Pediatric considerations in prehospital care
- Paul E Sirbaugh, DO
Paul E Sirbaugh, DO
- Associate Professor of Pediatrics
- Baylor College of Medicine
- Saranya Srinivasan, MD
Saranya Srinivasan, MD
- Assistant Professor of Pediatrics
- Baylor College of Medicine
- Pediatric Emergency Medicine Attending
- Texas Children's Hospital
- Section Editors
- Richard D Zane, MD
Richard D Zane, MD
- Section Editor — Emergency Medical Services/Disaster Medicine
- Professor and Chair of Emergency Medicine
- University of Colorado School of Medicine
- George A Woodward, MD
George A Woodward, MD
- Section Editor — Pediatric Signs and Symptoms
- Professor of Pediatrics
- University of Washington School of Medicine
- Deputy Editor
- James F Wiley, II, MD, MPH
James F Wiley, II, MD, MPH
- Senior Deputy Editor — Adult and Pediatric Emergency Medicine
- Senior Deputy Editor — Primary Care Sports Medicine (Adolescents and Adults)
- Clinical Professor of Pediatrics and Emergency Medicine/Traumatology
- University of Connecticut School of Medicine
The general approach to providing online medical direction and pediatric prehospital care considerations, including management, field triage, and transport decisions will be reviewed here.
A general understanding of the components of an effective EMS system for children, including personnel roles and capabilities and necessary preparation and equipment for providing prehospital pediatric care are discussed separately. (See "Prehospital pediatrics and emergency medical services (EMS)".)
Appropriate prehospital assessment and management of children is challenging and requires dedicated resources to ensure the best outcomes . In the past, it was common for emergency medical service (EMS) agencies to employ the “load and go” philosophy when providing prehospital care to an ill or injured child without strong emphasis on the provision of pediatric-specific stabilization. More recently, many agencies have improved the level of prehospital pediatric care and invested in training and equipment for their prehospital providers (eg, emergency medical technicians, paramedics).
In the United States, the federally supported Emergency Medical Services for Children (EMSC) program has been a major factor in promoting more intensive prehospital care within existing EMS systems . The EMSC program has supported prehospital pediatric research, developed educational tools for prehospital providers, and assessed the availability of equipment, online medical direction, and offline protocols for pediatric patients . As a result, pediatric focused offline protocols where providers can reference assessment tools, management pathways, or pediatric medication dosing or equipment types and sizing are more widely available. In addition, online medical direction by pediatric emergency medicine specialists with expertise in prehospital care is occurring in selected EMS agencies within the United States. The EMS for Children program is integrating quality improvement methodology into its work through the EMS for Children Innovation and Improvement Center .
ONLINE MEDICAL CONTROL
Online medical control consists of physician direction, supervision, and authorization of prehospital treatment by phone, radio, or at the scene in real time. The physician is often located at a base station that often is not located at the facility that will eventually receive the patient. In some settings, online medical control implies 24-hour availability of physicians to provide prehospital medical direction. (See "Prehospital pediatrics and emergency medical services (EMS)", section on 'Base station personnel'.)
- Committee on the Future of Emergency Care in the United States Health System. Summary. In: Emergency Care for Children: Growing Pains, The National Academies Press, Washington 2007. p.1.
- EMS for Children Innovation and Improvement Center. https://emscimprovement.center/resources/ (Accessed on September 12, 2016).
- Ball JW, Liao E, Kavanaugh D, Turgel C. The Emergency Medical Services for Children Program: Accomplishments and Contributions. Clinical Pediatric Emergency Medicine. 2006; 7: 6-14. http://www.clinpedemergencymed.com/article/S1522-8401(06)00002-4/abstract (Accessed on September 21, 2011).
- Dick WF. Anglo-American vs. Franco-German emergency medical services system. Prehosp Disaster Med 2003; 18:29.
- Committee on Pediatric Emergency Medicine and Committee on Bioethics. Consent for emergency medical services for children and adolescents. Pediatrics 2011; 128:427.
