February 2021 KCEMS RoundUp
February 2021KCEMS RoundUpClosing the LoopWelcome to this month’s second KCEMS RoundUp newsletter! This edition focuses on topicsrelated to emergency medical care for pediatric patients.EMS for Children—Appointing a Pediatric ChampionThe following information has been provided by the State of Michigan and Dr. Samantha Mishrawww.michigan.gov/EMSCMission: reduce child youth mortality and morbidity resulting from severe illness or traumaHow? Improve Pediatric Readiness of all emergency medical service providers and EMS agenciesPediatric Readiness: The ability to meet the immediate needs of an ill or injured child.What can an agency do to improve their readiness to manage and transport pediatric patients?Appoint a Pediatric Champion – connect with Dr. Sam Mishra – MishraS@michgian.govPediatric Champion - An individual responsible for coordinating pediatric specific activities for anagency/agencies. www.michigan.gov/PedsChampionsa. Ensure there is a dedicated individual identified in the EMS agency that representspediatric interest and advocates for improved pediatric readinessb. Access pediatric education modules, toolkits, and supportc. Connect with other pediatric champions – local projects, trainings etc.d. Provide input and feedback to the State EMSoffice related to what agencies and providersneed to improve readinessFor more information, please see the attached flyer.From the State of Michigan Division of EMS and Trauma:EMS on Air – New EpisodesAccess online or with your preferred podcasting app: https://www.emsonair.com/EMS for Children – Season 2 Episode 19Season 2 Episode 12 – Meet the founders, find out how we can decrease the number of babies that die intheir sleepSeason 2 Episode 23 – DOSE in Michigan
Multisystem Inflammatory Syndrome in Children (MIS-C)Multisystem Inflammatory Syndrome in Children (MIS-C) is a clinical entity that follows an acute COVID-19infection which may be mild or asymptomatic. This condition can affect children or any age, sex, or race.MIS-C follows an acute COVID-19 infection by an average of 4-6 weeks (range of 2-8 weeks), with the occasional case that develops while the child still has acute respiratory COVID-19. The clinical presentationis the result of significant hyper-inflammation similar to severe Kawasaki Disease or Toxic Shock Syndrome and can lead to multi-organ dysfunction and shock. Children present with fever and 2 or more of thefollowing: abdominal pain/vomiting/diarrhea, lymphadenopathy, rash, conjunctivitis, and extremity changes.Vital signs, especially blood pressure, can be volatile and rapidly worsen. Patients are triaged for admission vs. discharge based on clinical stability and laboratory indicators, all of which help determine if a patient qualifies for hospital admission and/or MIS-C treatment. Because these patients have volatile vitalsigns with a risk to rapidly worsen, paramedics should seriously consider transport for any patient with concern for MIS-C or who is currently under investigation for a MIS-C diagnosis.85 Reports statewide that meet the criteria since February of 2020, 6 of which were in Region 6.For up-to-date MIS-C information and statistics, pleasevisit: 8163 98173 104661---,00.htmlWritten by Dr. Rosemary M. Olivero, MD, Division Chiefof Medical Specialties, Helen Devos Children’s Hospitalof Spectrum Health and Dr. Erica A. Michiels, MD, Attending Physician and Associate Medical Director for HDVCH Emergency Department, Vice Chair, Department of Pediatrics, and Chair of Pediatric MSPC for Helen Devos Children’s Hospital of Spectrum HealthPediatric Accidental IngestionsWritten by Dr. Allek Scheele, pediatric hospital fellow, Dr. Andrea Hadley, Section Chief Pediatric Hospitalists, and Dr. Erica Michiels, Associate Medical Director of HDVCH EmergencyDepartmentWith the legalization of recreational marijuana in 2018, and theopening of retail sites in 2019, it has been hard not to noticethe increase in roadside advertising and apparent increasedavailability of THC containing products. Along with this, ourregion has seen a dramatic increase in children presenting to the hospital after having accidentally ingested edible THC products. The rate of children needing hospitalization with THC ingestion tripled in the yearafter legalization. The emergency department rate is 5x higher than it was prior to legalization.The danger in these products is not only that they are inherently appealing to children (cookies, brownies,candies, popcorn) but that as many as 8-10 ‘servings’ of THC can be in each product and the effects willtake as long as an hour to set in. This can easily lead to a small child consuming a large amount of THC ina short period of time, leading to profound effects an hour or so later.Children with accidental ingestions of edible products, particularly in regions with recreational legalization,see more profound neurologic effects of the THC, and require hospitalization at a higher rate than otherregions. Our region has seen children with an average age of 3, present with profound somnolence/altered
