Patient Profile: Pediatric Head Trauma
by Gary McCalla, MD, Medical Director

O n a late afternoon in early 2004, a 13-year-old boy was riding his bike when he was struck by a minivan traveling approximately 30-40 miles per hour.  The impact knocked the boy unconscious and caused him to roll beneath the still-moving vehicle.

The 9-1-1 system was activated.  Sacramento Metropolitan Fire District personnel responded within minutes and found the young boy unresponsive and barely breathing. Vomit and blood were rapidly accumulating in his airway. 

Attempts by the fire department paramedic to manage the child's airway with an endoctracheal tube were unsuccessful.  The patient had a clenched jaw caused by his closed head injury.  Further assessment by the Paramedics at the scene revealed a laceration to his neck, a large scalp abrasion, and an open fracture of his left leg.

Due to the patient's critical head injury, distance to the trauma center, and need for advanced airway management it was determined an air ambulance should be activated.

REACH's Sacramento base, REACH II, was dispatched. Pilot Tom Awiszus lifted off with the REACH medical team consisting of Flight Nurse Loyd Helmick and Flight Paramedic Larry
 Brown.  Just 12 minutes later the REACH team arrived at the scene.

The patient's airway was being managed with frequent suctioning and manual ventilations were being provided by bag-valve-mask.  By this time the young boy had been placed in spinal precautions and IV access was established in his left arm.

Following evaluation by the REACH medical team it was determined that this patient needed to undergo rapid sequence induction (RSI) with subsequent intubation for definitive airway management.

After assuring the IV was functioning and pre-oxygenating the child with high-flow oxygen, the patient underwent RSI utilizing an appropriate sedative and paralytic agent. The child was then intubated successfully by Paramedic Brown utilizing a 6.0 endoctracheal tube.  He was then ventilated by BVM with 100% oxygen which brought his oxygen saturation from 92% to 100%.

The patient received subsequent follow-up sedation and chemical paralysis and was transported to the University of California at Davis Medical Center's trauma center for further evaluation of his closed head injury.  During transport, his airway status was meticulously managed, maintaining oxygen saturation readings of 100% and end tidal C02 readings of between 34 and 36.

Following comprehensive assessment at UC Davis it was determined that the young boy had sustained a traumatic brain injury with left hemorrhage and bilateral punctate intracranical hemorrhages, an odontoid fracture, left pubic rami fracture, right parasymphyseal fracture, left acetabular fracture, left zygoma fracture, bilateral pulmonary contusions, left facial laceration, left clavical fracture, and multiple facial fractures.

Three weeks after the injury the patient was stable enough to be transferred from the pediatric intensive care unit to the rehabilitation department.  The patient spent a month in the hospital at UC Davis before being discharged.  In spite of all his injuries, this young boy was able to walk with assistance at the time of discharge. His continued recovery will include physical therapy, occupational therapy and speech therapy.





Care Guidelines: Closed Head Injuries
Basic Principles of  Management
by- Gary McCalla, MD, Medical Directorr

Closed head injuries, ranging from mild to devastating, continue to be a significant health care issue around the world.  Prehospital care and management of these injuries can dramatically affect the outcome of these patients.

Treatment of closed head injuries in the prehospital setting, and in the emergency department, has not changed dramatically over the past 15-20 years except for recognizing the need for adequate perfusion of the brain and affecting change in ventilatory management away from hyperventilation.

     The three major components of prehospital and emergency
           management of closed head injuries are as follows:
 
nAdequate oxygenation. The damaged brain tissue is in need of constant perfusion with well oxygenated blood.  Adequate oxygenation is one of the key components to this.  It is imperative that patients receive supplemental oxygen to ensure the brain receives as much oxygen as possible.

nPerfusion of the brain. The next important consideration is that of perfusion of the brain.  Perfusion has to do with what is called "cerebral perfusion pressure." Cerebral perfusion pressure can be defined by the simple mathematical equation of CPP = MAP - ICP (cerebral perfusion pressure equals mean arterial pressure minus intracranial pressure.) Intracranial pressure in the average adult ranges from 10-12 millimeters/mercury, but in the acute head injury patient can soar quite high.

  In the prehospital setting and in the emergency department it is impossible to determine intracranial pressure. For that reason it can be assumed that as patients have a decrease in level of responsiveness, their intracranial pressure is most likely rising and for that reason, mean arterial pressure must be maintained to maintain cerebral perfusion pressure.

