# Child in MVA



## leadfall (Dec 27, 2009)

So here is the question.  What are your thoughts on children in car seats in an MVA being removed vs packaged in the car seat?  What are your reasons for doing one or the other?  and how do you transport the car seat in the ambulance now that the car seat retention straps have most likely been cut during the extrication?


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## medichopeful (Dec 27, 2009)

leadfall said:


> So here is the question.  What are your thoughts on children in car seats in an MVA being removed vs packaged in the car seat?  What are your reasons for doing one or the other?  and how do you transport the car seat in the ambulance now that the car seat retention straps have most likely been cut during the extrication?



It depends: will the seat provide good stabilization of the back and neck?  If it will (with extra help from padding, etc.), than why remove them and risk possibly hurting them?  If they're in a secure position that can be transported, there's no reason to actually move them.  The point of spinal precautions is to prevent movement, which could aggravate or worsen a previous injury.  So if that movement can be prevented by keeping them in the seat, go for it!  Do what's best for the patient.  

Remember, the stretcher has straps too.  Use them to secure the car seat.  But make DAMN sure that car seat is strapped to something.  If YOU get in an accident and the seat is not secured, that patient does not have a chance.


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## Lifeguards For Life (Dec 27, 2009)

medichopeful said:


> Remember, the stretcher has straps too.  Use them to secure the car seat.  But make DAMN sure that car seat is strapped to something.  If YOU get in an accident and the seat is not secured, that patient does not have a chance.



Many ambulances allow for a car seat to be securely fastened in to the air chair.


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## wyoskibum (Dec 27, 2009)

leadfall said:


> So here is the question.  What are your thoughts on children in car seats in an MVA being removed vs packaged in the car seat?  What are your reasons for doing one or the other?  and how do you transport the car seat in the ambulance now that the car seat retention straps have most likely been cut during the extrication?



It is going to depend on how bad the MOI is.  Minor fender bender with no indication of injuries, but parents want transport to get child "checked out" vs severe MOI, major damage to vehicle, injuries to other occupants.

If the child is going to be a patient, then I will most likely transfer from child seat to backboard & gurney so I can do a good physical exam and have access to provide care.


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## JPINFV (Dec 27, 2009)

Lifeguards For Life said:


> Many ambulances allow for a car seat to be securely fastened in to the air chair.



All ambulances have stretchers that can properly secure a car seat. You might have to move a few seat belt straps around, but it is definitely possible.


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## firemedic1563 (Dec 28, 2009)

There are experts and authors of EMS texts that recommend both, in the same literature often times. They all tend to agree that it is only appropriate in more minor MVC's. But to answer your questions:

1. My thoughts: personally, I don't find that most car seats give proper positioning for securing an child/infant that you already suspect that at the least there is mechanism to potentially cause a spinal injury. First, there is no mechanism allowing for the larger heads. You could add padding under the shoulder, but if your going to manipulate them that much, why not remove them to a board? Second, while you can certainly support lateral movement with a horeshoe roll, every stop you make is going to tend to move the head forward against any tape, and with many car seats, the edge that you would normally secure the tape to may be higher than the head itself. The carseat would have to be transported sitting up. 

2. Why? Foremost because I dont believe that I can do an adequate physical assesment, to include the posterior. I also don't believe the car seat ensures proper immobilization and positioning to maintain an airway. Third, car seats that have sustained the force of any decent collision should not be used as they may no longer be structurally sound. Finally, our state protocols FORBID it, as the specific team protocols for the Pediatric Critical Care Team for which I work occasionally.


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## EMSBLONDIE24 (Dec 28, 2009)

I usually remove the child from the car seat and place them on a long board, especially in a serious accident. If it's a minor fender bender and the parents simply want the baby checked out, I might leave the child in the car seat. That would really be determined on scene though, from what I see of the accident damage and the child's general appearance.
Ideally, the child (in my opinion) should be lying flat and straight so the body falls in a  natural line or position. This allows you to do a full assessment and makes any abnormalities (laceration, swelling etc) more obvious than if a child was still in the seat and their legs are bent, back and spine are inaccessible etc.  As bought up by someone else, a postier check can't be done in a car seat. And what if a splint had to be created or a wound wrapped? Car seats would make that a difficult task. Also, if the child must suddenly be intubated :sad: or has difficultly breathing, I want them flat in case airways have to be inserted, CPR must be performed, IVs inserted etc.  
As to answering the second part of your question, if the car seat straps have already been cut I'd use cravats. Car seats have plenty of hooks to tie them to and hey, cravats can be used for pretty much anything!