mental status, ataxia, and respiratory depression. Some will present with nausea, vomiting, abdominalpain, or even hallucinations. Getting exposure history can be crucial for timely diagnosis in these patientsbut can be tricky due to a delay in the symptom onset, parental concern for CPS involvement, and thecommunity’s decreased perception of harm from these products. Increased awareness of this growingissue can make a huge difference in children’s safety.More information can be found in this article: Acute toxicity associated with cannabis edibles followingdecriminalization of marijuana in Michigan, American Journal of Emergency Medicine,B. Lewis, T. Fleeger,B. Judge, et al. on of Early On-Scene Management of Pediatric Out-ofHospital Cardiac Arrest on Survival OutcomesDr. Peter Nguyen, last year’s Spectrum Health Pediatric Emergency Medicine fellow, wrote the followingabout a study he performed on pediatric cardiac arrest survival rates and times to first epinephrine. Thisabstract was accepted for an ePoster session at the SAEM (Society of AcademicEmergency Medicine) Virtual Meeting this May.Background and ObjectivesBanjeree et al. (2018) demonstrated that with a shift to on-scene resuscitation inpediatric out-of-hospital cardiac arrest (POCHA), a significant sustained increase insurvival to hospital discharge from 0% to 23%. We evaluate and compare thefrequency of ROSC and neurologically intact survival in POCHA patients in whichresuscitation efforts were performed on scene to that of Polk County.MethodsWe conducted a retrospective chart review of our three local emergency medical services (EMS) agenciesthat serve Kent county for the calendar year of 2019 who provided POHCA care after implementation ofearly resuscitation. We evaluated basic demographic date including age, sex, gender. We also evaluatedEMS parameters including time on scene, time to CPR, bystander CPR, and time to first dose ofepinephrine with associated interquartile ranges (IQR). Our main outcomes metrics return of spontaneouscirculation (ROSC), survival to admission, and survival to discharge.ResultsBetween 1/1/2019 and 12/31/2019, we found 25 unique encounters of POHCA. 15 (60%) patients weremale, 18 (72%) presented with a presumed respiratory arrest, and 22 (88%) had asystole as the initialrhythm. Median time to; CPR was 2 min IQR (0 – 8.25min), EMS arrival 8 min IQR (5 – 11min), first dose ofepinephrine 8.5 min IQR (6 – 10 min). ROSC and survival to admission was achieved in 2 (8%) patients.Only 1 (4%) patient survived to discharged. There was no significant association with shorter mean time toepinephrine and survival to discharge.ConclusionImplementation of immediate on-scene resuscitative efforts did not result in any measurable improvementsin ROSC or neurologically intact survival in contrast to prior work showing a significant increase inneurologically intact survival. Future work should be directed towards a multi-county approach to decipherboth regional trends and differences in survival with immediate on-scene resuscitative efforts.
Feedback Wanted: Draft ProtocolsAttention providers: We would appreciate your feedback on a variety of draft protocols that are currently out for review. These protocols can be accessed by goingto the Updates section of the app and selecting Draft Protocols.Trauma Patient RecordingSpectrum Health Trauma Services is working to add a new tool for education and process improvement.Trauma video recording has been utilized for almost three decades by level 1 and level 2 trauma centersthroughout the United States. The Butterworth trauma bay has been outfitted with six cameras that cancapture activity in any of the three bays. Trauma, in conjunction with other impact departments, has beenworking to finalize a written protocol, determine appropriate safeguards, and establish the best use of thisnew tool. Trauma Services intends to utilize these recordings to support multiple areas of education andimprovement in communication and teamwork during trauma resuscitations by providing educationalevents in the future.From the State of Michigan Division of EMS and Trauma:Michigan Stay Well ProgramNEW: Register for a support group for Michigan Frontline WorkersPlease see the flyer here: Frontline Worker Support Group February.pdfBe Kind to Your Mind: First responders: your job is all about helping others. But what are you doing to helpyourself as the pandemic drags on? It's no secret that front-line workers are carrying a heavy burden thesedays. Many are experiencing emotional impacts from their day-to-day work that can result in a variety ofsymptoms: Having problems falling or staying asleepContinued on next pageContinued from previous page Experiencing more conflicts or tension with family members or otherpeople Having trouble concentrating or remembering things Experiencing an increase or decrease in your normal appetite Having a sense of despair, hopelessness, or emptiness about the future Drinking more alcoholic beveragesIf you recognize any of these reactions in yourself, talking to someone about it can improve your outlookand well-being. That's why a team of behavioral health professionals at the Michigan Department of Healthand Human Services created the Stay Well counseling line — a phone number you can call any time of theday or night to talk to a trained crisis counselor about your COVID-19-related distress.To reach the Stay Well counseling line, dial 888-535-6136 and listen for the prompt to press “8.”Counseling is free confidential. and available seven days a week, 24 hours a day.