Another way of stating this is that adequate blood pressure must be maintained at all times. Initiation of an IV and rapid and adequate fluid resuscitation are of paramount importance.
In light of the last two care measures it has been documented in multiple studies that a single episode of hypoxia, a pulse oxymetry of less than 90, or a single episode of hypotension, a systolic blood pressure of less than 90, have proven to double mortality rates of patients with closed head injuries.
 
nAirway management. Airway management is imperative in closed head injury patients. Prevention of hypoxia, as noted above, and management of the patient's ventilatory status, specifically their ETCO2, is essential.  The previous routine use of hyperventilation should now be a thing of the past in the management of head injured patients; it does still have a place in patients who are having an acute herniation as demonstrated by acute, severe change in neurological status consistent with herniation including rapid progressiveness to unconsciousness, unilateral blown pupil and sudden change in respiratory status. These are the only times in which brief, limited controlled hyperventilation are warranted.

The continued care of the closed head injured patient in the hospital involves evaluation for space occupying lesions (blood and swelling.) This is generally accomplished with a CAT scan and rapid transport to the neurosurgical suite should such a repairable entity be found, or meticulous monitoring of intracranial pressure should a non-operable region be found.

In summary, early and aggressive management of airway, oxygenation and blood pressure by prehospital and emergency department personnel is critical in patients who have sustained a closed head injury.

Pediatric Transport Program
11 Years of Specialty Service

I n 1993 REACH Air Medical Services began its journey of specializing in the care and transport of pediatric patients.  The journey was initiated by the development of internal, clinical training programs, relationships with pediatric specialty center physicians and nurses, and a commitment to doing what is right for the pediatric patient population: delivering excellent care.

Since 1993, REACH has transported approximately 2,700 pediatric patients to Northern California tertiary pediatric centers including Children's Hospital and Research Center Oakland, the University of California at San Francisco Medical Center, California Pacific Medical Center, the University of California at Davis Medical Center, select Northern California Kaiser facilities, and Sutter Memorial Hospital in Sacramento.  81% of this population were transported from referral hospitals, and the remaining 19% were transported to receiving facilities direct from 9-1-1 activated scene calls.

The past 11 years of providing this specialized service have been both rewarding and challenging.  Approximately 60% of the pediatric patients REACH transports are received by, or admitted to, the pediatric intensive care unit at the receiving hospital.   40% are admitted to the emergency department.

The development of a clinical staff capable of caring for such high-acuity patients is a continual process with checks and balances along the way.  REACH nurses, paramedics and respiratory therapists participate in classroom as well as “hands-on” pediatric intensive care clinical rotations. The care we provide to the patients we transport is reviewed by our Medical Director or Assistant Medical Director, flight crew peers, as well as the receiving PICU staff nurses and physicians.  Additionally, we participate in quality care review committees and follow-up with the specialists at the tertiary level facilities to ensure excellence in care we deliver. Most recently, REACH raised the bar of excellence by the addition of Dr. James Hanson as our Assistant Medical Director (please see profile on page five for more about Dr. Hanson.)

REACH has long supported existing systems, and has actively participated in the development of new systems, which support the care and transport of critically ill and injured children to specialty centers. Statistics support the fact that traumatically injured patients have improved outcomes if treated by trauma center personnel.  The pediatric population is no exception. REACH was key in the development of pediatric direct trauma triage policies within several counties in which we perform 9-1-1 missions.  These emergency medical systems have improved the outcomes of many children over the years.

REACH is committed to providing excellence in pediatric care and transport as we continue to dedicate ourselves to this mission.  It is with a vision of excellence that we move into our 12th year of providing pediatric specialty care.




Dr. James Hanson: 
REACH Assistant Medical Director  

It is with great pleasure REACH introduces our Assistant Medical Director, Dr. James Hanson.  Dr. Hanson joins REACH with extensive experience in the care and management of pediatric intensive care patients.

Dr. Hanson is presently the Medical Director of the Pediatric Intensive Care Unit (PICU) at Children's Hospital and Research Center Oakland (CHO) and has an extensive background in critical care medicine in the pediatric population.  As a pediatric intensivist, Dr. Hanson’s job is to be the ‘orchestrator’ or ‘care manager’ of all patients who are admitted to the PICU.

Dr. Hanson’s history with REACH goes back to 1988.  REACH was in its second year of service and
Dr. Hanson was just starting at CHO as a pediatric intensivist.

