injury Immersion Otherb
GCS, Glasgow Coma Score.
Number of incidents Mean age (range) (years) 115 51 52 48 42 41
5.9 7.5 9.2 12.2 3.8 6.0
(0.2–15.6) (0.9–15.5) (0.4–15.8) (5.8–15.8) (0.6–12.7) (0–16)
a Includes passenger in motor vehicle, bicycle collision with motor vehicle, motorcycle, driving car. b Includes seizures, collapse, burns.
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Paediatric HEMS emergencies Barker and Weatherall 3
Anatomical location of significant and severe injuries as defined by the Abbreviated Injury Score
Table 3 Injuries
Number
Head and neck Face Chest Abdomen Extremity External
71 12 27 18 35 21
External includes injury to skin, soft tissue and burns.
Procedures performed by the helicopter emergency medical services team
Table 4
Procedures Rapid sequence intubation Intravenous fentanyla Intravenous ketaminea Intravenous midazolama Hypertonic saline Blood transfusion Thoracostomy Peripheral nerve block
Number 49 43 21 15 12 5 3 2
a Figures do not include cases in which these drugs were used as anaesthetic induction or coinduction agents.
(range 1–38 min), and the mean transfer time between the incident scene and emergency department was 23 min (range 1–63 min). Interventions
A total of 285 (81%) children had at least one intervention performed at the incident scene by the HEMS team, with intravenous cannulation (61%) and crystalloid bolus (29%) being performed most often. Among the patients, 118 (34%) received care that could not have been provided by the EMS. A total of 150 HEMS-only procedures were performed (Table 4). Among the paediatric patients, 22% (n = 77) required intubation, of whom, 43 were below 5 years of age and four were below 1 year of age. The HEMS team performed 72 intubations. Among the patients, 49 required administration of anaesthetic agents for rapid sequence intubation and 26 were intubated as part of the advanced life support for cardiopulmonary arrest. Two patients, both of whom had suffered immersion injury and were initially asystolic, had a weak return of spontaneous circulation after CPR and adrenaline administration by the EMS and were intubated without medication. One patient could not be intubated and was managed with a laryngeal mask airway. In five cases, a child in cardiopulmonary arrest was intubated by the EMS before the arrival of HEMS. Blood transfusion (n = 5), thoracostomy (n = 3) and defibrillation (n = 1) were uncommon. Among the patients, 7% (n = 26) received CPR. Pain management beyond what can be provided by the EMS was administered to 54 patients – 33 received intravenous fentanyl, 11 received intravenous ketamine
and 10 received both fentanyl and ketamine. Fentanyl or ketamine used as anaesthetic induction or coinduction agents were not included in these figures. In all cases, ketamine was used for analgesia rather than procedural sedation. Two patients were treated with a local anaesthetic peripheral nerve block. Fifteen patients received midazolam; in eight cases, this was to prevent the psychotropic effects of ketamine, in one case for seizure control and in six cases for treatment of anxiety. Twelve patients received hypertonic saline as an osmotherapeutic agent for suspected raised intracranial pressure: nine were involved in motor vehicle incidents, two suffered immersion injuries, and one was a case of injuries due to hanging. All were intubated, and all but one had an initial Glasgow Coma Score (GCS) of less than 6. Patient outcomes
Follow-up data were available for 324 patients. Among them, 17 patients died within 24 h, all of whom received CPR at the scene. A further 10 children died within 30 days. Three patients who received CPR and adrenaline at the scene survived to 30 days, all had suffered immersion injury. Nontrauma cases were proportionally overrepresented in the deaths (50% nontrauma, 50% trauma). A total of 192 (59%) patients suffered severe or significant illness or injury (90 severe, 102 significant). As compared with the falls group, pedestrian versus motor vehicle (OR 5.52, 95% CI 2.3–12.0), other motor vehicle incidents (OR 2.33, 95% CI 1.2–4.6) and immersion (OR 2.4, 95% CI 1.2–5.0) were associated with significantly higher ORs for severe or significant injury or illness. Fifty-eight patients required surgery within 48 h of admission. Of 162 patients with severe or significant injury caused by trauma, 97% were taken directly to a paediatric trauma centre.
