Pediatric Emergency Medicine — Past, Present, And Future

Phyllis H. Stenklyft, M.D., FAAP, FACEP
Phyllis H. Stenklyft, M.D., FAAP, FACEP is Associate Professor, Emergency Medicine and Pediatrics and Director, Pediatric Emergency Services at the University of Florida Health Science Center / Jacksonville.

Introduction

Pediatric emergency medicine (PEM) is a relatively new field with ties to the specialties of pediatrics and emergency medicine. Tremendous advances have been made in the care of ill and injured children over the past 10 years. These advances involve improvements in education, equipment, injury and disease prevention. Pediatric emergency care has been the focus of intense media coverage and political attention in the 1990's.

Epidemiology And Scope Of Pediatric Emergency Care

Approximately 25-35 % of all emergency department (ED) visits are for ill or injured children, yet children account for only 5-10% of ambulance runs. Currently, children requiring emergency care are seen in one of the following scenarios: a pediatric emergency department (PED) in a children's hospital, a separate PED in a multidisciplinary hospital, or a combined adult-pediatric ED in a multidisciplinary or community hospital. About 85-90% of pediatric ED visits in the United States occur in general or community hospital ED's.^1-4

A predominance of children younger than 5 years is seen in ED's. Older children and adolescents are commonly seen for trauma related complaints, whereas young children and infants present more often with medical illnesses. Studies have found that parents and caretakers of children underutilize the 911 EMS system. Common reasons for calling 911 include seizures, respiratory distress, motor vehicle accidents, and falls.

Hospitalization is most commonly required for children seen in ED's with febrile illnesses, asthma, and trauma. Data collection systems for injured children are more advanced than systems for pediatric medical illnesses seen in the ED. There is one pediatric trauma death for every 42 injury-related hospitalizations and every 1,120 trauma-related ED visits. Unfortunately, there are limited data available on the epidemiology or morbidity and mortality of pediatric medical emergencies. Children admitted to pediatric intensive care units account for less than 1% of children seen in the ED. Emergency department hospitalization rates are lower for children than adults.^1-4

Pediatric Versus Adult Resuscitation

Children rarely present to the ED in full cardiac arrest or with cardiac arrhythmias. Most critically ill children initially present with the pre-arrest conditions, shock and respiratory distress. Pediatric and neonatal arrests are primarily respiratory. Schoenfeld and Baker reviewed 80,000 PED visits to the Children's Hospital of Philadelphia and found that only 201 (0.0025%) patients qualified to be treated in the resuscitation room. Only 58% of these 201 patients required endotracheal intubation, 30%, Pediatric Advanced Life Support (PALS) protocol drugs, and 2%, defibrillation or cardioversion.⁵ These statistics and others account for the lack of confidence most paramedics, pediatricians, and emergency physicians experience when faced with a critically ill child or a pediatric resuscitation.^6,7 The number of true pediatric resuscitations and life-saving procedures is so low that it is difficult to obtain and maintain these skills. There are many differences between pediatric and adult resuscitations, summarized in Table 1.^2,8

Unfortunately, most pediatric medical arrests occur in children less than 15 months of age. The survival rate for children that are apneic and pulseless on arrival to the ED is only 5-10%. Many of the survivors are left with severe neurologic compromise. The survival rate for children that present with apnea but have a pulse is 85-90%. Bystander cardiopulmonary resuscitation (CPR) is an important factor in predicting morbidity and mortality.^5,9,10 The American Red Cross and the American Heart Association offer pediatric CPR and basic life support courses. All parents, teachers, caretakers, and health-care providers should be encouraged to learn adult and pediatric CPR.

The leading causes of death in children older than 1 year of age are drowning, injuries, neoplasms, homicide, and suicide. Death in the infant is usually due to sudden Infant Death Syndrome (SIDS), perinatal complications, congenital anomalies, and infection. Sadly, death from abuse and AIDS are increasing in infants and children.^1-3

Past Accomplishments In Pediatric Emergency Medicine

Table 2 summarizes some of the historical advances in the field of PEM. There was very little emphasis on emergency care for children in the 1970's and early 1980's. The primary focus at that time was the development of prehospital systems, cardiac care programs, and promotion of the Advanced Cardiac and Advanced Trauma Life Support educational courses.¹¹ It was soon noticed that prehospital and emergency efforts were not adequately addressing the needs of children. These needs began to be addressed in the mid-1980's by the development and rapid spread of pediatric life support courses. Jacksonville, Florida was the site for many of the initial pediatric life support pilot courses.^1-3,12

