Pediatric emergency medicine trisk 1156

(a “no load”) When in doubt, it is usually safest to transport the patient Language barriers can be an important factor in accurately assessing a patient and situation, and it is important to address how to approach language incompatibilities ahead of time There are numerous resources for telephone-based interpreters available (at a cost), but these are difficult to access unless the EMS service already has an existing account with a translation service (such as Language Line) Using telephone interpreters is cumbersome in the EMS setting due to the need for privacy and mobility, but at times it is the only option It may also be useful to have printed medical translation cards specific to the demographics of the EMS service area All healthcare providers must understand their duties to provide care Questions often arise concerning issues of consent, especially when children are involved The doctrine of implied consent permits the treatment of minors without parental consent when a medical emergency exists In general, any minor with a condition that threatens “life and limb” is considered an emergency and should be treated and transported This is typically true even in the difficult situation when a parent refuses EMS for a patient who appears to be emergent Minor patients cannot refuse treatment and transport in an emergency situation The same is true when parents are incapable of understanding the risks of refusing care because of cognitive impairment from intoxication or injury The use of online medical command can help evaluate and resolve a situation where there may be disagreement at the scene regarding the need for transport Patient refusals for EMS transport are a large source of patient care liability for EMS providers If parents/guardians refuse care for their ill or injured child, and the EMS provider deems the child’s condition to be serious or feels that the parent is not acting in the child’s best interest, the EMS provider is warranted in escalating to medical control as well as calling the police when indicated The parents must be informed of the risk of not transporting a sick or injured pediatric patient, which typically may include death or permanent disability Regardless of religious beliefs or parental desires, a child must be treated and transported if there is a life-threatening emergency or if providers suspect child abuse, even if parents refuse Medical control should be involved early, and law enforcement may be necessary to ensure that the patient receives the necessary emergency stabilization and transport All EMTs, regardless of certification level, have a duty to report suspected child abuse at all times and in all patients Even if the ED says that they will report a suspected case later on, it is important to immediately report to the authorities to protect the EMS provider In some states, failure to report suspected child abuse is treated as a felony, and providers and medical directors should know the law in the state where they practice The EMSC program in Colorado and pediatric specialists at the University of Colorado offer an online training module to assist EMS providers recognize signs of child abuse, which can be found at https://www.identifychildabuse.org Many states have an EMS not resuscitate (DNR) protocol to limit resuscitative efforts for those who have made that decision with their physician These are under the authority of the parent/guardian, not the physician, and they can be revoked at any time if the parent changes his or her mind, something common in pediatric medical emergencies Providers and medical oversight physicians must be familiar with the specific documents required for an EMS DNR to be in effect, commonly a patient wristband as well as accompanying paperwork When in doubt, EMS providers must resuscitate a patient and transport them to the ED A challenging situation for EMS providers is when a clinician unknown to the EMS service stops at an emergency scene and wishes to participate in and/or direct the medical care This is a precarious situation for both the provider and clinician, since it is difficult to verify the qualifications of the bystander Wherever possible, this situation should be guided by a protocol, and at no time should the clinician be allowed to endanger the patient or providers ACEP has produced a policy statement that outlines the issues involved in having a bystander clinician involved in the care of the EMS patient Because of the liabilities involved in having an unknown bystander take a role in an established system of providing prehospital care, this is a circumstance where online medical control should be contacted to determine the ways in which the bystander may assist Options may range from providing an extra set of hands to having the clinician assume control for the patient and accompanying them to the ED It is strongly encouraged that EMS systems draft an information card or document to give to on-scene providers to explain how this will work for a specific service This should be written in conjunction with the EMS service’s medical director REGIONALIZATION Based on protocol and/or the online medical control, a decision is made regarding the receiving hospital, or point of entry (POE) The POE selection is based on various factors: patient condition, the capabilities of the receiving hospital, such as a cardiac catheterization team on-call or a pediatric trauma center, and the distance and time to a receiving facility Many EMS systems are now specifying certain hospitals as approved POE for conditions such as stroke, acute coronary syndrome, or pediatric trauma This assures that the patient is going to a facility that can best manage their condition Regionalization is “a process of organizing resources within a geographic region to ensure access to medical care of a level appropriate to a patient’s needs, while maintaining efficient use of available resources.” The purpose is to ensure that services and resources are optimally allocated and used to improve the health of