Discussion Falls and motor vehicle incidents were the most common types of incidents responded to by the HEMS service. These are also the most common mechanisms of injury in published data from the New South Wales, Australia, Trauma Registry [13] and in a comparable study of paediatric HEMS patients in the Netherlands [14]. Most children in this series required at least one on-scene intervention, 21% were particularly compromised requiring on-scene intubation. Intubating children in the prehospital setting is challenging. When directly compared with prehospital adult patients, intubation difficulties are more likely in children [9,10]. Only one child in this series could not be intubated; and, adequate oxygenation and ventilation was achieved with a laryngeal mask airway. Whether children should be intubated, and by whom, in the prehospital setting remains controversial. There are no studies comparing intubation by experienced
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
4 European Journal of Emergency Medicine 2013, Vol 00 No 00
practitioners and bag and mask ventilation. A large American study showed no difference in survival or neurological outcome when paramedics intubated paediatric patients on scene compared with bag mask valve ventilation [15]. The paramedics in this study had received 6 h paediatric airway training and therefore represent a different group compared with the HEMS practitioners, who generally have considerably more training than this. This study showed a 30% incidence of failed intubation, which was not observed in our population. Another study from the Netherlands reported decreased survival to hospital discharge and a high complication rate when EMS paramedics intubated children with a GCS of 3–4 compared with HEMS practitioners who were either anaesthesiologists or trauma surgeons with at least a 6-month in-hospital training in paediatric and adult intubation [16]. Distance between the incident site and hospital may have a bearing on the benefit of intubation. Intubation and ventilation theoretically improve control of oxygenation and carbon dioxide and prevent aspiration of gastric contents. These factors may become more significant over a longer transport period. In the American study, distances were short, with an average transport time of 6 min in comparison with 23 min in our series because of the larger area covered. Further studies comparing outcomes after bag and mask ventilation with rapid onscene intubation by practitioners with advanced training, experience and exposure to paediatric airway management are needed to determine which is the better option. Intravenous analgesia was administered to 15% of patients. Twenty-one patients received intravenous ketamine for pain relief. Ketamine is safe and effective in paediatric prehospital patients [17]. Paediatric pain is often undertreated in the emergency department [18,19]. Lack of analgesia administration before arrival at hospital is a risk factor for insufficient pain relief [20]. The prevalence of post-traumatic stress disorder symptoms after trauma in children is high [21], and evidence is emerging, particularly after burns, that more aggressive pain management reduces these longer term symptoms [22,23]. The EMS in Sydney administers methoxyflurane, intranasal fentanyl and intravenous morphine to children over 1 year of age. EMS protocols differ internationally, and in some areas EMS providers administer intravenous fentanyl and ketamine. In our service, the ability to administer an extra layer of fentanyl or ketamine analgesia at the incident scene and en-route to hospital increases the opportunity to provide adequate pain control. The service routinely carries two units of packed red cells. According to the data, five children received blood transfusions at the scene of the incident or en-route to hospital. These patients had massive head injuries with scalp lacerations, haemothoracies requiring thoracostomy or pelvic and femoral fractures. Twelve children received hypertonic saline as an osmotherapeutic agent in severe
head injury. Hypertonic saline use has increased in paediatric ICU since the publication of the 2003 guidelines for severe paediatric traumatic brain injury [24] and is increasingly used in the prehospital setting. The vast majority of children with a severe or significant traumatic injury were transported directly to a paediatric trauma center where treatment is associated with reduction in mortality and morbidity [13,25–27]. This was not the case in 2003–2008, in New South Wales, Australia, when two-thirds of children required a secondary transfer [13]. In more recent data from 2008 to 2010, children in the greater Sydney area with an injury severity score greater than 15 were more likely to go directly to a paediatric trauma centre in a significantly shorter time when the HEMS team was available compared with when it was not [11]. Having a team that is experienced in performing stabilization procedures at the scene and provides care