Protocols

Standardized protocols for telephone triage of seriously ill or injured children are essential. When a child’s status is in question and prehospital care is available, ambulance transport in the care of trained personnel is always preferable to transport by privately owned vehicle (POV). This obviates the potentially serious medical consequences of relying on unskilled and distraught parents without the ability to provide even basic life support (BLS) measures to an unstable child during transport to an ED. Practitioners can work with their local pediatric emergency care resource center (e.g., children’s hospital or academic department of pediatrics) to develop and maintain written protocols for office-based management of a range of conditions, including anaphylaxis, cardiopulmonary arrest, head trauma, ingestions, shock, status asthmaticus, status epilepticus, and upper airway obstruction. Regular practice using mock code scenarios has been shown to improve office-based practitioner confidence and self-efficacy in managing these problems.

Resuscitation Equipment

Availability of necessary equipment is a vital part of an emergency response. Every physician’s office should have essential resuscitation equipment and medications packaged in a pediatric resuscitation cart or kit (Table 61-1). This cart or kit should be checked on a regular basis and kept in an accessible location known to all office staff. Outdated medications, a laryngoscope with a failed light source, or an empty oxygen tank represents a potential catastrophe in a resuscitation setting. Such an incident can be easily avoided if an equipment checklist and maintenance schedule are implemented. A pediatric kit that includes posters, laminated cards, or a color-coded length-based resuscitation tape specifying emergency drug doses and equipment size is invaluable in avoiding critical therapeutic errors during resuscitation.

Table 61-1 RECOMMENDED DRUGS AND EQUIPMENT FOR PEDIATRIC OFFICE EMERGENCIES

E, essential; S, strongly suggested.

Adapted from American Academy of Pediatrics, Committee on Pediatric Emergency Medicine; Frush K: Preparation for emergencies in the offices of pediatricians and pediatric primary care providers, Pediatrics 120:200–212, 2007.

To facilitate emergency response when a child needs rapid intervention in the office, all personnel should have designated roles. Organizing a “code team” within the office ensures that necessary equipment is made available to the physician in charge, that an appropriate medical record detailing all interventions and the child’s response is generated, and that the 911 call for EMS response or a transport team is made in a timely fashion.

Transport

Once the child has been stabilized, a decision must be made on how to transport a child to a facility capable of providing definitive care. If a child has required airway or cardiovascular support, has altered mental status or unstable vital signs, or has significant potential to deteriorate en route, it is not appropriate to send the child via POV, regardless of proximity to a hospital. Even when an ambulance is called, it is the PCP’s responsibility to initiate essential life support measures and to attempt to stabilize the child before transport.

In metropolitan centers with numerous public and private ambulance agencies, the PCP must be knowledgeable about the level of service that is provided by each. The availability of BLS vs ALS services, the configuration of the transport team, and pediatric expertise vary markedly among agencies and across jurisdictions. BLS services provide basic support of airway, breathing, and circulation, whereas ALS units are capable of providing resuscitation drugs and procedural interventions as well. Some communities may have only BLS services available, whereas others may have a 2-tiered system, providing both BLS and ALS. It may be appropriate to consider medical air transport when definitive or specialized care is not available within an immediate community or when ground transport times are prolonged. In that case, initial transport via ground to an appropriate helicopter landing zone or a local hospital for interval stabilization may be undertaken, pending arrival of the air transport team. Independent of whether a child is to be transported by air or ground, copies of the pertinent medical records and any radiologic studies or laboratory results should be sent with the patient, and a call made to the physicians at the receiving facility to alert them to the referral and any treatments administered. Such notification is not merely a courtesy; direct physician-to-physician communication is essential to ensure adequate transmission of patient care information, to allow mobilization of necessary resources in the ED, and to redirect the transport if the emergency physician believes that the child would be better treated at a facility with specialized services.