- Reference personal communication: Jeffrey F. Linzer, MD (email@example.com) 7-6-2011.
- Woodward GA, Garrett AL, King BR, Baker MD. Emergency medical services and transport medicine. In: Textbook of Pediatric Emergency Medicine, 6th edition, Fleisher GR, Ludwig S. (Eds), Lippincott, Williams & Wilkins, Philadelphia 2010. p.85.
- EMSC Partnership for Children/National Association of EMS Physicians model pediatric protocols: 2003 revision. Prehosp Emerg Care 2004; 8:343.
- Cone DC. Knowledge translation in the emergency medical services: a research agenda for advancing prehospital care. Acad Emerg Med 2007; 14:1052.
- Grimm RH Jr, Shimoni K, Harlan WR Jr, Estes EH Jr. Evaluation of patient-care protocol use by various providers. N Engl J Med 1975; 292:507.
- Model pediatric protocols. EMSC partnership for children. National Association of EMS Physicians, 2003. http://www.kdheks.gov/cphp/download/cacs_template/ModelPediatricProtocols.pdf (Accessed on April 24, 2012).
- National Association of State EMS Officials (NASEMSO) Model Clinical EMS Guidelines. https://nasemso.org/Projects/ModelEMSClinicalGuidelines/index.asp (Accessed on September 12, 2016).
- Callaham M. Quantifying the scanty science of prehospital emergency care. Ann Emerg Med 1997; 30:785.
- Foltin GL, Dayan P, Tunik M, et al. Priorities for pediatric prehospital research. Pediatr Emerg Care 2010; 26:773.
- Gonzalez RP, Cummings GR, Phelan HA, et al. On-scene intravenous line insertion adversely impacts prehospital time in rural vehicular trauma. Am Surg 2008; 74:1083.
- Gausche M, Lewis RJ, Stratton SJ, et al. Effect of out-of-hospital pediatric endotracheal intubation on survival and neurological outcome: a controlled clinical trial. JAMA 2000; 283:783.
- Youngquist S, Gausche-Hill M, Burbulys D. Alternative airway devices for use in children requiring prehospital airway management: update and case discussion. Pediatr Emerg Care 2007; 23:250.
- Ritter SC, Guyette FX. Prehospital pediatric King LT-D use: a pilot study. Prehosp Emerg Care 2011; 15:401.
- Chen L, Hsiao AL. Randomized trial of endotracheal tube versus laryngeal mask airway in simulated prehospital pediatric arrest. Pediatrics 2008; 122:e294.
- Kahalé J, Osmond MH, Nesbitt L, Stiell IG. What are the characteristics and outcomes of nontransported pediatric patients? Prehosp Emerg Care 2006; 10:28.
- Seltzer AG, Vilke GM, Chan TC, et al. Outcome study of minors after parental refusal of paramedic transport. Prehosp Emerg Care 2001; 5:278.
- Texas Statute 166 – Health and safety code: Advance Directives.
- American College of Surgeons Committee on Trauma, American College of Emergency Physicians Pediatric Emergency Medicine Committee, National Association of Ems Physicians, et al. Withholding or termination of resuscitation in pediatric out-of-hospital traumatic cardiopulmonary arrest. Pediatrics 2014; 133:e1104.
- American Academy of Pediatrics, Section on Transport Medicine. Air and Ground Transport of Neonatal and Pediatric Patients, 3rd edition, Woodward GA, Insoft RM, Kleinman ME. (Eds), American Academy of Pediatrics, Elk Grove Village, Illinois, USA 2006.
- National Association of State EMS Officials. Regionalization of care: Position statement of the National Association of State EMS Officials. Prehosp Emerg Care 2010; 14:403.
- American Academy of Pediatrics. Committee on Pediatric Emergency Medicine. American College of Critical Care Medicine. Society of Critical Care Medicine. Consensus report for regionalization of services for critically ill or injured children. Pediatrics 2000; 105:152.
- Hunt RC, Brown LH, Cabinum ES, et al. Is ambulance transport time with lights and siren faster than that without? Ann Emerg Med 1995; 25:507.
