# Pediatric head trauma



## RedAirplane (May 1, 2015)

You're on a break when a huge swarm of people converging upon you. There's a woman holding a child, and a man and some other kids in tow. 

The lady reports her 3yo daughter fell out of the car head first into pavement. The child reported inability to breathe immediately following the incident. 

The patient has pale skin, is not crying, and has a 1cm laceration as well as not icicle swelling to the head. Pupils unreactive. Patient can answer questions and obey commands. 

V/S WNL

Mom and dad want kid to be transported to the emergency room at Our Lady of rhe Worthless Miracle. 

This would be straightforward if it were an adult. Any tips for dealing with kid? How do you explain things like ice and gauze without terrifying her?


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## Ewok Jerky (May 1, 2015)

What is "not icicle swelling to the head"? Is that a typo?

Im not exactly clear here, so she was unresponsive and not breathing, but is now alert and A&Ox3?

How far is the pedi ED vs local ED? What are the actual vitals? Both pupils are unreactive? Any other neuro finding? Does she appear sleepy?

I need to be more sure of the scenerio before I pass judgement.


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## RedAirplane (May 1, 2015)

Noticible swelling

(Yes a typo)

Never lost consciousness. Complained to mom that she couldn't breathe immediately after impact 

both pupils unreactive but it could be just the ambient light 

She was acting quiet, reserved, but mom says that's normal for her. 

You have your choice of every hospital under the sun, all within 10 minutes L&S or 15 minutes normally


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## RedAirplane (May 1, 2015)

HR 96
RR 26


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## Ewok Jerky (May 1, 2015)

How did she fall out of the car? Slip and fall or something similar? Fever/recent illness?

So she fell out of the car, told her mom she couldnt breath, but moments later is without complaint and physical exam is negative? I will give a comfortable ride to whatever ED her parents want as long as they accept kids. Don't necessarily need a peeds level 1.

but my spidey sense is tingling that there is more to the story.


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## RedAirplane (May 1, 2015)

Not so much concerned about that part as-- how to deal with kids? (Mannerisms)

I'm awkward enough with adults. I'm terrified that kids may be terrified of me

yes the MOI is ambiguous but can't get more into unfortunately


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## RedAirplane (May 1, 2015)

(Also, since I don't do transport, just first reapinse, I usually pass the hospital preference up the chain. I know when trauma, STEMI, and stroke centers are appropriate, but am less certain about pediatric, especially since all hospitals are required to accept all patients?)


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## Angel (May 1, 2015)

they are but given the distance you are better off taking them to a trauma center since they will most likely (if they are) be transferred out later. 
I tend to always bribe kids with watching cartoon stuff on my phone
i always call the BP cuff inflating an 'arm hug'
and try to smile a lot, explain each and every thing I will be doing to them as I'm doing it.


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## Flying (May 1, 2015)

Angel already went over most of it.

Smile.
Keep the parents involved.
Distraction. I try to start a simple conversation before doing anything. Common topics: favorite foods, school, bikes.
Explain everything you are doing. You don't necessarily have to use simple vocabulary, but it definitely helps.

I did none of that when I was in a position similar to yours and looked like a total schmuck.


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## RedAirplane (May 1, 2015)

I like the "arm hug." Do you usually take BP on pediatrics? For some reason I recall BP being de-emphasized under age 12.


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## cruiseforever (May 1, 2015)

Bubbles are one of the best things that I have found to keep a child occupied.


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## RedAirplane (May 1, 2015)

Bubbles?


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## LACoGurneyjockey (May 1, 2015)

If the kids scared of you and a bunch of other strangers in weird yellow pants all standing around her and doing strange things to her, that's a good mental status. I'm a lot more concerned when we walk in and the 3 year old is unphased.
We stock beanie babies in the unit. I wanna try the bubbles. Time permitting, show them what you're gonna do on yourself or the parent so they know it's not gonna hurt. Talk to them about whatever they'll talk abou, school, siblings, what they were doing for fun earlier, whatever. Use the parents to your advantage to calm the child, and emphasize to the parent that if they're calm or anxious themselves, the child's attitude will follow accordingly.
And for future reference, most likely you're not gonna have a normal mental status and pupils non-react. Check them again in the unit where there's less light, or cover one eye and watch it's response when you uncover it in the light.


