I have to admit some of my fondest childhood memories were made on our family trampoline. However, my mom, also an ER nurse, had the strictest rules in the neighborhood. She required permission slips, no more than one jumper at a time, and always insisted on adult supervision. She even kicked a kid out of our yard once for breaking the rules. A huge embarrassment to me until I learned the kid went down the street to another trampoline and promptly broke her arm.

Injury statistics for trampolines are dismal and led to the 2012 (reaffirmed in 2015) American Academy of Pediatrics (AAP) policy stating that home use of trampolines is dangerous for children and should be strongly discouraged. Sales of bounce houses, trampolines, and outdoor toys have jumped worldwide as families practice COVID-19 social distancing. As we head into our 2020 trauma season we will likely see an increase in trampoline injuries.

The trampoline was created in the 1930s and the first reported trampoline-related injury dates back to 1956.

In recent years, trampoline injuries have become an increasingly common. Between 2002 and 2011:

• Trampoline-related injuries accounted for an estimated one million emergency department (ED) visits.
• Health care costs for these injuries exceeded one billion dollars.
• Children younger than 16 sustain 96% of trampoline-related injuries.
• One in 200 injuries leads to permanent neurological damage.
  

As reports of injuries have increased, the American Academy of Pediatrics (AAP) has strongly discouraged the use of trampolines. The AAP recommends both mini and full-sized trampolines never be used at home, in routine gym classes, or on playgrounds.

Fractures account for nearly 1/3 of trampoline-related ED visits. In the most recent decade, the incidence of pediatric trampoline fractures per person increased by an annual average of 3.85%. In 2017, trampolines were the cause of nearly one in 16 pediatric fractures presenting to an ED in the United States. The highest incidence of fractures occurred in children between the ages of 5 and 9 years old. Radius and ulnar fractures are the most common type of fracture seen overall. Despite an increase in fractures, however, the hospitalization rate for trampoline injuries has remained relatively constant. Approximately 12% of children are hospitalized for their trampoline-associated injury and 20-30% of children require surgical intervention. The most feared trampoline injuries are those sustained to the head and neck. Head and/or neck injuries account for 10-17% of all trampoline-related injuries and 0.5% of all trampoline injuries result in permanent neurologic damage.

• Approximately 75% of trampoline injuries occur when more than one child is on the equipment.
• A smaller child is fourteen times more likely to be injured than a larger child.
• Approximately 20% of trampoline injuries are due to direct contact with the springs and frame. Safety features (such as nets or padding) have not been shown to decrease trampoline-related injuries.

Recently, there has been an increase in trampoline parks and outdoor recreation facility trampolines. In 2009, there were fewer than 10 documented parks in existence. In 2018, there were more than 1,000 parks established worldwide. Injuries at trampoline parks are more likely to be musculoskeletal and have a higher chance of leading to hospitalization.

Notably, however, more than 85% of trampoline injuries occur at home. Many homeowner insurance policies have trampoline exclusions or require trampolines to be enclosed with restricted access. The AAP recommends parents check their homeowner's policy and obtain a rider to cover trampoline-related injuries if these are not included in the basic policy.

Treating Fractures

Pain is under-recognized and under-treated in pediatric patients. Effective pain control can improve both the experience for the child and make it easier for you to assess and care for them. One of the most effective ways to aid in your treatment efforts is to distract attention away from the injury. Phones/tablets/toys are great tools to have on hand for this.

Pediatric IV starts can be a significant source of anxiety for providers. IV access can be avoided in some cases by utilizing intranasal administration of medications. This route is an effective way to administer some pain medication, but it does have limitations. The maximum amount of medication is dictated by the volume being administered. If you exceed 2mL of volume in the nose the patient could experience a “drowning sensation” and the med will have minimal additive effect as excess volume is lost down the throat.

For pain control,

• Fentanyl 2 mcg/kg intranasal x 1 (using 50mcg/ml, max 100mcg) is a great option. Its onset of action is 5-10 minutes.
• Midazolam (Versed) is a great medication choice for anxiety. Midazolam should be used with caution in head trauma due to the medication changing mental status assessments. Dosing for midazolam is 0.3mg/kg intranasal x1 (using 5mg/mL, max 5 mg) may repeat x 1 in 10 minutes if needed (max 10mg total). Onset of action is about 4-6 minutes.

Open fractures are also more common as we come into the summer. Antibiotics are required to treat open fractures. The first antibiotic that should be administered is cefazolin 50mg/kg (Max 2000mg). Gustilo-Anderson Classification is a method of classifying an open fracture. Type I = an open fracture with a wound smaller than 1 cm long and clean; Type II = an open fracture with a laceration greater than 1 cm long without extensive soft tissue damage, flaps, or avulsions; and Type III = either an open segmental fracture, an open fracture with extensive soft tissue damage, or a traumatic amputation. This classification helps determine if additional antibiotics are needed. A Type III fracture and those contaminated with soil, require the addition of metronidazole (Flagyl) 10mg/kg (Max 500mg) which will provide additional microbial coverage.

https://www.uptodate.com/contents/osteomyelitis-associated-with-open-fractures-in-adults?search=open%20fracture%20antibiotics&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1 accessed 4/30/2020

Some exciting news! The 2020 update of the Utah EMS Protocol Guidelines has just been released!