Access to the EMS System

Virtually all Americans have access to the 911 telephone service that provides direct access to a dispatcher who coordinates police, fire, and EMS responses. Some communities have an enhanced 911 system, in which the location of the caller is automatically provided to the dispatcher, permitting emergency response even if the caller, such as a young child, cannot give an address. The extent of medical training for these dispatchers varies among communities, as do the protocols by which they assign an emergency response level (BLS vs ALS). In some smaller communities, no coordinated dispatch exists, and emergency medical calls are handled by the local law enforcement agency.

When activating the 911 system, the physician must make clear to the dispatcher the nature of the medical emergency and the condition of the child. In many communities, emergency medical dispatchers are trained to ask a series of questions per protocol that determines the appropriate level of provider to be sent.

Provider Capability

There are many levels of training for prehospital EMS providers, ranging from individuals capable of providing only first aid to those trained and licensed to provide ALS. All EMS personnel, whether basic emergency medical technicians (EMTs) or paramedics, receive training in pediatric emergencies; however, pediatric cases actually constitute roughly 10% of all EMS transports.

First responders may be law enforcement officers or firefighters, who are dispatched to provide emergency medical assistance, or bystanders. Public safety personnel have a minimum of 40 hours of training in first aid and CPR. Their role is to provide rapid response and stabilization pending the arrival of more highly trained personnel. In some smaller communities, this may be the only prehospital emergency medical response available.

In the USA, the bulk of emergency medical response is provided by EMTs, who may be volunteers or paid professionals. Basic EMTs may staff an ambulance after undergoing a training program of approximately 100 hours. They are licensed to provide BLS services but may receive further training in some jurisdictions to expand their scope of practice to include intravenous catheter placement and fluid administration, management of airway adjuncts, and the use of an automated external defibrillator.

Paramedics, or EMT-Ps, represent the highest level of EMT response, with medical training and supervised field experience of approximately 1,000 hours. Paramedic skills include advanced airway management, including endotracheal intubation; placement of peripheral, central, or intraosseous lines; intravenous administration of drugs; administration of nebulized aerosols; needle thoracostomy; and cardioversion and defibrillation. These professionals provide ALS services, functioning out of an ambulance equipped as a mobile intensive care unit. In a consensus policy statement entitled Equipment for Ambulances, the American College of Surgeons Committee on Trauma, the ACEP, the National Association of EMS Physicians, the Pediatric Equipment Guidelines Committee of the EMSC Partnership Stakeholder Group, and the AAP have published guideline standards for essential ambulance equipment, medications, and supplies necessary to provide BLS and ALS care across the age spectrum. This essential equipment list represents one of the reference standards that the federal EMSC program has adopted as a performance measure for state-level operational readiness to care for children in an EMS system.

Both basic EMTs and paramedics function under the delegated licensing authority of a supervisory EMS medical director. This physician oversight of prehospital practice is broadly characterized under the umbrella term medical control. Direct, or on-line, medical control refers to medical direction either at the scene or in real time via voice or video transmission. Indirect, or off-line, medical control refers to the administering of medical direction prior to and after the provision of care. Off-line activities such as provider education and training, protocol development, and medical leadership of quality assurance/quality improvement programs represent areas in need of greater pediatric input. As a measure of the degree to which EMSC permanence is being established in state EMS systems, the federal EMSC program has required demonstration of participation in on-line and off-line medical direction activities for pediatric patients and the seating of an EMSC advisory committee at the state level. These advisory bodies are well positioned to support EMS agencies in their pediatric readiness as well as provide a forum for the active engagement of pediatric care experts at a system level.