PEM fellowship training programs have grown to the present number of 40 programs with 54 first year positions available in the 1999 PEM fellowship Match program.¹³ Most fellowship programs are now 3 years duration and involve a significant research component. University of Florida Health Science Center-Jacksonville began one of the first PEM fellowship programs in 1983. In 1992 the first certifying exam was held for PEM.¹⁴ There are now approximately 1000 board certified subspecialists in PEM.¹⁵

Emergency Medical Services for Children (EMS-C) grants have improved pediatric care at both a state and national level. In 1984, Congress approved a demonstration grant program to expand access to and improve the quality of emergency medical services for children available through existing EMS systems and to generate knowledge and experience that other states and localities could draw on in their efforts to enhance care for children. Initially, EMS referred to prehospital and emergency care systems. There is now a broader vision for EMS-C as part of a comprehensive approach to children's health care including primary care, emergency care, tertiary care, and rehabilitation. Numerous EMS-C educational materials and products are available from the National EMSC Resource Alliance (NERA). In 1995, the Maternal and Child Health Bureau (MCHB) and the National Highway Safety Traffic Safety Administration (NHTSA) published a 5-year plan for EMS-C. The plan's objectives are based on recommendations laid out by the Institute of Medicine in the 1993 report, Emergency Medical Services for Children. Current and past EMS-C grants are largely responsible for PEM public awareness and data collection.^1-3,16,17

Injury and disease prevention efforts have dramatically changed the scope of illness seen in the ED. The introduction of the Haemophilus influenzae type b (Hib) vaccine in 1990 has almost eliminated epiglottitis in children and markedly decreased the incidence of meningitis, sepsis, and septic shock.¹⁸ The recommended change in infant sleep position has decreased the incidence of SIDS as well as the incidence of children presenting to the ED with cardiac arrest.^19,20 Injury prevention efforts, such as bicycle helmet requirements and drowning prevention programs, are beginning to decrease morbidity and mortality in children. Drowning and motor vehicle accidents remain the leading killers of Florida's children over one year of age.^21,22

Progress has also been made in the development and implementation of equipment and life-saving procedures used in children. National organizations such as ACEP have published recommended equipment guidelines for prehospital units and ED's.²³ Much of the focus in EMS-C grants has been on training paramedic, ED, and hospital staff in the appropriate use of pediatric emergency equipment.¹⁶ The ED must have equipment to meet the needs of a premature newborn to an adult-sized adolescent. New technology has centered on meeting pediatric airway and circulation needs. Rapid sequence induction with sedative and paralytic agents has become an acceptable technique for intubation of children and infants in the ED. The technique is well described in the APLS course and skill stations.^8,12

In the late 1980's, intraosseous (IO) infusion resurfaced as a life-saving procedure for establishing vascular access in pediatric patients requiring resuscitation. Featured in The PALS and APLS educational programs, the IO technique has almost replaced the need for saphenous cut down procedures in children while decreasing the need for central lines.^8,12 Studies have shown the IO procedure can be successfully taught to paramedics in a 3- to 4-hour workshop resulting in an 80% success rate in less than 30 seconds.²⁴ Tsai et al found that intravenous (IV) access could only be successfully established in 50% of pediatric cardiac arrest victims of all ages. Furthermore, obtaining successful IV access in pediatric resuscitation often takes longer than 10 minutes.⁴

Pediatric Emergency Medicine In Jacksonville

Jacksonville and the surrounding area is fortunate to have two pediatric emergency departments, one at University Medical Center and one at Baptist Medical Center. Both emergency departments are involved in teaching PALS and other educational programs to physicians, nurses, and paramedics.