patients across an entire region Regionalization incorporates categorization to delineate available regional resources, accreditation to verify institutional commitment to provide the needed services, and designation to preclude the inefficient duplication of resources In the 1980s, evidence supporting the regionalization of trauma care was published, and the ACS-COT formed the trauma center verification review program in 1987 The past decade has seen the development of regionalized systems of care for ST-elevation myocardial infarction and stroke Pediatric emergency care regionalization in the United States is still undergoing development and refinement It has been recognized as a priority by the IOM, and the EMSC program has published a Pediatric Regionalization of Care Primer, available at https://emscimprovement.center/programs/sproc/sproc-grantresources-and-products/ The primer is an excellent resource for those who are interested in organizing shared resources to optimize access to pediatric specialty care PEDIATRIC PREHOSPITAL AIRWAY MANAGEMENT Respiratory arrest is the most common cause of pediatric cardiac arrest and is associated with three conditions seen frequently in the prehospital setting: trauma, respiratory distress, and seizures Emergency airway management can be lifesaving for critically ill children; however, it requires a significant amount of training and experience and a broad range of skills in evaluation and interventions The high-risk and low-frequency nature of pediatric airway management allows for controversies in current recommendations ETI is taught in the majority of paramedic schools and has been accepted in the scope of practice for paramedics for decades The current literature on pediatric prehospital ETI highlights several shortcomings, and few studies have shown improved patient outcomes Errors and adverse events are frequent, with successful intubation rates documented between 60% and 85%, while complications such as esophageal intubation or unrecognized tube dislodgement are noted in 2% to 25% of successful intubations In addition, skill deterioration is almost inevitable, as only 1% to 5% of pediatric patients treated in the prehospital setting receive airway management In some systems, paramedics may attempt pediatric intubation no more than once a year The largest randomized controlled trial of ETI versus noninvasive bag-valve-mask (BVM) ventilation was published in 2000 The study included 830 patients under the age of 13 in two large metropolitan counties served by 56 EMS agencies Results demonstrated no difference in mortality or neurologic outcomes across the study population; however, the results also noted that scene time and total prehospital time was significantly longer in the ETI group Retrospective review of the National Pediatric Trauma Registry revealed significantly higher observed versus expected mortality for children intubated in the prehospital setting across all injury severities Both of these studies were performed before the common use of rapid sequence intubation (RSI) medications Newer technologies can aid in placement of endotracheal tubes or provide enhanced ventilation without an endotracheal device Video laryngoscopy has been employed in the hospital setting to improve airway visualization and supervision of trainees Studies in a simulated prehospital setting have shown promise for its widespread use; however, none of these studies have addressed pediatric patients Alternatives to ETI include supraglottic airway devices, such as the laryngeal mask airway device and laryngeal tube device The laryngeal mask airway is available for use in smaller patients, including neonates, while commercially available laryngeal tubes, like the King airway (Kingsystems, Noblesville, IN), are not suitable for use in patients under 10 kg Available research on supraglottic devices in pediatric patients is limited to studies performed in the operating room or simulation setting, and further studies on the use of these devices in the prehospital setting is needed Chemically assisted intubation with medications, drug-facilitated intubation or RSI, is commonly used in the ED setting and has wide use in U.S aeromedical and European EMS systems An international meta-analysis including pediatric patients has documented increased ETI success rates with the use of RSI Perspectives from an expert panel on RSI for head-injured patients concluded that literature examining RSI by EMS systems is inconclusive with differences in outcomes, possibly related to EMS and trauma system characteristics This group offered guidance to EMS systems considering the addition of RSI protocols that include emphasis on initial and ongoing training Key messaging for EMS systems is that basic airway management, including positioning and effective BVM ventilation, is an imperative skill for EMTs of all levels to learn and maintain Due to the lack of evidence supporting the use of ETI in pediatric patients and the recognition that educational efforts to maintain proficiency have severe limitations, some systems have discontinued the practice In general, however, protocols for pediatric prehospital airway management have been determined by conventional wisdom over published evidence and impacted by local/regional transport scenarios EMS systems should perform rigorous self-evaluation and continuous quality assurance when creating airway support protocols Methods supported in protocols should be based on the skill level of the providers, equipment and medications available, ongoing training and experience of providers, average transport times, and most importantly, medical oversight CHILDREN WITH SPECIAL HEALTHCARE NEEDS Special healthcare needs in children are defined as long term (lasting longer than months) and are more significant than that of the general population The prevalence of this group in the United States is 15.1% and has been described as the most rapidly growing group of the pediatric population who require emergency medical care Special considerations for EMS systems