Educational Opportunities / Upcoming EventsEducation Modules – with CEs1. DOSE – Infant Safe Sleep 0336/2. Autism and Spectrum Disorders - tools for first 93699/3. Child abuse – recognition and 2369/4. Out of hospital births and 174/Neonatal Resuscitation series coming throughout 2021 – more information to come!From the State of Michigan Division of EMS and Trauma:EMS Leadership Education OpportunityOur office is excited to team up with SafeTech Solutions LLC to offer a new year of EMS leadership education. Come sharpen your saw with us starting in January. Continuing education credits are provided withattendance free of charge. Join us for this exciting leadership series.Visit https://mcrh.msu.edu/education/EMS%20Webinars.html to register.Community Integrated Paramedicine (CIP) Virtual AssemblyPlease join us for our monthly Community Integrated Paramedicine (CIP) Monthly Virtual Assembly, heldthe third Thursday of every month from 9:00 a.m. to 12:00 p.m.Join on your computer or mobile app:Click here to join the meetingOr call in (audio only)248-509-0316 Phone Conference ID: 843 967 318#
MULTI-SYSTEM INFLAMMATORYSYNDROME IN CHILDRENFAST FACTSMichigan.gov/CoronavirusMultisystem Inflammatory Syndrome in Children (MIS-C) is a condition where multiple organ systems becomeinflamed during illness. The cause of MIS-C is still unknown; however, it is known that MIS-C is associated withCOVID-19. MIS-C is not contagious, but it is life-threatening and is indicative of previous exposure to someonewith COVID-19, or infection with the virus that causes COVID-19. Providers are asked to maintain a high degreeof suspicion for MIS-C in pediatric patients presenting with symptoms of Kawasaki Disease or ill individuals whohave been previously exposed to COVID-19.CLINICAL PRESENTATION AND SYMPTOMS OF MIS -C:Presentation varies widely; symptoms may initially seem mild or vague but can progress rapidly.Per CDC guidelines, providers should have increased concern for MIS-C if:Persistent fever 24 hoursElevated inflammatory markers in the bloodPositive PCR antibody test for SARS-CoV-2Complete or partial overlap of symptom criteria of Kawasaki DiseaseChild resides in area with community spread of COVID-19Two or more organ systems rointestinal-RespiratoryDermatologicMIS-C CASE DEFINITION (CDC) 21 years presenting with fever*, laboratory evidence of inflammation**, and evidence of clinicallysevere illness requiring hospitalization, with multisystem ( 2) organ involvement (cardiac, renal,respiratory, hematologic, gastrointestinal, dermatologic, or neurological); ANDNo alternative plausible diagnoses; ANDPositive for current or recent SARS-CoV-2 infection by RT-PCR, serology, or antigen test; or exposure to asuspected or confirmed COVID-19 case within the 4 weeks prior to the onset of symptoms.*Fever 38.0 C for 24 hours, or report of subjective fever lasting 24 hours**Including, but not limited to, one or more of the following: an elevated C-reactive protein (CRP), erythrocytesedimentation rate (ESR), fibrinogen, procalcitonin, d-dimer, ferritin, lactic acid dehydrogenase (LDH), or interleukin 6(IL-6), elevated neutrophils, reduced lymphocytes and low albumin.REPORTING MIS-CReport suspect and confirmed cases of MIS-C to your local health department.Visit Michigan.gov/Coronavirus for more information.