“I remember when REACH was just starting,” recalled Dr. Hanson.  “I also remember when REACH became the preferred provider for CHO in 1993.”

“Since then, REACH has been an extension of CHO,” said Dr. Hanson. “REACH’s commitment to children is unparalleled.”

When asked what interested him in the position at REACH, Dr. Hanson said “What has always impressed me is REACH’s dedication to help patients, often times when there is no financial reward.  I am also impressed by REACH’s dedication to quality.”

“I have been on the receiving end of critical care transfers for years,” continued Dr. Hanson. “This is an opportunity for me to understand more about the transport aspect of patient care and to learn more about what goes on in the field.”

“I believe I will be able to contribute to the further enhancement of the pediatric aspect of REACH’s program, while at the same time I will be able to educate my fellow physicians about what to expect on the receiving end of these critical transfers,” mentioned Dr. Hanson.

“Jim Hanson brings the next level of ‘treatment expertise’ to REACH,” said Dr. Gary McCalla, REACH medical director.  “Dr. Hanson will bring to REACH the ‘fine tuning’ of all pediatric care, but especially to his specialties including fluid management, shock therapy and ventilatory management.”

“I have worked with Dr. Jim Hanson through REACH for the last five years,” said Flight Nurse Loyd Helmick. “He is an excellent clinician and a great mentor.  When I heard he was coming to work at REACH, I was overjoyed.  He has always cared for patients by doing what is right for them, which is the same philosophy Dr. McDonald worked by and founded this company on.  His expertise in pediatrics is well established in the pediatric  intensive care community. Having Dr. Hanson working for REACH will only further enhance the care that we provide to critically ill and injured children throughout Northern California.”

“It is time for us to dedicate in-house medical direction to our pediatric patients,” said Jennifer Hardcastle, director of program development. “We have always worked closely with tertiary level pediatric centers to ensure excellence in our pediatric care.  Having Dr. Hanson on-staff at REACH brings a very vital resource to our fingertips.”

“Dr. Hanson’s involvement in clinical education, mentoring and review of our work are the next logical steps toward further establishing REACH as the pediatric transport provider of choice,” continued Hardcastle.

Dr. Hanson is married to his wife, Dianne Nicolini, and has two children, Tommy, 18 years old, and Monica, 14 years old.  In his free time Dr. Hanson enjoys coaching his daughter’s soccer team and looks forward to traveling to the University of Hawaii where his son will be studying pre-dentistry.

Dr. Hanson joined the REACH team on June 1, 2004.  He will be closely involved with the REACH clinical crews as he will be on call for advice as well as be involved with education and review of pediatric care and protocols for REACH. 

Welcome, aboard, Dr. Hanson. We look forward to the contributions you will bring to our team.




Scene Corner: 
Direct Triage to the Pediatric Center

Pediatric trauma presents one of the greatest challenges to health care delivery systems nationwide.  In the United States, trauma is the leading cause of death and disability in pediatric patients. More children die from trauma-related injuries than all other causes combined.  Each year, approximately 25,000 children die and another 100,000 are permanently disabled from traumatic injuries in the United States.

The survival of children who sustain major trauma is dependent on many factors including good prehospital care, appropriate triage, appropriate destination decision (including rapid transport), resuscitation by an experienced pediatric trauma team in a specialized emergency center, and effective emergent surgery.

Expert pediatric trauma care during the "first hour" is critical to maximizing positive patient outcomes. Although the principles of resuscitation for injured children are similar to those for adults, a thorough understanding of the differences in airway anatomy, response to blood loss, thermoregulation, and knowledge of the equipment required, is essential for successful initial resuscitation.

In 2004, the National Trauma Data Bank published a study in the Journal of Trauma describing the relationship between trauma and rapid surgical intervention. The authors looked specifically at pediatric trauma patients in which a surgical procedure was required.  All patients less than 18 years of age with trauma were included.  Of these, 30% underwent surgery.  Approximately half of these (57 %) required emergent surgery.  Patients with penetrating trauma, and/or the presence of shock or coma, are most likely to require emergent surgery.

This study reminds us that trauma is still a surgical disease, and many pediatric trauma patients require specialized pediatric trauma care. Early identification and destination planning are imperative to facilitate rapid transport to a pediatric trauma center. 
To achieve this level of care, most county policies have provisions for pediatric trauma triage direct to a regional pediatric trauma center.  We encourage you to understand how and when to apply these potentially life-saving policies.