include the identification of these patients in the community, additional education for providers on unique care and transport needs, and the importance of preparedness for disasters Educational programs available to the prehospital provider are listed in Table 134.5 Spaite et al also note the importance of adherence to existing EMS protocols to optimize treatment for this population of patients It is important to recognize that these patients may be transported on a more frequent basis than their counterparts, therefore specific needs, learning, and feedback from each interaction can be used to anticipate and prepare for the next encounter EM and PEM providers are an important part of that feedback loop The AAP and ACEP have recommended that families with CWSHCN use an emergency information form (EIF) to assist in providing accurate and complete information that will aid the prehospital provider in assessment and transport decisions Medical jewelry has also been noted as a useful adjunct to help provide immediate access to critical information Use of healthcare directives is important, but can be especially challenging for the EMS provider in an acute situation Clear protocols should address this issue for each service, and medical control providers should be literate with this issue Identification of the medical home can help families and providers plan and partner for optimal interactions Contact information for providers who can help with care and process can be invaluable TABLE 134.5 CWSHCN EDUCATIONAL PROGRAMS AVAILABLE TO THE PREHOSPITAL PROVIDER Educational programs available to the prehospital provider Program Online resource Special children’s outreach and prehospital education http://www.childrensnational.org/files/PDF/EMSC/PubRes/Scope_Instructor.pdf A full-day course for prehospital providers that covers the care and management of CSHCN Developed by the EMS and Children with Special Health Care Needs Project at Children’s National Medical Center in Washington, DC Instructor’s manual is available via the link Teaching resource for http://webdoc.nyumc.org/nyumc/files/cpem/u3/trippbls.pdf instructors in prehospital pediatrics Developed at New York University, Langone Medical Center, with input from subject matter experts from across the country and incorporating American Heart Association guidelines Utah telehealth http://www.utahtelehealth.net/education/ems_childrens/ Developed by pediatric emergency medicine physicians at the University of Utah Consists of eight online learning videos covering topics from general pediatric prehospital care, to CSHCN Pediatric education for http://www.peppsite.com/ prehospital professionals Sponsored by the AAP, this course comes in 9.25-hr BLS and 16.75-hr advanced life support versions for a wide array of prehospital providers and covers a range of general pediatric topics Reprinted from Kaziny BD The prehospital care of children with special health care needs Clin Pediatr Emerg Med 2014;15:89–95 Copyright © 2014 Elsevier With permission EMERGENCY PREPAREDNESS EMS systems are an essential component to a coordinated emergency preparedness program EMS is ready every day for an emergency, and should be integrated into local and national preparedness initiatives EMS providers and students should be educated in mass casualty incident triage systems, such as that outlined in the Model Uniform Core Criteria (MUCC), which was developed to help ensure interoperability among multiple existing triage tools Current mass casualty incident triage systems include Simple Triage and Rapid Treatment (START) and its pediatric equivalent, Jump START, as well as Sort-Assess-Lifesaving Interventions-Treatment/Triage (SALT) and Sacco Triage Method These triage systems generally begin by differentiating ambulatory from nonambulatory victims, then identifying signs of death or immediately life-threatening conditions, such as airway obstruction or hemorrhage Victims are then further triaged based on physiologic and severity of injury criteria and transport from the scene is delayed for stable victims Triaging children during a mass casualty incident or disaster presents unique challenges Firstly, children may not follow commands well Children may hide from rescuers rather than presenting themselves for care Children separated from adult family members may be scared and difficult to console, as well as quite challenging for families and providers Some injured children will be extricated from disaster scenes by adults present on the scene, and the triage personnel may not know the circumstances in which the child was found, making judgment of the severity of injury difficult In the case of a well child accompanying an injured adult, triage personnel may need a dedicated supervisor to monitor mobile children who may wander off Additional pediatric emergency preparedness resources are available at http://disasterinfo.nlm.nih.gov/dimrc/children.html EMS FOR CHILDREN PROGRAM The EMSC program was established when Congress approved the Preventive Health Amendments of 1984 The intent was to enhance the pediatric capability of EMS systems originally designed primarily for adults, with a goal of reducing child and youth mortality and morbidity sustained as a result of severe illness or trauma The program is administered through the Maternal and Child Health Bureau of the Health Resources and Services Administration (HRSA) Project efforts have included systems development, injury prevention, research, ... Developed by pediatric emergency medicine physicians at the University of Utah Consists of eight online learning videos covering topics from general pediatric prehospital care, to CSHCN Pediatric. .. shared resources to optimize access to pediatric specialty care PEDIATRIC PREHOSPITAL AIRWAY MANAGEMENT Respiratory arrest is the most common cause of pediatric cardiac arrest and is associated... almost inevitable, as only 1% to 5% of pediatric patients treated in the prehospital setting receive airway management In some systems, paramedics may attempt pediatric intubation no more than once