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## medichopeful (Dec 28, 2009)

EMSBLONDIE24 said:


> As to answering the second part of your question, if the car seat straps have already been cut I'd use cravats. Car seats have plenty of hooks to tie them to and hey, cravats can be used for pretty much anything!



Are cravats really strong enough to hold a car seat in an MVC?


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## Lifeguards For Life (Dec 28, 2009)

medichopeful said:


> Are cravats really strong enough to hold a car seat in an MVC?



What is a Cravat?


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## WTEngel (Dec 29, 2009)

Interesting conversation...

As for utilizing the car seat in the ambulance, keep in mind that most manufacturers recommend that the car seat be discarded after any accident, as the structural integrity may have been compromised. This is one way that car seats help protect, is that they will deform and absorb the impact. 

I say this because if you were to have another accident in the ambulance while transporting, the protection of the car seat could come into question.

Where I work we have gone to many referral hospitals that have received the child in a car seat from EMS and kept the child immobilized in that car seat. The first thing we do is remove the child from the car seat, place them on a rigid board, and package them appropriately. As someone mentioned earlier, it is not possible to do a proper assessment with the child in the car seat. I have heard the argument before that the agitation caused by removing the child and boarding them may outweigh the benefit, however, there is no substitute for the evidence based practice of proper spinal immobilization. I know that proper spinal immobilization is defensible in court, I am not sure how defensible packaging in the car seat is...that is between you and your medical direction.

Not to hijack the thread, but nothing frustrates me more than to see EMS transporting children on the parents lap on the stretcher. This is incredibly dangerous. Some would argue that they do not want to seperate the parent from the child, however, sometimes this just is not possible to avoid. Some medics will not immobilize an extremity or use c spine precautions because it cuases too much distress for the child. I have heard some medics attempt to excuse not placing an IV in a child because they did not want to hurt or agitate the child. This is all well and good for the child who does not need an IV, but the children who do need one will need one regardless of whether it hurts or agitates them. Unfortunately treating children is rarely fun, but this is no excuse to not do it appropriately because it may cause the child some discomfort or agitiation. Sorry to get on my soapbox, but I have worked with peds for 2 years now, and I just see some things that make me want to scream some days! I will climb off of my soapbox now...

BTW, a cravat is better known as a triangle bandage in some areas...


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## JPINFV (Dec 29, 2009)

WTEngel said:


> there is no substitute for the evidence based practice of proper spinal immobilization.



Now that's a contradiction of terms.


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## reaper (Dec 29, 2009)

Ain't that the truth!


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## WTEngel (Dec 29, 2009)

Bear in mind I said "proper" immobilization...rarely achieved due to many circumstances...


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## JPINFV (Dec 29, 2009)

I don't think I've ever seen a published study that has shown a decrease in secondary injury due to spinal immobilization. I accept that spinal immobilization is the standard of care. I'll accept that showing benifit is hard considering how over used spinal immobilization is. I'll accept that studying the benefits of spinal immobilization is hard to do. I'll accept that lack of evidence is not the same as no benefit. However, I don't think I'd apply the phrase "evidence based" to spinal immobilization at this time.


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## Lifeguards For Life (Dec 29, 2009)

JPINFV said:


> I don't think I've ever seen a published study that has shown a decrease in secondary injury due to spinal immobilization. I accept that spinal immobilization is the standard of care. I'll accept that showing benifit is hard considering how over used spinal immobilization is. I'll accept that studying the benefits of spinal immobilization is hard to do. I'll accept that lack of evidence is not the same as no benefit. However, I don't think I'd apply the phrase "evidence based" to spinal immobilization at this time.