Last year, REACH transported nearly 600 critical pediatric patients to regional pediatric specialty centers and is currently on pace to exceed last years’ volume. REACH advocates for policies and systems that transport high risk patients to specialty centers by air or ground.

Sources: Adelson PD: Pediatric trauma made simple. Clin Neurosurg 2000; 47: 319-395; Dodson TB, Kaban LB: Special considerations for the pediatric emergency patient. Emerg Med Clin North Am 2000 Aug; 18(3): 539-48; Nguyen, MD; Considerations in Pediatric Trauma. October 2003; Furnival RA, Schunk JE: ABCs of scoring systems for pediatric trauma. Pediatric Emerg Care 1999 Jun; 15(3.)

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Partners
Sacramento Metropolitan Fire District Agency Profile

Ehe Sacramento Metropolitan Fire District provides services through
42 stations and 720 uniformed and support personnel to nearly 600,000 people in a 417 square mile area. Metro Fire represents 16 predecessor fire agencies.

Some of these fire agencies were founded in the early twenties to provide fire protection in remote parts of the county. The varied demographics of the district provide opportunity for its personnel to respond to emergencies in rural, suburban and urban settings. The wide diversity of emergency incidents require firefighters to be proficient in wildland fire fighting, structural fire fighting, crash fire rescue, technical rescue, swift water rescue, hazardous material mitigation, and paramedic medical services.

Area served: (sq. mi.)417
Population: 599,257
Counties served: Sacramento and Placer
Cities served: City of Citrus Heights, City of Rancho Cordova
Geography: Two rivers, American & Consumnes
Physical Resources
 
Fire Stations (Full Time): 38
Fire Stations (Volunteer): 2
Fire Stations (Part Time): 2
Engine Companies: 39
Truck Companies: 5
Transporting Medic Units: 10
Personal Watercraft Response Units: 2
Aircraft - Helicopter: 1
Inflatable Rubber Boat Response Units: 2
ARFF Units:  3

Image and Information courtesy of Sacramento Metropolitan Fire District Website: www.smfd.ca.gov

News This Fall:
California Pediatric Emergency Care Conference
The California Pediatric Emergency Care Conference, taking place in Fairfield, Calif., on Thursday and Friday, Oct. 28 & 29, is a conference you don’t want to miss.  This will be the eighth year REACH has presented a pediatric conference, and features, for the first time, PRE-HOSPITAL and HOSPITAL tracks on both days.

Please contact us to register or to obtain more information.

Registration costs:  One day = $85 Both days = $170 (with discounts for “early bird registration” discounts before Sept. 28.)

Group Discounts: $5 per person discount/per day for groups of five or more when registration and payments are completed as a group.

NorCal Trauma Conference
April 1, 2005

Mark your calendar for a day of education “targeting trauma.” This coming year the NorCal Trauma Conference will take place on Friday, April 1, 2005.

This past April, 225 students attended the one-day conference.  The second NorCal Trauma Conference is sure to offer another “star” line-up of speakers and topics to be presented.  Topics “on-tap” include:  Shaken Baby Syndrome, Snake Bites and other shocking subject matter. Please keep your eyes peeled for more information.


REACH Training Insitute Becomes American Heart Community Training Center
We are pleased to announce the REACH Training Institute (RTI) has been approved by the American Heart Association (AHA) and is now an official AHA Community Training Center (CTC.)

REACH has been providing emergency cardiovascular care courses in ACLS, PALS and BLS since April 2000, in conjunction with an area CTC. It is as a result of the RTI’s growth and demand that we have recently been designated as a CTC. 

“This is an exciting move for the RTI,” said Eric Rodgers, EMT-P, REACH training institute coordinator. “Being our own CTC will improve our abilities to provide education out in the rural communities. We are very pleased.”

Now Offering Pediatric Prehospital Care (PPC) and Prehospital Trauma Life Support (PHTLS) Courses
The REACH Training Institute has added two courses to our suite of offerings: PPC and PHTLS. Both courses are being offered beginning this winter in both Santa Rosa and Elk Grove, Calif. locations. Please refer to our course brochures or website for details.

Training Institute News & Calendar

SCHEDULED COURSES for WINTER
see course listing on website




Rivets Facts:
DO YOU KNOW?

 *  REACH Training Institute is now an American Heart Association Community Training Center.

*  Trauma is the leading cause of death and disability in children, and in fact, more children die from trauma-related injuries than all other diseases combined.

*  REACH teams transport approximately 600 pediatric patients each year.