Future Challenges In Pediatric Emergency Care

Advancing injury and disease prevention remains the greatest challenge in improving the care of children.²² Florida has active drowning prevention and bicycle helmet programs as well as other safety programs.²¹ This challenge extends to all areas of pediatric care. Maintenance of pediatric resuscitation skills is a new dilemma caused by the national decrease in pediatric morbidity and mortality and the reduction and/or elimination of Hib-related systemic disease. Future controversial issues to address include the national debate on what type of physicians should take care of pediatric emergency patients and whether there is a need for pediatric facility standards.^25,26

REFERENCES

1. Diekmann RA, ed. Pediatric Emergency Care Systems: Planning and Management. Baltimore, Maryland: Williams and Wilkins; 1992.
2. Institute of Medicine, Committee on Pediatric Emergency Medical Services. Durch JS, Lohr KN, eds. Emergency Medical Services for Children. Washington DC: National Academy Press; 1993.
3. Seidel JS, Henderson DP, eds. Emergency Medical Services for Children: A Report to the Nation. Washington, DC: National Center for Education in Maternal and Child Health; 1991.
4. Tsai A, Kallsen G. Epidemiology of pediatric prehospital care. Ann Emerg Med. 1987;16:284-292.
5. Schoenfeld PS, Baker MD: Management of cardiopulmonary and trauma resuscitation in the pediatric emergency department. Pediatrics. 1993; 91:726-729.
6. Maibach EW, Scheiber RA, Carroll MFB: Self-efficacy in pediatric resuscitation: Implications for education and performance. Pediatrics. 1996; 97:94-99.
7. Paul RI, King L. Technical skills experiences in pediatric emergency medicine fellowship programs. Ped Emerg Care. 1996;12:10-12.
8. American Academy of Pediatrics, American College of Emergency Physicians. APLS: The Pediatric Emergency Course. 1993.
9. Schindler MB, Bohn D, Cox PN, et al. Outcome of out-of-hospital cardiac or respiratory arrest in children. NEJM. 1996; 335:1473-1479.
10. Hickey RW, Cohen DM, Strausbaugh S, Dietrich AM. Pediatric patients requiring CPR in the prehospital setting. Ann Emerg Med. 1995;25:495-501.
11. American Heart Association. Advanced Cardiac Life Support. Dallas, TX: American Heart Association; 1994.
12. American Academy of Pediatrics, American Heart Association. Pediatric Advanced Life Support. Dallas, TX: American Heart Association; 1997.
13. American Academy of Pediatrics. The section on emergency medicine news. 1997; 6:1-11.
14. Shaw, KN, Schunk J, Ledwith C, Lockhart G, et al and members of the Three-Year Academic Subcommittee of the PEM Fellowship Committee of the Section of Emergency Medicine, American Academy of Pediatrics. Pediatric emergency medicine (PEM) fellowship: Essentials of a three-year academic curriculum. Ped Emerg Care. 1997;13:77-81.
15. Personal correspondence with American Academy of Pediatrics.
16. Feely HB, Athey JL. Emergency Medical Services for Children: 10 Year Report. Arlington,VA: National Center for Education in Maternal and Child Health;1995.
17. US Department of Health and Human Services, Health Resources and Services, Health Resources and Services Administration, Maternal and Child Health Bureau. Emergency Medical Services for Children: Abstracts of Active Projects FY 1997. Torrence, CA. National Emergency Medical Services for Children Resource Alliance.
18. Subedar N, Rathore MH. Changing epidemiology of childhood meningitis. J Florida MA. 1995;82:467-469.
19. Willinger M. SIDS prevention. Pediatric Annals. 1995;24:358-364.
20. American Academy of Pediatrics Task Force on Infant Positioning and SIDS. Positioning and SIDS. Pediatrics. 1992;89:1120-1126.
21. Injuries in Florida: 1993 Mortality Facts. Florida Injury Prevention and Control Program. State of Florida, Department of Health and Rehabilitative Services.
22. Rivara FP, Grossman DC. Prevention of traumatic deaths to children in the United States: How far have we come and where do we need to go? Pediatrics. 1996; 97:791-797.
23. American College of Emergency Physicians. Pediatric equipment guidelines. Ann Emerg Med. 1995;25:307-309.
24. Smith RJ, Keseg DP, Manly LK, Standeford T. Intraosseous infusions by prehospital personnel in critically ill pediatric patients. Ann Emerg Med. 1988; 17:491-495.
25. American Academy of Pediatrics Committee on Pediatric Emergency Medicine: Guidelines for pediatric emergency care facilities. Pediatrics. 1995; 96:526-537.
26. Eitzen E, Schafermeyer RW, Strange GR. The role of the emergency physician in providing pediatric emergency care - a membership survey. Ann Emerg Med. 1990;19:532-535.

March, 1999/ Jacksonville Medicine

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