> Hauswald M, Ong G, Tandberg D, et al: "Out-of-hospital spinal immobilization: Its effect on neurologic injury." Academic Emergency Medicine. 5(3):214–219, 1998.
> 
> The University of New Mexico (UNM) School of Medicine has an excellent Department of Emergency Medicine. In this study, one of their faculty members, Mark Hauswald, performed an interesting study. Dr. Hauswald retrospectively reviewed all cases of prehospital spinal immobilization brought to the UNM Medical Center over a five-year period. Then, these were compared with cases from a similar hospital in Malaysia for the same five-year period.
> 
> ...


. 
Are traumatic injuries involving the spine in a third world country, compatible with traumatic injuries in the U.S

But what is the scientific evidence to support field stabilization of the spine? To be honest, there is none — none then, none now. Back then, there was no structure in place to perform prehospital research. And now, it would be difficult to get approval for a study that withholds field spinal stabilization.

So what do we currently know about this frequently practiced skill?

1.*Correctly performed spinal stabilization* can effectively limit — but not eliminate — spine movement.
2.Very few patients undergoing prehospital spinal stabilization have a spinal fracture.
3.Potential adverse effects of spinal stabilization include: pain, pressure ulcers, respiratory compromise, and aspiration.
4.There is little scientific proof that field spinal stabilization saves lives or limits disability.


> It is estimated that 3% to 25% of spinal cord injuries occur after
> the initial traumatic insult, either during transit or early in the course of
> management.(11,12,40,46,78,92) Multiple cases of poor outcome from mishandling of cervical
> spinal injuries have been reported.(9,49,78,92) As many as 20% of spinal column injuries involve
> ...





> Overall, 180 consecutive patient records were reviewed. They were separated into two groups. Group one arrived by EMS, and group two by police and private vehicle (P/PV). Out of those, 88 arrived by EMS and 92 by P/PV (77 by police and 15 by private vehicle). Seven of the 88 (8.0%) EMS patients survived to hospital discharge compared to 16 or 92 (17.4%) of those that arrived by P/PV.
> 
> Time to injury and arrival at the hospital was not because it was unavailable or unreliable from the P/PV group. The mean EMS pre-hospital time was 19.0 +/- 9.0 (range, 5-54) minutes. The EMS patients more often exhibited signs of life in the field and had a lower injury severity scored in comparison to the P/PV group. Moreover, EMS patients were more likely to lose SOL prior to ED arrival despite more aggressive attempts at CPR.


http://www.jems.com/news_and_articles/columns/Wesley/Scoop_and_Run.html
http://www.spineuniverse.com/pdf/traumaguide/1.pdf
http://www.wildernessdoc.com/assets...Smith CSEC Telluride Spine Appendix Notes.pdf
http://pdm.medicine.wisc.edu/Volume_20/issue_1/kwan.pdf


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## firemedic1563 (Dec 29, 2009)

The benefits of spinal immobilization are without a doubt controversial. That is another debate. I would argue that while it MAY not be beneficial in the vast majority of cases, I would not want to be the provider who did not apply it to the neurolgically intact trauma victim, only to have them moved and havea disability.

Now, to take over the soapbox from the previous poster. Would you place an adult patient on the stretcher in their car seat? Ok, a bit of an exageration, but would you? A good rescue company could cut their seat out with no problem. Why then transport the injured/potentially injured child in theirs(which may have already sustained damage that would make it fail in an ambulace MVC).

Its quite easy, and not very time consuming to rapidly move the child to a pediatric imobilizer with just a padded board splint and two or three providers. Our interfaciltiy pediatric team has the policy of immobilizing ALL trauma's except for isolated extremeties. Know why? Because even in the local ED setting, spinal injuries have been ruled out when there was in fact one found once at the pediatric trauma center.


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## EMSBLONDIE24 (Dec 29, 2009)

medichopeful said:


> Are cravats really strong enough to hold a car seat in an MVC?



I wouldn't use them to permanently secure the child in the car seat, just on the way to the hospital if it was determined the child would remain in the car seat and the straps were cut. 
Hope that makes sense...


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## EMSBLONDIE24 (Dec 29, 2009)

Lifeguards For Life said:


> What is a Cravat?



Cravat- otherwise known as a triangular bandage. Sorry, my Squad calls them cravats, I know others call them triangular bandages


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## JPINFV (Dec 29, 2009)

firemedic1563 said:


> I would not want to be the provider who did not apply it to the neurolgically intact trauma victim, only to have them moved and havea disability.