- Brown LH, Whitney CL, Hunt RC, et al. Do warning lights and sirens reduce ambulance response times? Prehosp Emerg Care 2000; 4:70.
- Ho J, Casey B. Time saved with use of emergency warning lights and sirens during response to requests for emergency medical aid in an urban environment. Ann Emerg Med 1998; 32:585.
- Kupas DF, Dula DJ, Pino BJ. Patient outcome using medical protocol to limit "lights and siren" transport. Prehosp Disaster Med 1994; 9:226.
- Bledsoe BE. The Golden Hour: fact or fiction? Emerg Med Serv 2002; 31:105.
- Lerner EB, Moscati RM. The golden hour: scientific fact or medical "urban legend"? Acad Emerg Med 2001; 8:758.
- Maguire BJ, Hunting KL, Smith GS, Levick NR. Occupational fatalities in emergency medical services: a hidden crisis. Ann Emerg Med 2002; 40:625.
- Whiting JD, Dunn K, March JA, Brown LH. EMT knowledge of ambulance traffic laws. Prehosp Emerg Care 1998; 2:136.
- Chapleau W. Lights & sirens. Emerg Med Serv 2002; 31:59.
- Wolfberg D. Lights, sirens and liability. JEMS 1996; 21:38.
- Charalambous N. Sirens to be limited to emergencies. Anderson Independent-Mail (November 21, 2002).
- National Highway Traffic Safety Administration (NHTSA). Recommendations for the Safe Transportation of Children in Emergency Ground Ambulances. Public meeting. August 5, 2010. http://www.nhtsa.gov/staticfiles/nti/ems/pdf/EMSconference05aug2010.pdf (Accessed on September 21, 2011).
- Gerlacher GR, Sirbaugh PE, Macias CG. Prehospital evaluation of non-transported pediatric patients by a large emergency medical services system. Pediatr Emerg Care 2001; 17:421.
- Haines CJ, Lutes RE, Blaser M, Christopher NC. Paramedic initiated non-transport of pediatric patients. Prehosp Emerg Care 2006; 10:213.
- Kannikeswaran N, Mahajan PV, Dunne RB, et al. Epidemiology of pediatric transports and non-transports in an urban Emergency Medical Services system. Prehosp Emerg Care 2007; 11:403.
- Moss ST, Chan TC, Buchanan J, et al. Outcome study of prehospital patients signed out against medical advice by field paramedics. Ann Emerg Med 1998; 31:247.
- Schmidt TA, Atcheson R, Federiuk C, et al. Hospital follow-up of patients categorized as not needing an ambulance using a set of emergency medical technician protocols. Prehosp Emerg Care 2001; 5:366.
- Hauswald M. Can paramedics safely decide which patients do not need ambulance transport or emergency department care? Prehosp Emerg Care 2002; 6:383.
- Silvestri S, Rothrock SG, Kennedy D, et al. Can paramedics accurately identify patients who do not require emergency department care? Prehosp Emerg Care 2002; 6:387.
- Selden BS, Schnitzer PG, Nolan FX. Medicolegal documentation of prehospital triage. Ann Emerg Med 1990; 19:547.
- ONLINE MEDICAL CONTROL
- Medical direction training
- General approach
- OFFLINE MEDICAL CONTROL
- TIMING OF PREHOSPITAL INTERVENTIONS
- PREHOSPITAL INTERVENTIONS
- Medical and surgical emergencies
- Pediatric procedures
- Difficult situations
- - Disagreement with prehospital provider
- - Patient refuses treatment
- - Transport refusal by legal guardian
- - Advanced directives
- - Suspected child abuse
- - Withholding or stopping resuscitation in traumatic cardiopulmonary arrest
- FIELD TRIAGE AND TRANSPORT DECISIONS
- Ground versus air transport
- Hospital destination
- Safe transport
- - Lights and sirens
- - Child restraint
- Decision not to transport
- ADDITIONAL RESOURCES