en-route to hospital may facilitate more children travelling the increased distance to the paediatric trauma centre. In international terms, Sydney is a moderately sized city. Children represent only 10% of severe traumatic injuries in New South Wales [13,28]. In this population, the number of children treated is relatively small, but some children were critically ill. Complex or critically ill paediatric patients are increasingly cared for in specialist units by physicians and surgeons with specialist paediatric training. Specialized paediatric ICUs have lower mortalities [29]. The use of paediatric retrieval teams for interhospital transfer is associated with improved survival [30]. In addition, children who receive definitive care at a paediatric trauma centre have a survival advantage over those treated at an adult centre [13,25–27]. At present, separate paediatric prehospital services are uncommon; they are usually not economically viable owing to the low volume of paediatric cases [6,8]. Prehospital medicine is one of a limited number of medical disciplines in which the practitioner treats patients of all ages. Because of the selection of more severely injured cases, at initial tasking, each member of the HEMS team will encounter critically ill children at a higher frequency when compared with an EMS paramedic. Prehospital practitioners should aim to attain and maintain paediatric resuscitation skills and knowledge at par with that of a paediatric critical care specialist. This is a huge challenge for a busy specialist with a mixed practice. Of the patients, 59% were significantly injured or ill; therefore, 41% were ‘overtriaged’. This is consistent with results from other reports [6,31,32], which state that between 40 and 70% of paediatric patients attended by a HEMS crew do not have a potentially life-threatening injury or illness requiring emergency medical treatment. Mechanism of injury and anatomical criteria are often the only information available at the time of the emergency call, and it becomes necessary to have a low threshold for activation in order to dispatch a team immediately to
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Paediatric HEMS emergencies Barker and Weatherall 5
severe cases. Motor vehicle incidents and immersion had the highest probability of significant or severe illness or injury. However, falls, by far the most common reason for tasking the service, had the highest total number of severe or significant injuries over the 5-year period, accounting for four deaths. This highlights the difficulty in selecting severe or significant patients on the basis of the mechanism of injury. Physiological variables, which have the highest predicative value for severe injury [33,34], are not available at the time of triage. Even when these are available, paediatric patients still tend to be ‘overtriaged’ [12,35]. The proportion of children in our series receiving advanced medical intervention is considerably higher than what has been reported in some studies [6,31] and is similar to that reported in others [32]. Paediatric intubation rates of between 3.7 and 21% have been reported by HEMS crews. Our intervention and triage rates suggest that, in comparison to European services, we are not overutilizing the service. One group from the Netherlands reported a higher proportion of paediatric patients with life-threatening conditions requiring advanced interventions [14]. This may be due in part to the method of activation of this service – either primary, through the EMS dispatch centre, or secondary, through the EMS at the incident location. Secondary activation results in increased specificity but adds a time delay, especially in less-urbanized areas where time to EMS arrival at the incident site increases. We believe an overtriage rate of 41% and the marginal cost of $595 (AUD) for an average 23.8 min flight to and from nonsignificantly injured patients is acceptable in order to get a team as quickly as possible to severely injured or ill patients. This cost figure is based on the fuel cost of the average helicopter fight time from base to patient of 11.9 min as well as the flight back to base. Staff and standing costs are not included in this figure, as they are incurred whether or not the helicopter flies. Limitations of the study
Detailed follow-up data were unavailable for 25 children. Of these, 16 children were declared nonsignificantly injured by the assessing team and were transferred to a local hospital by EMS paramedics. One child received CPR and another had an initial GCS of 5 and required intubation, blood products and 7.5% saline. Outcome data were not compared with outcomes for non-HEMStreated patients.
severe or significant injury or illness. Prehospital practitioners need to attain and maintain adequate critical care skills and knowledge in paediatrics.
Acknowledgements The authors thank Alan Garner, Medical Director, CareFlight for reviewing the manuscript. Conflicts of interest
There are no conflicts of interest.
