Pediatric emergency medicine

• ANATOMY OR SYSTEM AFFECTED: All

DEFINITION: The decision making and actions necessary to prevent death or any further disability in children with life-threatening injuries, illnesses, and other health crises

Science and Profession

Physicians who specialize in pediatric emergency medicine are trained to diagnose and treat patients to prevent death or any further disability for children in health crises. They are also skilled at health promotion and injury prevention efforts. For some young patients, emergency departments are the only source of routine medical care. Pediatric emergency physicians represent the front line of medicine.

Emergency medicine emphasizes the anticipation and recognition of a life-threatening process, rather than seeking a definitive diagnosis. The emergencies that these physicians treat are often the type that parents hope never to see. The perceptions and complaints of the patients or the people who bring them to the emergency department or pediatric trauma center define the emergencies themselves. Most children treated in an emergency department will be seen in a general hospital whose staff may not include pediatric specialists. Each year, 25 to 50 percent of the children who visit the emergency department are there because of an injury. Other visits are the result of illnesses, such as asthma or life-threatening meningitis. Services are available twenty-four hours a day, seven days a week, 365 days a year, in the hospital and the field. They are provided by a network of health specialists, nurses, paramedics, emergency medical technicians, police officers, firefighters, and others dedicated to offering emergency medical services to children and adults.

Pediatric emergency specialists are needed because children are not little adults. The differences between children and adults are so great that they exist in virtually every organ system, body part, physiological process, and disease syndrome. For example, children’s lungs are smaller and more fragile than those of adults, so they require gentler thrusts during cardiopulmonary resuscitation (CPR). Children have faster heart and respiration rates than do adults, so what may look like normal adult rates may be a sign of serious trouble in a child. Children require different and special equipment, different-sized instruments, different doses of different medicines, and different approaches to the psychological support and remedial care given to the ill or injured patient.

Physicians and other health care providers who lack pediatric emergency medical training and experience may find it difficult to recognize children who are critically ill and require the most urgent care. For example, infants may not develop a fever to signal infection. In children, respiratory arrest or shock signals the risk of cardiopulmonary arrest, rather than the arrhythmias that typically precede cardiac arrest in adults.

Diagnostic and Treatment Techniques

Prompt identification and treatment of serious illness or injury in children is critical for positive patient outcomes. Emergency services personnel use a system called triage to decide whether patients are at risk for severe illness or imminent death, whether they have less urgent but still serious medical problems, or whether they have routine problems.

Health care professionals also use a system called the ABCs. Children who are choking (A for airway obstruction), in respiratory distress (B for breathing), or in shock (C for circulatory collapse) are treated immediately. The sickest patients always come first. Comprehensive training programs such as Pediatric Advanced Life Support (PALS) generally include the ABCs or a similar method called the primary survey (DRABC), which includes checking for Danger, assessing for a Response from the casualty, opening the Airway, checking for Breathing, and assessing Circulation, or severe bleeding.

Doctors often make the most important decisions about a patient within the first five to fifteen minutes of care. The physician first determines whether the patient is in need of treatment and confirms or rules out the presence of catastrophic disease as quickly as possible. The doctor then stabilizes the patient’s vital signs to reduce the risk of worsening symptoms or death. Next, the physician acts to relieve the most acute symptoms. The patient may then be hospitalized or discharged with directions about what to do next.

Perspective and Prospects

Physicians have been treating pediatric emergencies for centuries, but only in the late twentieth century did the medical community and the public realize that pediatric emergency care requires unique training, equipment, and procedures.

Emergency medicine as a discipline in the United States dates to 1968, when the American College of Emergency Physicians was formed. During the 1970s, pediatricians and pediatric surgeons recognized that children’s emergency care needs were not receiving adequate attention. The American Medical Association (AMA) and the American Board of Medical Specialties recognized emergency medicine as the twenty-third medical specialty in 1979. In the early 1980s, growing numbers of pediatric specialists and professional societies began to participate in the development of emergency medical systems. The first subspecialty board examination in pediatric emergency medicine was administered in 1992. In 1993, a committee of the Institute of Medicine (now the National Academy of Medicine) published a major study on the state of emergency care for children. The committee focused on standardizing the emergency care system so that the quality of emergency care would be consistent from state to state and community to community. It encouraged the creation of a nationwide 911 emergency response system and the establishment of minimum standards of care.

Into the twenty-first century, federal funding from the Emergency Medical Services for Children (EMSC) Program continued to support state-level and academic research and overall pediatric health care readiness across emergency departments and pre-hospital services. The Pediatric Emergency Care Applied Research Network (PECARN), a branch of the EMSC, investigates and publishes information relating to childhood illness and injuries, while the EMSC Innovation and Improvement Center provides tools to care providers to ensure proper treatments are available to all children during emergencies and disasters.

The tools, technologies, treatments, and problem-solving methods used by pediatric emergency physicians advanced rapidly in the early twenty-first century. Simulation-based training for resuscitation, telemedicine resources for treating patients in remote locations without pediatric specialists, and quality metrics for readiness assessment all improved emergency pediatric care. With these advancements, specialists gained the knowledge and tools needed to address myriad children’s emergencies, including the medical and behavioral crises of newborns, infants, toddlers, young children, and adolescents. Emergency physicians continue to be responsible for the development of new treatment techniques and the widespread availability of specialized pediatric equipment.

Bibliography

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