The American College of Emergency Physicians and the American Academy of Pediatrics released a policy statement advocating the use of an Emergency Information Form (EIF) for children with special healthcare needs The EIF is a medical summary that describes the patient’s medical conditions, medications, and special healthcare needs This can help improve the accuracy of the history and improve the quality of care administered Currently there is not a central standardized electronic repository of EIFs; however, individual groups have demonstrated feasibility on a smaller scale, suggesting that a central repository may be possible with the appropriate advocacy and oversight When caring for the technology-assisted child, several important principles emerge that should be used in the acute care setting ( Table 135.1 ) First, common things are common; common pediatric illnesses may afflict children with medical devices This point is always important to remember when evaluating a seemingly complicated child who presents with the routine signs and symptoms characteristic of typical childhood diseases For example, a child with a CSF shunt may have vomiting caused by gastroenteritis Second, the presence of indwelling devices predisposes the patient to infection When a child presents with symptoms associated with a specific piece of equipment, the clinician must be suspicious of infection of that equipment For example, if a child with a tracheostomy presents with fever, cough, and increasing secretions, it is crucial to evaluate for the possibility of tracheitis At the same time, the equipment has a tendency to become colonized with commensal organisms Therefore, all bacterial growth does not indicate acute infection and other sources of infection should be considered Above all, families should be relied on for important information because they often have become knowledgeable of specific illnesses and equipment Parents are sensitive to subtle changes in their children Families are experts and should play an integral role in the evaluation, management, and ultimate disposition of their child in the ED setting Children with chronic illnesses have a higher likelihood of being admitted to the hospital, resulting in longer lengths of stay in the ED The practitioner should realize that the families of technology-assisted children often have sufficient equipment and trained personnel available in the home setting to care for an exacerbation of a chronic problem or an unrelated acute problem For example, family members whose child has a chronic respiratory illness often have supplemental oxygen in the home and are facile with its use Knowing that families of technology-assisted children are compliant and likely to return to the ED if their child’s degree of illness exceeds the capabilities of the home care is reassuring Thus, the practitioner should consider altering the usual criteria for admission in this specific population On the other hand, technology-dependent children may show more subtle signs of illness and can deteriorate rapidly Having a technology-assisted child in the home creates a stressful situation for family members and other caregivers A visit to the ED for an acute problem exacerbates this level of stress These families may be more likely to question the diagnostic tests and therapies offered during the evaluation of their child because of their level of medical knowledge, as well as the constant illness-related anxiety that intrudes upon their lives The ED visit is more effective if the practitioner recognizes the psychosocial issues associated with this population of patients TABLE 135.1 APPROACH TO THE TECHNOLOGY-DEPENDENT CHILD IN THE EMERGENCY DEPARTMENT Common pediatric illnesses can afflict chronically ill children Presence of foreign bodies or hardware predisposes the patient to infection Families are the experts in their children’s problems—rely on them for important information Consider altering the usual criteria for admission Latex allergy is common among technology-dependent children TRACHEOSTOMY CARE Background Advances in neonatology and pediatric critical care medicine have enabled children to survive the complications of premature birth, congenital anomalies, and severe life-threatening illnesses As home care has become more widely recognized as an alternative to prolonged and costly hospitalization, the number of children managed at home with tracheostomies and mechanical ventilation has increased dramatically Consequently, the number of such children seeking care in the ED has also increased To approach these situations calmly and systematically, the emergency physician should (1) appreciate the physiologic differences in a patient with chronic respiratory insufficiency (CRI), (2) be familiar with the equipment used in the care, and (3) understand the commonly encountered complications and their management Pathophysiology In healthy people, respiration is maintained via a complex mechanism involving the alveolocapillary network, the diaphragm and intercostal musculature, and the central respiratory centers in the brainstem Respiratory compromise results when one or more components of this mechanism are affected by disease Chronic respiratory support may be a part of the management plan for children with diverse disease processes, including neurologic and neuromuscular disorders, central hypoventilation syndromes, obstructive apnea, congenital facial and airway anomalies, and others Processes such as bronchopulmonary dysplasia once accounted for the majority of CRI; however, recent epidemiologic studies have demonstrated a shift in the proportion of CRI from chronic lung disease to neurologic and neuromuscular disorders Equipment The complexity of the many tubes and attachments extending from the patient’s airway can be overwhelming, especially in the emergent situation Familiarity with the equipment used in caring for a patient with a tracheostomy ensures the emergency physician’s adept management of these situations Starting from the patient’s neck, each piece of equipment can be easily identified ( Fig 135.1 ) FIGURE 135.1 Tracheostomy parts Tracheostomy Tubes Modern tracheostomy tubes are made of polyvinylchloride, a soft substance that conforms to the shape of the trachea, but is rigid enough to avoid collapse Unlike their metal predecessors, they have little tissue reactivity, causing less tracheal wall irritation Several manufacturers package sterile tracheostomy tubes for onetime use Intensivists directing the long-term airway management of their patients may prefer one manufacturer to another, but the emergency physician does not need to know the minor differences among the products However, the emergency physician should know what types of tracheostomy tubes are stocked by the ED’s facility and how to convert from the patient’s brand and size to an available tube with suitable dimensions Three dimensions determine the size of a tracheostomy tube: the inner diameter, the outer diameter, and the length The inner diameter refers to the same measurement used in describing the size of an endotracheal tube, ranging from 2.5 to 10 mm This measurement is generally imprinted on the flanges of the tracheostomy tube and is standardized among manufacturers The outer diameter and length are often not identified on the tube and can vary considerably among manufacturers When a tracheostomy tube change is indicated and an identical replacement is not available, the clinician should choose a tube that has dimensions as close as possible to the patient’s original Select a replacement tube that has all three dimensions either equal to or slightly smaller than the patient’s usual tube Down sizing to a smaller tube may be indicated as a temporizing measure until a more suitable replacement tube can be located A tracheostomy tube may be cuffed or uncuffed An infant or young child may have a cuffed tracheostomy tube, especially if he or she has an airway anomaly or has developed tracheomegaly Checking for the presence of a cuff is important because the cuff must be deflated before removing the tube Some tracheostomy tubes are fenestrated The hole in the posterior aspect of the tube facilitates retrograde movement of air through the larynx, allowing vocalization In addition, some tracheostomy tubes have an inner cannula that is positioned within the lumen of the tracheostomy tube (i.e., the outer cannula) so that it can be removed for cleaning while the airway is maintained by the outer cannula Importantly, the proximal portion of the inner cannula is required to connect the tracheostomy to the manual resuscitator bag; therefore, the inner cannula must be in place when bag–valve ventilation is performed ( Fig 135.2 ) ... population of patients TABLE 135.1 APPROACH TO THE TECHNOLOGY-DEPENDENT CHILD IN THE EMERGENCY DEPARTMENT Common pediatric illnesses can afflict chronically ill children Presence of foreign bodies... technology-dependent children TRACHEOSTOMY CARE Background Advances in neonatology and pediatric critical care medicine have enabled children to survive the complications of premature birth, congenital... may prefer one manufacturer to another, but the emergency physician does not need to know the minor differences among the products However, the emergency physician should know what types of tracheostomy