How to spot symptoms of MIS-C,a rare condition in childrenexposed to COVID-19WHAT WE KNOW ABOUT MIS-CMulti-system Inflammatory Syndrome in Children (MIS-C) occurs as multiple organ systemsbecome inflamed. Many signs of MIS-C seem mild or vague, but the illness can progress rapidly.MIS-C is currently associated with COVID-19, cases have been reported in areas where COVID-19 ismost prevalent. It typically appears several weeks after exposure - caregivers may not be awarethat the child had or was exposed to COVID-19.MAINTAIN A HIGH DEGREE OF SUSPICION FOR MIS-CAsk if the child was exposed to COVID-19, or had any contact with a sick person. The presentationvaries widely among patients. Some children may experience severe illness - they usuallydecompensate rapidly, requiring prompt critical care. Consider MIS-C if any child presents withFEVER ( 100.4) for 48 hours with involvement of at least two of the following organ systems:Gastrointestinal (GI)DermatologicRespiratoryNeurologicHematologic - LymphaticCardiacRenalSYMPTOMS MAY INCLUDE ANY OF THE FOLLOWING:Abdominal pain (most common complaint)Fatigue (irritability or sluggishness)Poor appetite/difficulty feeding, too sick todrink fluidsNausea (with or without vomiting/diarrhea)Rash anywhere on the body (pale, patchyor blueish)Conjunctivitis or bloodshot eyesPharyngitis (red, swollen or sore throat)Enlarged lymph nodes on the neck - can beone sided (may be described as "neck pain")Red or cracked lipsRed (strawberry) tongueSwollen or red hands or feetVital signs – are VITAL for any child seen, especially those with fever and concernfor MIS-C. Acquire full set of accurate vital signs – BP, HR, RR – repeat themeasures. Look for evidence of shock - altered mental status, tachycardia,hypotension and/or tachypnea - as some children decompensate quickly.INCREASED SUSPICION FOR SYNDROME PROGRESSION IF:Child was seen by healthcare provider before this EMS call and sent home (multiple visits)Known COVID exposure – especially a few weeks agoTachycardia, hypotension, or elevated respiratory rateChest pain with MIS-C signs/symptomsIncreased concern for serious consequences of MIS-C and cardiac involvementGet an EKG – likely to demonstrate EKG changes (indicates need for workup now)
Pediatric Champion or Pediatric Emergency Care Coordinator (PECC)An individual(s) who is responsible for coordinating pediatric specific activities. A designatedindividual(s) who coordinates pediatric emergency care need not be dedicated solely to this role; it canbe an individual(s) already in place who assumes this role as part of their existing duties. Theindividual(s) may be a member of the Emergency Department (ED) staff, EMS agency, or work at acounty or regional level and serve more than one agency.Purpose:The intent of designating and developing the role of a Pediatric Champion/PECC is to ensure that thereis a dedicated individual(s) identified in the Emergency Department or local EMS agency that representspediatric interest and performs the roles listed below. An Emergency Department or EMS agency doesnot have to have a single person performing the functions of a Pediatric Champion/PECC. Theresponsibilities can be fulfilled by two or more people.Who can fill this role?Some certifications of the individual(s) who might fulfill the PECC role include, but are not limited to:EMS Agencies Emergency Medical Technician (EMT)ParamedicRegistered Nurse (RN)Advanced Practice Nurse (APN)Physician Assistant (PA)MCA medical directorEMS ChiefTraining officerOther Prehospital professionalsAdditionally, there could be a region wide individual(s) that performs the responsibilitiesas a PECC for EMS agencies within a regionEmergency Departments Registered Nurse (RN)Advanced Practice Nurse (APN)Physician Assistant (PA)ED PhysicianTrauma CoordinatorED ManagerED Clinicians
ResponsibilitiesSome responsibilities of the individual(s) who might fulfill the PECC role include, but are not limited to:EMS Agencies Ensures that the pediatric perspective is included in the development of EMS protocols.Ensures that fellow EMS providers follow pediatric clinical practice guidelines.Promotes pediatric continuing-education opportunities.Oversees the pediatric-process improvement.Ensures the availability of pediatric medications, equipment, and supplies.Promotes agency participation in pediatric-prevention programs.Promotes agency participation in pediatric-research efforts.Liaises with the emergency department pediatric emergency care coordinator.Promotes family-centered care at the agency.Emergency Departments Ensures that the pediatric perspective is included in the development of ED protocols.Ensures that fellow ED providers follow pediatric clinical practice guidelines.Promotes pediatric continuing-education opportunities.Oversees the pediatric-process improvement.Ensures the availability of pediatric medications, equipment, and supplies.Promotes ED participation in pediatric-prevention programs.Promotes ED participation in pediatric-research efforts.Liaises with local EMS agency pediatric emergency care coordinators.Promotes family-centered care in the ED.
Spectrum Health Trauma Services is working to add a new tool for education and process improvement. Trauma video recording has been utilized for almost three decades by level 1 and level 2 trauma centers throughout the United States. The Butterworth trauma bay has been outfitted with six cameras that can capture activity in any of the three bays.
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