Destination Determination

The destination to which a pediatric patient is transported may be defined by parental preference, provider preference, or jurisdictional protocol, which is typically predicated on field assessment of anatomic and physiologic criteria and, in the case of trauma, mechanism of injury. In communities served by an organized trauma or regionalized EMS system that incorporates pediatric designation based on objectively verified hospital capabilities, seriously ill or injured children may be triaged by protocol to the highest-level center reachable within a reasonable amount of time. The mantra is to deliver the child to the “right care in the right time,” even if it requires bypassing closer hospitals. An exception is the child in full arrest, for whom expeditious transport to the nearest facility is always warranted. Regionalization in the context of EMS is defined as a geographically organized system of services that ensures access to care at a level appropriate to patient needs while maintaining efficient use of available resources. This system concept is especially germane in the care of children, given the relative scarcity of facilities capable of managing the full range and scope of pediatric conditions (Fig. 61-2). Regionalized systems of care coordinated with emergency medical dispatch, field triage, and EMS transport have demonstrated efficacy in improving outcomes for pediatric trauma patients, especially for younger children and children with isolated head injury. Emerging evidence also suggests a similar benefit conferred to children in shock identified in the field who are preferentially transported to hospital EDs with documented pediatric ALS capability. The existence of statewide or regional standardized systems that formally recognize hospitals able to stabilize and/or manage pediatric medical emergencies is another federal EMSC performance measure against which operational capacity to provide optimal pediatric emergency care in this country is currently being judged.

Figure 61-2 Transport options within a coordinated, regionalized emergency medical services system model. The objective is to ensure access to definitive care at a level appropriate to meet patient needs. Solid arrows, primary transport; dotted arrows, interfacility transport.

(Adapted from Institute of Medicine, Committee on the Future of Emergency Care in the US Health System: Hospital-based emergency care: at the breaking point, Washington, DC, 2006, National Academies Press.)

In communities that do not have a hospital with the equipment and personnel resources to provide definitive pediatric inpatient care, interfacility transport of a child to a regional center should be undertaken after initial stabilization (Chapter 61.1). When interfacility transport is to be undertaken, indications for transfer, parental consent for transfer, and acceptance of the patient by the receiving physician must all be clearly documented in the medical record.

Disaster Preparedness

Children constitute about 30% of the population; in a catastrophic event, natural or man-made, several unique factors place children at disproportionate, increased risk. During the day large groups of children are typically cohorted, separate from their families, in schools and daycare centers where mass casualties can easily occur and reunification is challenging. Further, in the event of a biologic or chemical attack, unique anatomic, developmental, and physiologic features make children especially vulnerable to absorption and/or inhalation of toxic agents. In the days and weeks following the 2005 Gulf Coast hurricanes Katrina and Rita, pediatricians in Houston taught us lessons in the rendering of care to large numbers of acutely displaced families in the Astrodome, a reminder that when the need arises, EMSC knows no bounds. In 2008, Congress established the National Commission on Children and Disasters with a mandate to conduct a comprehensive study to examine and assess the needs of children as they relate to preparation for, response to, and recovery from all hazards, including major disasters and emergencies. The Commission’s report to the President and to Congress is due in late 2010.

Research

Building the evidence base for pediatric emergency care and EMSC is especially challenging, given the relative infrequency of critical conditions of research interest and need, and the rare occurrence of adverse outcomes. No single medical center or EMS agency is able to generate sufficient sample size to conduct scientifically rigorous controlled studies, let alone randomized trials, of emergency pediatric problems. In 2001, the Health Resources and Services Administration announced a competitive research funding opportunity, entitled the EMSC Network Development Demonstration Project (NDDP). The NDDP funding stream has supported a now mature national research network known as the Pediatric Emergency Care Applied Research Network (PECARN), which accounts for more than 800,000 ED visits of children distributed among nearly two dozen sites around the country. The PECARN is exploring some of the most vexing questions in pediatric emergency care and challenging practice dogma by leveraging the strength of its number of potential subject enrollees in randomized, controlled trials. According to the specific IOM recommendation, the National Resource Center (NRC) of the EMSC program has generated a comprehensive Gap Analysis of EMS Related Research, which can be accessed electronically from the EMSC NRC website, www.childrensnational.org/EMSC.