On Topic

Trends in Trampoline Fractures: 2008–2017 | Pediatrics

General Prevention - Summer Injuries

Are Adolescent Climbers Aware of the Most Common Youth Climbing Injury and Safe Training Practices? | International Journal of Environmental Research and Public Health

Wildfires Send Kids to ERs for Breathing Problems | U.S. News

Fire Safety Checklist | Safe Kids Worldwide

Burn Treatment & Prevention Tips for Families | HealthyChildren.org

COVID-19 and Kawasaki Disease in Children

There are reports that COVID-19 is manifesting as Kawasaki Disease in children. Numerous cases from the United Kingdom and now from hospitals in New York have alerted us that children exposed to COVID-19 may later develop signs and symptoms of a commonly known childhood disease called Kawasaki Disease. Symptoms are fevers for at least 5 days, rash, lymphadenopathy, red eyes, red lips, and irritability. Treatment is imperative in order to prevent damage to the heart further down the line. If you see a child with this spectrum of illness please consider COVID-19. Protect yourself and encourage them to seek treatment for Kawasaki (aspirin and IVIG).

- Handtevy - Pediatric Emergency Standards, Inc

Recently, hospitals across the US and the UK are sharing stories of children diagnosed with pediatric multi-system inflammatory syndrome. This is a new condition thought to be associated with the novel coronavirus. The symptoms are similar to Kawasaki disease or toxic shock syndrome. Some cases have been severe enough to cause breathing difficulties or injure the heart. The inflammation may occur several weeks after a child was initially infected with coronavirus.
At this point, we are in the very early stages of learning about this syndrome. The number of children requiring ICU level care is very low compared to the total number of cases of COVID-19.
So, does this change anything we should be doing for our children? At this point, no. Continue with social distancing, following cautiously what your local areas are advising.

Seek out medical care if your child develops any of the following:

• Fever of 100.4 or higher for 5 days in a row
• Difficultly breathing
• Severe abdominal pain
• Dehydration
• Chest pain
• Lethargy, irritability, or confusion

@drjuliarawlins

COVID-19 Surge Preparations at Primary Children’s Hospital

Many have asked how will Primary Children's Hospital (PCH) be utilized if COVID-19 patient volumes surge in Utah? Intermountain is working with other health systems to prepare for this. Primary Children’s Hospital has a specific role in this system-wide plan.

Primary Children’s Hospital’s role in the system COVID-19 Surge Plan

• First, if there is increased disease in the community and a growing need for beds, all inpatient pediatric hospital care at Intermountain facilities across the Wasatch Front will temporarily move to be provided solely at Primary Children’s Hospital in Salt Lake City. By temporarily converting the Utah Valley, Riverton, and McKay-Dee pediatric inpatient units to adult care units, those hospitals will be able to increase their capacity to care for a potential surge in adult COVID-19 patients.
• Second, Primary Children’s Hospital in Salt Lake City may temporarily increase the admission age to 30 years of age or younger, if the need arises. We are actively developing inclusion and exclusion criteria for these older patients right now, and will inform you if and when this may occur.
  
• Third, we may also transfer pediatric patients from post-acute care facilities to Primary Children’s. This will allow those beds at the post-acute care site to be then converted to adult beds to better serve the community at large. We will provide ongoing information about any developments.
  

This plan is constantly being reviewed and will evolve with the needs of the community but rest assured PCH is preparing and is living up to their mantra of keeping the child first and always.

COVID-19 - New Resources for Helping Families and Healthcare Staff

The impact of the Coronavirus/COVID-19 pandemic goes beyond the threat of infection and physical disease. This evolving situation also has a psychological and emotional impact. The Center for Pediatric Traumatic Stress has updated their online toolbox to provide resources to help families and care providers navigate our current reality.

What you'll find:

Resources for children and families - Learn how to help your child cope, downloadable tipsheets, and additional resources.