Are you including patients who meet Canadian C-Spine or NEXUS criteria to forgo spinal immobilization?


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## gcarlisle (Dec 29, 2009)

with my limited experience, I have to agree with firemedic. Even beyond the argument of benefit of pre-hospital spinal immobilization, what EMT/Paramedic would want the liability of their patient having a spinal injury and it coming back to them in a lawsuit with the patient saying that it was the fault of the provider and having the provider lose their license?

Now, on the main topic, I've heard arguments that leaving a child in a car seat is less harmful than moving the child to a backboard, but there is no way to complete a thorough examination of the posterior without moving a child from a car seat, so why would you move the child, then put them back in the car seat?


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## WTEngel (Dec 29, 2009)

+ 1 firemedic


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## firemedic1563 (Dec 30, 2009)

JPINFV said:


> Are you including patients who meet Canadian C-Spine or NEXUS criteria to forgo spinal immobilization?



To be honest, I am not familiar with either. My protocols aside, I feel that if there is a mechanism that carries the possibility of spinal injury, than the patient should be immobilized until injury is ruled out. Keep in mind that the mechanism required is much less for infants and young children. That said, our local protocols and trauma decision tree, much debated nationally and revised following the crash of our Trooper 2, are pretty clear on who we immobilze. We are forbidden to use car seats to immobilize. And any child under the age of 8, who has sustained a "traumatic mechanism which could cause spinal injury" must be immobilized.

I am well aware of the studies. But the fact is that spinal immobilization, at least in the US is the standard of care. Much like NFPA standards and other standards, they may not be law (in many cases, like our protocols, they are), but courts will hold providers to standards of care. Now I can't speak for other areas protocols which may endorse other methods, but I truly beleive a car seat is not an acceptable method of true immobilization, and certainly limits assesment and potentially treatments


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## Aidey (Dec 30, 2009)

I'm curious as to what methods people use to immobilize infants, or those too small for the pediatric back board/mummy wrap.


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## firemedic1563 (Dec 30, 2009)

Aidey said:


> I'm curious as to what methods people use to immobilize infants, or those too small for the pediatric back board/mummy wrap.




Excellent question. Here we carry pediatric immbilizers that I have secured as small as a 1 month to. In lieu of a cervical collar on a small infant, a horseshoe roll(blanket) can be used to wrap the sides and top of head and tape used on forehead and chin. To transfer the infant from carseat to board, lay the seat back, remove straps, place a padded board splint as a bridge between the seat and the board and slide the patient over the head of the carseat onto the board.


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## medichopeful (Dec 30, 2009)

EMSBLONDIE24 said:


> I wouldn't use them to permanently secure the child in the car seat, just on the way to the hospital if it was determined the child would remain in the car seat and the straps were cut.
> Hope that makes sense...



Yes, that does make sense, but I don't think you realized what I meant.  I probably wasn't clear.

If you are using cravats to secure a seat in an ambulance, and there is an accident, are those cravats REALLY going to do a good job of securing the seat?


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## EMSLaw (Dec 30, 2009)

Aidey said:


> I'm curious as to what methods people use to immobilize infants, or those too small for the pediatric back board/mummy wrap.



You can use a KED for pediatric immobilization, though I'm not sure it would work for an infant.  

An article on it is located here in PDF.


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## CAOX3 (Dec 30, 2009)

EMSLaw said:


> You can use a KED for pediatric immobilization, though I'm not sure it would work for an infant.
> 
> An article on it is located here in PDF.



Good point we often use the KED for immobilization of children.

We have infant devices but we use the ked for the patients that fall in between the infant immobilization device and long board.


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## RescueYou (Dec 31, 2009)

I normally keep it if it passes this checklist:
~the carseat allows for good head/neck/spinal stabilization
~your stretcher allows for it
~the carseat can be safely strapped onto the stretcher
~the seat does not prevent other necessary treatment interventions
~the child is comfortable enough for a ride to the hospital in it with the injuries
~it's not going to be a super hard pain on you to get the whole contraption out of the car
~the child has good ABCs and no significant MOIs
~the scene is completely safe and allows for you to remove the carseat
~the carseat is not covered in any bodily fluids whether they be the child's or not

If ALL of those pass, then I'll normally keep them in it but it always depends on the situation.


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