With the move to DPS, EMSC will be changing the software used to create the EMSC Connects newsletter. The format and email address that you receive this publication from will be different, likely starting with our the next issue. Please reach out if you are having any difficulty accessing future issues. Tdickson@utah.gov

Tia Dickson, RN, BSN

Primary Children's Hospital

Injury is the leading cause of death in children and adolescents. Bleeding can be severe enough to warrant massive transfusion protocol (MTP) activations. In adults, the use of balanced resuscitation and study of MTP have led to improved outcomes. In children, MTP requires further research, development and standardization. Primary Children's is on the cutting edge of this research and our expert today will give us a basic understanding of this life saving practice.

Chance Basinger, MPA, MPAS, PA-C

PCH Miller Campus, Intermountain Trauma Services

Excerpts from July 8, 2024 PETOS

It is difficult to talk about massive transfusion protocols (MTP) without first talking about the causes of death for children. In the United States, unintentional injury or trauma is still the leading cause of death by far. The 10 leading causes of death for children 1-18 years are listed below.

Since 2019 the leading cause of death among children and adolescents in the Unites States is firearm injury, surpassing the historically number 1 motor vehicle crashes. Tragically, in Utah 88% of our firearm deaths are suicides.

Another important point is that 90% of pediatric emergency ED visits take place in a local or general hospitals and at least 50% of admitted injured children at pediatric trauma centers are transfers. This means the initial resuscitation of injured children is generally NOT provided by pediatric specialists.

Shock is poorly recognized in children

• Shock in peds does not equal hypotension
• Hypotension is often a LATE finding
• Clinical presentation of shock is variable

There are common presenting symptoms prior to hypotension

• Tachycardia: nonspecific (not related to fever or crying), the most important early indicator
• Skin changes: cool, clammy, pale and mottles in cold shock or flushed with flash capillary refill in warm shock
• Impaired mental status: listless or agitated
• Lactic acidosis: increased lactic acid production caused by inadequate delivery of oxygen and decreased clearance of lactate by the liver, kidneys and skeletal muscle

When a child is in hemorrhagic shock, they need volume resuscitation with what they have lost. A bleeding patient should be resuscitated with blood or blood products in a balanced ratio. Studies have shown that children who receive a high ratio of FFP/RBC resuscitation have survival advantage.

Even though it can be life saving, few children receive blood prior to arrival at a pediatric center. Utah's EMS ground agencies are not yet carrying blood products and many outside facilities are uncomfortable or unequipped to give blood to children. One study showed that in the rare circumstance a child is transfused outside a pediatric center, they were under-resuscitated.

There is no standardized definition of massive transfusion in pediatrics and the data we do have comes from adult research. What we do know is delays in recognizing shock and pulling the trigger on an MTP will effect the child's survivability (Every minute counts: Time to delivery of initial massive transfusion cooler and its impact on mortality).

There are two primary hemostatic resuscitation options

• Empiric transfusion uses RBSc, plasma, and platelets in a 1:1:1 unit ratio or low titer group O whole blood.
• Goal directed hemostatic resuscitation uses labs (TEG/ROTEM) in real time to identify what blood component the patient is missing and replacing that.

There is very little data into whole blood vs. component transfusion in pediatrics. Primary Children's Hospital has just joined a study to look into this. Initial studies that have shown whole blood resuscitation is safe in pediatric trauma patients. And some have reported it to be superior to component therapy.

Advantages of whole blood resuscitation:

• Volume of product required for component therapy (680ml) is less for whole blood (500ml)
• There are far less additives and anticoagulants in the whole blood product
• Whole blood costs less than component therapy

• Helps reduce fibrinolysis and clot degradation
• Antifibrinolytic - by blocking plasmin. Healthy tissue cells release normal amounts of tPA, damaged cells release larger amounts of tPA.
• Loading dose: 1000mg in 100ml sodium chloride IV over 10 mintues
• Maintenance dose 1000mg in 500ml sodium chloride over the next 8 hrs

• Citrate preservatives are added to blood products, citrate binds to calcium, making it inactive
• Calcium cleaves to clotting factor to help activate it
• 2 grams (27.2 mEq) in 100ml sodium chloride IV over 10 minutes
• PCH used calcium gluconate
• Use extreme caution when infusing through a peripheral IV

• Helps trigger Von Willebrand Factor and Factor VIII release improving adhesion and aggregation of platelets.
• Consider based on TEG results
• Dose 0.3 mcg/kg in 100ml sodium chloride IV over 20 minutes

• Cold insoluble portion of plasma that precipitates when FFP is thawed
• Cryoprecipitate contains high levels of Factor VIII and Fibrinogen

In June of 2022 Primary Children's Hospital implemented a set massive transfusion protocol. If a hemorrhaging patient has required up to 40cc/kg of saline we will activate our MTP. An Advanced Pediatric Practitioner (APP) led MTP team will respond.