Resources for healthcare staff - Learn how stress of the pandemic impacts healthcare staff, how to build coping and resilience skills, and signs of secondary traumatic stress.

https://emscimprovement.center/domains/preparedness/covid-19-coronavirus/mental-behavioral-health/healthcare-providers/

Resource For Healthcare Providers

Dear healthcare colleagues;

First of all, THANK YOU for all you are doing. As a pediatric emergency medicine physician with more than 30 years of practice experience, I can only imagine what you and your healthcare provider teams are going through. As a clinical hypnotherapist for more than 15 years, I introduce hypnosis into my medical practice. Hypnosis activates the parasympathetic system which brings about a state of perceived safety for the body. When the body is in this state of perceived state, the immune system functions at peak levels. Therefore, in order to help boost the immune system of your healthcare providers, please see the links below which are audio self-hypnosis sessions specifically for healthcare providers. They are shorter than 20 minutes each and are in 'voice only' and 'voice plus music' formats. There is a session to prepare before a shift and a session to listen to after leaving a shift.
https://sapienwellness.com/covid-19-resources/

Robert Sapién, MD, MMM
CMO, sapienWELLNESS, LLC

From the Children's Safety Network

Coronavirus Resources & Tips for Parents

Ways to Promote Children’s Resilience to the COVID-19 Pandemic | Child Trends

Parent’s Checklist to Preventing Injuries During Coronavirus | Safe Kids Worldwide

COVID-19 Resources | The Network for Public Health Law

How to Talk to Children About the Coronavirus | Harvard Health Publishing

Stay Safe at Home During the COVID-19 Pandemic: Home Safe with Young Children | U.S. Consumer Product Safety Commission

Resources to Support Mental Health and Coping with the Coronavirus (COVID-19) | Suicide Prevention Resource Center

COVID-19 Numbers

Johns Hopkins Global tracker (desktop)

Johns Hopkins Global tracker (mobile)

Utah Department of Health

Thank you to the EMS professionals on the frontlines of the COVID-19 crisis. We understand the 2020 EMS Week is probably not a top priority as the COVID-19 crisis continues. We all recognize that EMS professionals spend time on the crisis everyday; planning, adapting, and responding to take care of their citizens and communities. Because of the impact of COVID-19 on many EMS services across the nation it is unlikely they will be able to celebrate and participate in EMS Week in the normal ways.

As a result, this year’s campaign will focus on recognizing the selfless calling that makes EMS so vital. The 2020 EMS Week theme is Ready Today. Preparing for Tomorrow. This theme, which was developed long before the COVID-19 crisis, is particularly meaningful now as we see the EMS community rallying to continue supporting those affected by this crisis, all while still responding to the everyday emergencies that continue to occur in their communities. All while dealing with challenges, such as the lack of access to appropriate PPE and fellow workers who are stricken with this virus. Now more than ever, it is important that we honor and celebrate our EMS professionals who are supporting the health and well-being of our nation. Especially those brave individuals who give the ultimate sacrifice with their lives.

We will be sharing through the EMS Week/EMS Strong web pages information on ways to recognize our EMS heroes. There will also be information on personal safety and mental health to help protect our EMS personnel who are experiencing adverse effects of their experiences during this crisis. We will be planning a special EMS Strong celebration later in the year once the COVID-19 crisis is over and will be sharing more details once they are finalized. We will use this special celebration to honor and celebrate our EMS professionals who supported the health and well-being of our nation during the crisis.

We send our best wishes for the safety and health of all EMS personnel on the first lines.
Presented by ACEP in partnership with the National Association of EMTs (NAEMT)

• Emergency Medical Services for Children (EMSC) Day - May 20, 2020
• 2020 EMS STRONG theme - "Ready Today. Preparing For Tomorrow"

We always look forward to spending breakfast with our EMS providers on EMSC Day up at Primary Children's Hospital. This year COVID-19 has cancelled our plans. Each and every one of you make such a difference in the care we provide to the children of this state. They appreciate it, we appreciate it, and while we may not be able to celebrate with you, we are sending you good wishes from 6 feet away!

- Your EMSC Staff

Do you have a question for our EMSC Medical Director, Hilary Hewes, MD, PCH, ER Attending Physician about this newsletter topic or anything pediatric related? Shoot an email to the address below and look for her response in our next newsletter.

tdickson@utah.gov

The National Pediatric Readiness (NPRP) Assessment, scheduled to launch in June 2020, has been postponed due to the rapidly evolving situation with COVID-19. We appreciate the tireless efforts of the EMS and EMSC community to prioritize their state response to these changing health needs. We will provide more detail on the timing of the NPRP Assessment as details emerge. Visit www.pedsready.org to stay current on assessment details. We wish continued health and safety to all.

Contact PCH EMS Liasion Lynsey Cooper at Lynsey.Cooper@imail.org

OR use the dedicated EMS follow up email

PCH-EDRTU-EMS@imail.org

If you are a pediatric advocate within your agency, we need you. Please contact our program manager, Brianne Glenn (brianneglenn@utah.gov) to find out how you can help.

The Emergency Medical Services for Children (EMSC) Program aims to ensure that emergency medical care for the ill and injured child or adolescent is well integrated into an emergency medical service system. We work to ensure that the system is backed by optimal resources and that the entire spectrum of emergency services (prevention, acute care, and rehabilitation) is provided to children and adolescents, no matter where they live, attend school, or travel.

Email: tdickson@utah.gov
Website: https://bemsp.utah.gov/
Phone: 801-707-3763
Facebook: facebook.com/Chirp-UtahDepartmentofHealth