drewkitty

You are a spectator at a breakdancing event. You witness this:

http://www.youtube.com/watch?v=D3Lr70lwaVg

What do you do now?

For the sake of this exercise, the child does not get up, and the breakdancer is not a scene threat.

Answers behind the cut.

Bystander: Do not allow others to move the injured child, including the mother. Ask someone to call 911 or call yourself. Only if the child is choking to death, use the head-tilt chin lift maneuver to open the airway. Try to calm mother and child if possible until medics arrive.

First Aid: Do not allow others to move the injured child, including the mother. Identify yourself as first aid trained and ask people to call 911 and meet the medics at the street. Assess the ABCs of Airway, Breathing and Circulation. Try to hold the head and neck in the position which they are found. Upon discovering airway problems, consider carefully whether opening the airway is necessary. If trained and necessary, use the jaw thrust maneuver, remembering that a child's head does not need to be leaned as far back as an adult. At last resort use the head-neck tilt only if necessary because the child is unable to breathe. Do head-to-toe checks and continuous monitoring until higher levels of care arrive and take over. Try to calm and reassure mother and child if possible.

First Responder: Remember that calming or controlling the parent is essential to scene management. The child's injuries are likely severe and you should call for paramedics immediately. Pending their arrival, think about how the child was injured. Check for ABCs, then conduct a primary survey. Enlist a bystander to hold C-spine. Do a head to toe and evaluate the likelihood of head, neck, back and chest injuries. You may notice diminished breathing and altered breathing with one side not drawing air as well. You may also notice blood and/or clear fluid leaking from mouth, nose and ears. From the mouth could be cut mouth / broken teeth but could also be a lung injury. Nose and ears would be head injury. If equipped take vital signs and start a history with primary surveys repeated every five (5) minutes for an unstable patient. Be ready to assist breathing with mask ventilations and/or oxygen if equipped.

EMT: Consider mechanism of injury. We have two major MOIs. (Look at the video again.) #1 is blunt force trauma to the left chest, probably resulting in flail chest with rebound. Sufficient energy is imparted to cause the child to fly through the air for MOI #2. #2 is a head-down compaction injury to the cervical spine, possibly additional facial injury with airway compromise. Your initial assessment in the first moments will be critical.

Remember that flail chest (two or more ribs broken on two or more sides) is a likely outcome here and that a child's ribs may be deceptively soft, concealing the extent of internal injuries. Also remember that while children are capable of absorbing amazing trauma without injury, landing squarely on the head could have fractured the skull or broken the neck, or both, and this patient cannot be safely moved without pediatric packaging equipment.

This is a severe pediatric trauma with C-spine and possible multiple airway compromises. If you were not in a highly urbanized area, this would meet trauma criteria for evacuation helicopter activation (severe trauma MOI on a child, fall from greater than own height). Activate ALS immediately and request additional resources for crowd control.

If equipped once C-spine and primary survey has been established, give oxygen at 15L by non-rebreather, or if no pediatric mask, blow-by. If child is unconscious, consider oral airway. (Nasal is contraindicated by possible fractured skull.) Also check lung sounds and for other signs of serious airway problems (bright blood on lips, trachea deviation, reverse movement of the chest on inspiration and exhalation, etc.) Take BPs if equipped with peds kit, else pulse and cap refill checks.

When paramedics arrive, transition care and be ready to assist as a resource in patient stabilization, scene management and packaging for transport.