• Trauma APP - writes orders and directs the care
• ED Trauma RN - delivers the product (using a Belmont fast infusing fluid warmer)
• ED Tech - runs to and from the blood bank to deliver the product to the team

The team uses a tracking worksheet to guide the resuscitation. Under 20 kg we use a weight based dosing, greater than 20kg will get unit dosing. The implementation of this protocol has increased our balanced resuscitation rates to 85%. Primary Children's helped the UPTN to develop an MTP similar to theirs that is available to all.

• While ground EMS are not carrying blood products, they do play an important role in early recognition of shock.
• Obtaining and securing good access will smooth the resuscitation process.
• If you suspect your patient is in shock, quick communication with your receiving facility can help them prepare.
• Encourage those hospitals to consider early blood transfusion especially if you've already given 40cc/kg of crystalloid.
  
• When your patient is actively bleeding, consider using transfusion adjuncts if you carry them.

For additional guideline direction check out the UPTN website or the new app, "Utah PTN" on android and apple devices.

Training officers may review the topic above as a team training AND perform a simulation/skills check as directed. Once complete, send a roster of participants to Utah.PETOS@gmail.com and those listed will be issued 1-hour of CME credit from the DHHS Office of EMS and Preparedness.

Individuals who don't have a training officer can get CME credit on their own by viewing a PETOS presentation in our archives and completing the instructions on the webpage.

1. Discuss and practice pediatric IV insertion.
2. Discuss and practice IO sites and insertion using your agency equipment
3. Practice pediatric fluid administration
4. If you carry the transfusion adjuncts discussed in this NL, practice dosing and administration of those specific to your agency.

Thank you to the almost 7,000 EMS and fire-rescue agency participants in our national initiative to measure and improve prehospital care for children! A special thanks to State Partnership program managers and the EMSC Data Center (EDC) for their dedication in engaging agencies in the assessment and to the EDC for facilitating the assessment. The EDC will spend several months cleaning and analyzing the data. Results will be shared in the coming months. Agencies will be encouraged to use their gap reports to explore the Prehospital Pediatric Readiness Project Toolkit. If your agency can’t find a copy of its gap report, contact your state manager (Jared Wright jaredwright@utah.gov).

Ensure your next pediatric interfacility transfer is smooth sailing. Access the updated Pediatric Interfacility Transfer Guide: https://bit.ly/3yVmZ9D

National EMSC has a newsletter filled with fantastic pediatric information, resources, and links. Check it out!

Utah EMS and fire-rescue agencies ROCK! We were able to achieve a 99% response rate on the National Prehospital Pediatric Readiness Survey. Only 1 agency did not complete the survey. This excellent response means the data you've collected will give us a truly accurate picture of pediatric readiness in Utah. We plan to use this data to direct EMSC activities, funding and efforts in the future to improve the care of our children in Utah and in the nation. Thank You!

If your agency is interested in Jeff's autism training or in receiving the free John Wilson autism kits, contact Jeff @jeffwilson122615@gmail.com.

Look for Jeff at EMS World and on Wednesday at 10:00 pm on the channel 2 news!

The Medical Home Portal is a unique source of reliable information about children and youth who have special health care needs (CYSHCN) and offers a “one-stop shop” for their:

· families

· physicians and medical home teams

· other professionals and caregivers

The presence of pediatric emergency care coordinators (PECCs) in EDs significantly increases pediatric readiness scores and is considered the most effective strategy for improving pediatric emergency care.

National guidelines recommend every ED have one nurse and one physician PECC. To assist ED clinicians in taking on the PECC role, the EMSC Program is creating a learning module series. The second module, “The Role of the Pediatric Emergency Care Coordinator and Pediatric Readiness,” is now available. This module, along with the first, can be found here [trm4toyab.cc.rs6.net]. The modules take an estimated 20 minutes to complete and completion certificates are available.

For hospital PECCs

• EMSC has launched its first pediatric emergency care coordinator (PECC) learning module for ED-based PECCs. You are invited to view the module and provide feedback.

For EMS PECCs

• EMS PECC resources can be found on the EIIC website here.

The Emergency Medical Services for Children (EMSC) Program aims to ensure emergency medical care for the ill and injured child or adolescent is well integrated into an emergency medical service system. We work to ensure 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, regardless of where they live, attend school, or travel.

Email: tdickson@utah.gov
Website: https://bemsp.utah.gov/
Phone: (801) 707-3763