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## Ewok Jerky (May 1, 2015)

Ice and gauze aren't terrifying. Kids who are actually hurt are usually ok with me treating them. I've also had success by enlisting the kids help. "Here is an ice pack do you want to put it on your head where it hurts?" "Can you hold this tape while I wrap your booboo?" Or even have the parent s do it for you.

I've only had very young kids refuse a bp cuff. Just like an adult I document "refused by pulling away/non compliant" or whatever.


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## zzyzx (May 3, 2015)

Based on the mechanism, I don't think you need to take her to a trauma center. You could always do a consult with your base if you are unsure.

 She may or may not get a CT. I don't think she meets criteria for a CT, but it is going to be up to the doctor's preferance.


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## escapedcaliFF (May 3, 2015)

With kids best advice I can give is use a low tone of voice and always explain what your doing using simple explanation before doing it. Kids tend to hate the unknown and are already affraid naturally of strangers so explaining things is definitely a good idea.


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## RedAirplane (May 3, 2015)

The transporting unit ended up going to the non-pediatric community hospital of choice. 

That's their issue, not mine, although I've wondered about how I would make transport decisions if I were in their shoes. 

The main concern was... how to deal with the patient as in words, gestures, attitudes. Pediatrics and geriatrics tend to get me a little anxious, probably because I don't see many.


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## RedAirplane (May 3, 2015)

I appreciate all of your replies.


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## Ewok Jerky (May 3, 2015)

Treat them like humans because that's what they are.


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## Jwan (May 4, 2015)

Ishan said:


> I like the "arm hug." Do you usually take BP on pediatrics? For some reason I recall BP being de-emphasized under age 12.


 
I usually will tell the boys its seeing how strong they are, then whatever number it is I just act very impressed and point to my badge reel (its the incredible hulk) and say that they are stronger than him. Usually after that the kid likes me enough and I can get done whatever I need to get done. I simply use the "arm hug" for female peds.

As far as BP's on peds patients goes, I work on an inpatient pediatrics unit so our BP's are done every four hours unless the child is under 2y.o. however it is widely known that a BP on a child is ultimately useless because when a child is in distress from whatever illness or injury they have they are great at compensating.  They will compensate, compensate, compensate untill they decompensate and crash, so unless you get a perfectly timed BP at the moment they are crashing it wont really show anything symptomatic.

Ultimately when dealing with kids try to remember being a kid. When they are younger they can get excited or terrified at the slightest thing, Just keep it happy, keep them talking and engaged and make it fun. Not every child will be pleasent and there are quite a few who will scream the whole time, just do your best and keep the parents invovled they will appreciate what you are doing even if the child does not.


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## DesertMedic66 (May 4, 2015)

I don't get along with kids in the slightest. My medic school had us spend 4 hours at the schools daycare to help us. It was a very awkward moment for all of us. 

Luckily I work in an area that has a huge number of geriatrics and not an extreme amount of kids. It's usually a very awkward transport. I'll usually have the kids parent in the back to keep them entertained.


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## 281mustang (May 4, 2015)

Ishan said:


> The main concern was... how to deal with the patient as in words, gestures, attitudes. Pediatrics and geriatrics tend to get me a little anxious, probably because I don't see many.


Don't see many geriatrics? Say wha?


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## Carlos Danger (May 4, 2015)

DesertEMT66 said:


> My medic school had us spend 4 hours at the schools daycare to help us. It was a very awkward moment for all of us.



That's....unusual.


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## chaz90 (May 4, 2015)

Remi said:


> That's....unusual.


At my paramedic school we went to a local daycare to do pediatric assessments as well. They had a variety of different age groups and we just talked to them really. I found it helpful as I don't have kids of my own yet nor do most of my friends. This was all pre-clinical. After we started clinicals, we did several shifts in the Children's Hospital to see some sick kids.


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## Carlos Danger (May 4, 2015)

chaz90 said:


> At my paramedic school we went to a local daycare to do pediatric assessments as well. They had a variety of different age groups and we just talked to them really. I found it helpful as I don't have kids of my own yet nor do most of my friends. This was all pre-clinical. After we started clinicals, we did several shifts in the Children's Hospital to see some sick kids.


