 AP Photo/Dimitri Messinis |
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As my now 23-year-old daughter reminds me, “Dad, be nice to me as I will be the person who decides when your diaper will be changed!” Her comments strike home on many different levels — related especially to being sure we care for and about our children.
EMSC Day should remind every EMS provider that we are wholly responsible to ensure the next generation of colleagues are properly trained and achieve the mastery of knowledge and skills required to properly care for the children they will encounter; the sick and injured as well as those learning from injury and illness prevention programs.
EMSC Day provides a great opportunity to look at a specific category of injuries that is all too frequently forgotten: equestrian injuries.
Horse-related injuries are an unfortunate part of American life. Nearly 275,000 youths are involved in horse-related activities, according to the CDC and the National Ag Safety Database, and are at a much greater risk for injury than their adult counterparts.
In 1996, there were 25,446 individuals with horse-related injuries presenting to Emergency Departments younger than 25 years of age. An important thing to remember is that the younger the child, the greater the contribution the mass of their head adds to their overall weight. This provides them with similar aerodynamics to that of a badminton birdie — the weighted head always falls first!
Studies have found that of horse riders, children are at the greatest risk of injury especially those involving the head, and that a high index of suspicion must be maintained in the evaluation and care of any child hurt during a horse-related activity.
The case: “MS 142 respond to a girl injured at the Fairgrounds, no other information available.”
Upon arrival you find your patient sitting on the back deck of a horse trailer. Your “20 foot” rule — what the child looks like from 20 feet away — reveals a dust-covered teenaged female sitting in a tripod style-position. She looks your way as you approach, but then looks toward the ground as you get closer.
There is no obvious bleeding or extremities bending in directions they shouldn’t. The Pediatric Assessment Triangle (PAT) helps us identify that her “Appearance” seems normal, her “Work of Breathing” is increased and her ventilation volume appears shallow, and her “Circulation” might be OK as she is sitting up by herself. You can’t tell if she is pale or cyanotic because of the dust she has acquired from the arena.
Once you get next to her, she tells you her name is Kala. As you begin your assessment you find that:
- Her distal pulse rate is rapid and weak.
- In checking central pulses, you find them to be rapid and not as weak.
- In your questioning of the events leading up to the injuries, she tells you the last thing she remembers is getting ready to show her horse.
Her father tells you she “got her bell rung and the wind knocked out of her and, by the way, she has a small cut on the back of her head but she’ll be fine.” he reassures you.
After she approves you starting the assessment process, you remove her hat to find a 1-2 inch avulsion laceration to the occipital skull and notice a large scrape mark on her mid to lower posterior thorax area. One of the other cowboys tells you she was getting on her horse when it spooked and she ended up underneath the rear legs.
He wasn’t sure if she got kicked or trampled, but she was unconscious for a second or two. The father was the first person to her and states that she was “a little foggy,” until he got her out of the arena about 60 seconds later.
Your assessment continues with a visualization of her modestly exposed back. It is obvious that the scrape marks are from the horse’s hoof and it appears Kala’s head and back were stepped on by this 1000-pound (454 Kg) animal. Breath sounds are present, moderately diminished on the right, and with a noticeable decrease in inspiratory effort.
Kala’s work of breathing is increased; her PAT is now flying red flags! Throughout the assessment, you notice that she does not seem to be as responsive as you would anticipate. Your concern is increased due to the possibility of a head injury. Several times throughout your assessment, Kala tells you she is OK and just needs to catch her breath; a stoic presentation common among the agricultural community.
Your treatment includes cervical spine precautions per protocol and oxygen by non-rebreather at 10 l/m. As you prepare to place her on the backboard, she tells you she can’t lie down and begins to fight your efforts to place her in a supine position.
Respiratory status
What should you do? Many protocols call for full spinal movement restriction or precautions in cases like this. In the supine position, her respiratory status could become compromised and she is not in a position of comfort. As part of your assessment skills remember that Kala has been picked up, walked, and is sitting up on her own power so one might surmise that her thoracic spine is intact.
You must follow your protocols as determined by your EMS System and Medical Direction, but consider treating the patient not the generic protocol. The decision is made (and protocols allow) for Kala to be transported in an upright position with adequate padding around her head, neck, lower back and under her knees to support her in this medically appropriate and her chosen position of comfort.
Her vital signs reveal that she has a decreased blood pressure (74 / 50) and increased heart rate (152/min), and a respiratory rate of 22/min, slightly labored and shallow. She has point tenderness over the avulsion-laceration area on her occipital skull and about her entire right posterior thoracoabdominal area.
The rest of her assessment is unremarkable. Her low blood pressure and elevated pulse increase your concern that she is in compensated shock from her thoracoabdominal injury. Despite her having a physical injury to the cranium, the potential of her head injury being the primary cause of her physiological presentation is less likely.
While she does have a head injury and therefore must be continually reassessed for change, it appears to be a secondary concern at this time. Put another way, “What is killing her first?!” Both injuries must be constantly reassessed, prioritized, and cared for appropriately.
Physiological presentation
Kala is at the division between being considered an adult by some and a child by others. Because of her age, 14, she has a significant ability to compensate in the face of shock, which unfortunately also allows for a uniquely rapid transition from compensated to decompensated shock. Your treatment must focus on her physiological presentation not her chronological age: Treat the patient!
Other therapies such as volume replacement should be cautiously considered as newer research is showing that driving her blood pressure up to 100/70, a normal range for this young lady, will do more damage than good. As Dr. Peter Rosen stated, “All bleeding will stop . . . sooner or later!” Don’t force the blood out with IV fluids.
You safely transport Kala and her father to the Emergency Department. Once there, you provide the ED Nurse and Physician with a complete report including your assessment findings, the history provided, and the treatments facilitated. The handoff to the next level of care is completed when you thank Kala and her father for helping you care for her and wish her well in her recovery.
Several hours later the ED Doctor informs you that Kala has a concussion without radiographic significance, a contused right lung and liver, does not need surgery at this time, but was admitted to the ICU. She will recover to ride again.
Horses helped bring our ancestors to many regions of the world and have been an integral part of the American lifestyle for hundreds of years. During this EMS Week and especially on EMSC Day, think about the injuries you can prevent and the children you will care for. Be a “Proud Partner in Your Community.”
Injury prevention information:
The American Academy of Pediatrics (AAP) recommend that young riders in all organizations and activities that promote or sanction horseback riding wear helmets that meet the 1988 ASTM testing standard as certified by SEI when riding horses
Bicycle helmets have reduced traumatic brain injuries in bicyclists by 88 percent. ASTM and SEI estimates helmet use during equestrian events will have a similar positive effect.
