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?
Child in MVA
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medichopeful
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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.
Lifeguards For Life
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Many ambulances allow for a car seat to be securely fastened in to the air chair.
wyoskibum
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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.
JPINFV
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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.
firemedic1563
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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.
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.
EMSBLONDIE24
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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!
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!
medichopeful
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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?
Lifeguards For Life
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What is a Cravat?
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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...
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
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Now that's a contradiction of terms.
reaper
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Ain't that the truth!
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Bear in mind I said "proper" immobilization...rarely achieved due to many circumstances...
JPINFV
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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.
Lifeguards For Life
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.
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.
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
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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.
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.
EMSBLONDIE24
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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...
EMSBLONDIE24
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Cravat- otherwise known as a triangular bandage. Sorry, my Squad calls them cravats, I know others call them triangular bandages
JPINFV
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Are you including patients who meet Canadian C-Spine or NEXUS criteria to forgo spinal immobilization?
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?
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?