Never heard of that. Interesting.


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## RedAirplane (May 4, 2015)

281mustang said:


> Don't see many geriatrics? Say wha?



Mostly special events, so the vast majority of my patients are 18-40.


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## Gurby (May 4, 2015)

Jwan said:


> I usually will tell the boys its seeing how strong they are, then whatever number it is I just act very impressed



Brilliant!


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## ERDoc (May 8, 2015)

In regards to dealing with a peds pt, be slow and calm, especially if they are scared.  Get the parents involved in the care when appropriate, do an "exam" on the parent to show the child what is going to happen and that it is not scary.  Never stand over a kid, try to always be at their level.  I am constantly on my knees when taking care of kids.

As for the medical treatment of this kid (I know it's not what the OP was asking about), the community hospital should be fine.  Although a few details are missing, it doesn't sound like this kid needs a head CT (see the PECARN head CT study).  We've all fallen and hit our heads at some point.


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## Amelia (May 8, 2015)

Ishan said:


> Not so much concerned about that part as-- how to deal with kids? (Mannerisms)
> 
> I'm awkward enough with adults. I'm terrified that kids may be terrified of me
> 
> yes the MOI is ambiguous but can't get more into unfortunately




Well, my first concern is that this MOI isn't really a concern with you. Even as a FR, your first priority is to the patient, being awkward or not. A 4 year old simply doesn't fall out of a car (as a mother of 2 boys and being a nanny of 5 boys for 7 years in college), let alone hitting her head so hard that she has an altered mental status (not believing the mom at this point) because a normal reaction would be to hold your arms out to protect the pumpkin head. Were there lacerations on the hands or elbows? If you see these things and encounter the mother and she says these things, you absolutely need to tell the EMS en route your general impression. This should absolutely be your first concern. 2nd, if you smile and goof off with them, most likely you'll be ok with the kid. But my first concern is your lack of concern of the MOI.


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## Amelia (May 8, 2015)

^ That is just going off by what you say... during my first cup of coffee. If I had misread, I apologize, but the "fell out of a car and is normally quiet" doesn't cut it for me, to be honest. Possible? Absolutely, but I'd at least tell the EMS that something is a bit off- if they see it too, good, if not, good too.


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## RedAirplane (May 8, 2015)

Amelia said:


> Well, my first concern is that this MOI isn't really a concern with you. Even as a FR, your first priority is to the patient, being awkward or not. A 4 year old simply doesn't fall out of a car (as a mother of 2 boys and being a nanny of 5 boys for 7 years in college), let alone hitting her head so hard that she has an altered mental status (not believing the mom at this point) because a normal reaction would be to hold your arms out to protect the pumpkin head. Were there lacerations on the hands or elbows? If you see these things and encounter the mother and she says these things, you absolutely need to tell the EMS en route your general impression. This should absolutely be your first concern. 2nd, if you smile and goof off with them, most likely you'll be ok with the kid. But my first concern is your lack of concern of the MOI.



Not to say I wasn't concerned about the MOI. 

I meant in terms of what I was asking on the forum, I felt comfortable enough with head trauma, coordinating with EMS, etc. the part I was less sure about was the dealing with kids bit so that's what I asked


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## RedAirplane (May 8, 2015)

Amelia said:


> ^ That is just going off by what you say... during my first cup of coffee. If I had misread, I apologize, but the "fell out of a car and is normally quiet" doesn't cut it for me, to be honest. Possible? Absolutely, but I'd at least tell the EMS that something is a bit off- if they see it too, good, if not, good too.



Yes the MOI can see a bit bizzare, passed up the chain with concern of whay actually happened noted


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## Amelia (May 8, 2015)

Ok.  I'm a mom so those things catch my attention big time. But as for kids- be smiley, goofy, cartoon-like. If it doesn't fly, go into teddy-bear, soft caring mode. Let the kid help with what s/he can. Don't ask permission, but like "Which arm should we hug?" (with the bp cuff). "Which eye should I look at first?" "Do you have a tongue?" etc.... just remember what you liked when you were a kid.


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