References 1
2
3
4
5
6
7 8
9
10 11
12
13
14
15
16
Conclusion
The HEMS service in Sydney offers advantages of extra medical management over the emergency services. Just over one-third of patients receive interventions limited to the HEMS team at the incident scene. The majority of patients assessed and treated are taken directly to a paediatric trauma centre. Of the patients, 59% have
17 18
19
Sullient EE, Faul M, Wald MM. Reduced mortality in injured adults transported by helicopter emergency medical services. Prehosp Emerg Care 2011; 15:295–302. Galvagno SM, Haut ER, Zafar SN, Millin MG, Efron DT, Koenig EJ. Association between helicopter versus ground emergency medical services and survival for adults with major trauma. JAMA 2012; 307:1602–1610. Hesselfeldt R, Stienmetz J, Jans H, Jacobsson ML, Anderson DL, Buggeskov K, et al. Impact of a physician-staffed helicopter on a regional trauma system: a prospective controlled observational study. Acta Anaesthesiol Scand 2013; 57:660–668. Timmermann A, Russo SG, Hollmann MW. Paramedic versus emergency physician emergency medical service: role of the anaesthesiologist and the European versus the Anglo-American concept. Curr Opin Anaesthesiol 2008; 21:222–227. Gomes E, Araujo R, Carneiro A, Dias C, Costa-Pereria A, Lecky FE. The importance of pre-trauma centre treatment of life-threatening events on the mortality of patients transferred with severe trauma. Resuscitation 2010; 81:440–445. Eich C, Russo SG, Heuer JF, Timmermann A, Gentkow U, Quintel M, et al. Characteristics of out-of-hospital paediatric emergencies attended by ambulance and helicopter-based emergency physicians. Resuscitation 2009; 80:888–892. Quan L, Kinder D. Pediatric submersions: prehospital predictors of outcome. Pediatrics 1992; 90:909–913. Suominen P, Silfvast T, Korpela R, Erosuo J. Pediatric prehospital care provided by a physician-staffed emergency medical helicopter unit in Finland. Pediatr Emerg Care 1996; 12:169–172. 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–e170. Boswell WC, McElveen N, Sharp M, Boyd CR, Frantz EI. Analysis of prehospital pediatric and adult intubation. Air Med J 1995; 14:125–127. Garner AA, Lee A, Weatherall A. Physician staffed helicopter emergency medical service dispatch via centralized control or directly by crew-case identification rates and effect on the Sydney paediatric trauma system. Scand J Trauma Resusc Emerg Med 2012; 20:82. Carron PN, Taffe P, Ribordy V, Schoetther P, Fishman D, Yersin B. Accuracy of prehospital triage of trauma patients by emergency physicians: a retrospective study in western Switzerland. Eur J Emerg Med 2011; 18:86–93. Mitchell RJ, Curtis K, Chong S, Holland AJ, Soundappan SV, Wilson KL, et al. Comparative analysis of trends in paediatric trauma outcomes in New South Wales, Australia. Injury 2011; 44:97–103. Gerritse BM, Schalkwijk A, Pelzer BJ, Scheffer GJ, Draaisma JS. Advanced medical life support procedures in vitally compromised children by a helicopter emergency medical service. BMC Emerg Med 2010; 10:6. Gausche M, Lewis RJ, Stratton SJ, Haynes BE, Gunter CS, Goodrich SM, et al. Effect of out-of-hospital pediatric endotracheal intubation on survival and neurological outcome. A controlled clinical trial. JAMA 2000; 283:783–790. Gerritse BM, Draaisma KM, Schalwijk A, van Grunsven PM, Scheffer GJ. Should EMS-paramedics perform paediatric tracheal intubation in the field? Resuscitation 2008; 79:225–229. Bredmose PP, Grier G, Davies GE, Lockey DJ. Pre-hospital use of ketamine in paediatric trauma. Acta Anaesthesiol Scand 2009; 53:543–545. O’Donnell J, Ferguson LP, Beattie TF. Use of analgesia in a paediatric accident and emergency department following limb trauma. Eur J Emerg Med 2002; 9:5–8. Brown JC, Klein EJ, Lewis CW, Johnson BD, Cummings P. Emergency department analgesia for fracture pain. Ann Emerg Med 2003; 42: 197–205.
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
6 European Journal of Emergency Medicine 2013, Vol 00 No 00
20 Tcherny-Lessenot S, Karwowski-Soulie F, Lamarche-Vadel A, Ginsburg C, Brunet F, Vidal-Trecan G. Management and relief of pain in an emergency department from the adult patients’ perspective. J Pain Symptom Manage 2003; 25:539–546. 21 Schreier H, Ladakakos C, Morabito D, Chapman L, Knudson MM. Posttraumatic stress symptoms in children after mild to moderate pediatric trauma: a longitudinal examination of symptom prevalence, correlates, and parent-child symptom reporting. J Trauma 2005; 58:353–363. 22 Saxe G, Stoddard F, Courtney D, Cunningham K, Chawla N, Sheridan R, et al. Relationship between acute morphine and the course of PTSD in children with burns. J Am Acad Child Adolesc Psychiatry 2001; 40: 915–921. 23 Stoddard FJ, Sorrentino EA, Ceranoglu TA, Saxe G, Murphy JM, Drake JE, et al. Preliminary evidence for the effects of morphine on posttraumatic stress disorder symptoms in one- to four-year-olds with burns. J Burn Care Res 2009; 30:836–843. 24 Bennett TD, Statler KD, Korgenski EK, Bratton SL. Osmolar therapy in pediatric traumatic brain injury. Crit Care Med 2012; 40:208–215. 25 Potoka DA, Schall LC, Gardner MJ, Stafford PW, Peitzman AB, Ford HR. Impact of pediatric trauma centers on mortality in a statewide system. J Trauma 2000; 49:237–245. 26 Potoka DA, Schall LC, Ford HR. Improved functional outcome for severely injured children treated at pediatric trauma centers. J Trauma 2001; 51:824–832. 27 Pracht EE, Tepas JJ 3rd, Langland-Orban B, Simpson L, Pieper P, Flint LM. Do pediatric patients with trauma in Florida have reduced mortality rates when treated in designated trauma centers? J Pediatr Surg 2008; 43: 212–221.
28
Curtis KA, Mtichell RJ, Chong SS, Balohh ZJ, Reed DJ, Clark PT, et al. Injury trends and mortality in adult patients with major trauma in New South Wales. Med J Aust 2012; 197:233–237. 29 Pearson G, Shann F, Barry P, Vyas J, Thomas D, Powell C, et al. Should paediatric intensive care be centralized? Trent versus Victoria. Lancet 1997; 349:1213–1217. 30 Ramnarayan P, Thiru K, Parslow RC, Harrison DA, Draper ES, Rowan KM. Effect of specialist retrieval teams on outcomes in children admitted to paediatric intensive care units in England and Wales: a retrospective cohort study. Lancet 2010; 376:698–704. 31 Selig HF, Trimmel H, Voelckel WG, Huphl M, Trittenwein G, Nagele P. Prehospital pediatric emergencies in Austrian helicopter emergency medical service – a nationwide, population-based cohort study. Wien Klin Wochenschr 2011; 123:552–558. 32 Helm H, Biehn G, Lampl L, Bernhard M. Pediatric emergency patients in the air rescue service. Mission reality with special consideration to ‘invasve’ measures. Anaesthetist 2010; 59:896–903. 33 Newgard CD, Rudser K, Atkins DL, Berg R, Osmond MH, Bulger EM, 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; 13:420–431. 34 Centers for Disease Control and Prevention. Guidelines for field triage of injured patients. Recommendations of the National Expert Panel on Field Triage, 2011. MMWR 2012; 61:1–21, Available at: http://www.cdc.gov/ mmwr/pdf/rr/rr6101.pdf. 35 Engum SA, Mitchell MK, Scherer LR, Gomez G, Jacobson L, Grosfield JL. Prehospital triage in the injured pediatric patient. J Pediatr Surg 2000; 35:82–87.
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
