The pediatrie patient has long heen the orphan of the emergency medical services (EMS) system, the primary focus of which has been on adult cardiac arrest and more recently, resuscitation of traumatized patients. However, emergency departments, whether in community, general, or children's hospitals, have increasingly begun to respond to the unique management of the acutely ill child; education, equipment, and organizational changes have all resulted in marked care improvement.
Although traumatic injuries are the most common cause of death in children after the first year of life, and sudden infant death syndrome (SIDS) the most common cause under age 1, respiratory illness is the most common underlying condition in children and is often life-threatening. Respiratory compromise can quickly lead to hypoxia, acidosis, and ultimately, complete respiratory failure. Children may also rapidly develop hypovolemia from excessive vomiting or diarrhea, leading to impaired perfusion, compensated shock, acidosis, and eventually cardiac arrest. These two processes, either alone or together, can quickly progress to cardiopulmonary arrest.
Clearly, early recognition and stabilization are fundamental to halting this process. Primary care physicians have pivotal roles in the preparation and management of pediatrie emergencies. They must be knowledgeable and skilled in resuscitation and early stabilization of the critically ill child and should have appropriate equipment and personnel support. Rirthermore, patient education is essential in prevention and early recognition of life-threatening conditions. It is essential to discuss options for access to the emergency medical services system, as well as to the local emergency department and hospital facilities. Parents must be taught to respond to emergencies in a calm and orderly fashion and should prepare emergency cards for each of their children to carry, which should include:
* The child's name, address, age, significant medical problems, and any medications he or she is taking.
* The parents' names and home and work telephone numbers.
* The rescue squad's telephone number (commonly 911).
* The fire department's telephone number.
* The doctor's telephone number.
* The emergency department's telephone number.
* The poison control center's telephone number.
* Authorization for treatment in parental absence.
EVOLVING RESPONSES TO THE PEDlATRIC PATIENT
In designing systems that can respond to pediatrie emergencies, respiratory problems and management must be considered first, for cardiopulmonary arrest to occur, there must be progressive deterioration of respiratory and circulatory function secondary to acidosis or hypoxia.
Cardiac arrest and its accompanying multiple organ failures, although rare in children, have resulted in greater than 90% mortality in some studies. In contrast, respiratory arrest is associated with a 33% mortality, with most children in this group under 1 year of age. Out-of-hospital cardiac arrest in children is commonly the result of SDDS, drowning, or preceding respiratory arrest and occurs most commonly in children under age 1 .
Increasingly, new approaches and technologies have been introduced in pediatrie resuscitation, resulting in major improvements in care. A return to old techniques, including intraosseous infusion of fluids, and the use of Broselow tape (which correlates a patient's length with average weight, drug doses, . and endotracheal, nasotracheal, and suction catheter sizes) and rectal diazepam, have enabled clinicians to provide better care to their critically ill pediatrie patients.
Educational programs are now available through the American Academy of Pediatrics, the American College of Emergency Physicians, and the American Heart Association to teach physicians to provide emergency care to children, both in and out of the hospital. The Pediatrie Advanced Life Support (PALS) program teaches health professionals early recognition of and intervention in care of children with life- threaten ing illnesses, concentrating on shock and respiratory failure, as well as newborn resuscitation. The Advanced Pediatrie Life Support (APLS) course is a nationally standardized program that also concentrates on the management of these illnesses in hospital settings; it is more disease-specific and comprehensive than the PALS course.
As we enter the 1990s, we realize that the practitioners of pediatrics and emergency medicine each bring unique expertise to the care of the critically ill child. There are already accredited combined residency training programs, allowing graduates to gain certification in both pediatrics and emergency medicine. Pediatrie emergency medicine and critical care medicine fellowships have been developed to train pediatricians beyond standard residency training in these areas. These programs have been accredited and graduates of critical care medicine fellowships have been certified; certification of pediatrie emergency medicine is anticipated.
In addition, the Society for Pediatrie Emergency Medicine (SPEM) was established to provide a forum for pediatrie emergency practitioners. Other professional organizations, including the American Acad' emy of Pediatrics and the American College of Emergency Physicians, have also established active groups within their organizations for these purposes.
EMERGENCY MEDICAL SERVICES
The components of the pediatrie health care system are varied and must include persons responding to the initial emergency, as well as a network of emergency services and hospitals to provide definitive care. A firm commitment by all health care professionals is essential to the success of this system. '
Parents, day care workers, teachers, and others in daily contact with children must be trained to recognize the signs and symptoms of critical illnesses and injuries. They must know whether to call their doctor, the rescue squad, or the poison control center, or to take the child directly to the nearest hospital emergency department. It is essential that they understand how to contact their local fire, police, or ambulance dispatch systems.
Primary physicians, when presented with a lifethreatening situation in the office, must know how to access immediate emergency assistance. Preparation for handling such emergencies is essential, in terms of training office personnel and having the appropriate equipment and medications on hand. Routine drills of office personnel may facilitate responsiveness. The EMS system must be viewed as an adjunct to office emergency care, having more advanced capabilities than those available in most office settings and a ready expertise to initiate stabilization procedures and transport the child to a hospital emergency department.
The prehospital EMS capabilities must be assessed within each community and upgraded as appropriate. The system must be capable of providing basic and advanced life support in the field and be in communi' cation with a responsible EMS base station or hospital emergency room.
Transport vehicles must be equipped with appropriate equipment and drugs to manage pediatrie emergencies. Triage arrangements must allow for rapid transport to emergency departments.
A network of hospitals must be prepared, so children with a variety of critical care needs can be stabilized at the receiving hospital and transferred to a tertiary care hospital for more definitive treatment.
Much work is left to be done, Seidel reported that 41% of training programs for EMS personnel have 10 or fewer hours of pediatrie training, and 55% of those personnel had no clinical experience with children.2 Numerous studies have demonstrated the need for increased attention to pediatrie emergencies. Ramenoisky found that 53% of pediatrie trauma deaths might be averted. * Children have a higher death rate in prehospital situations than adults, primarily because critical pediatrie care does not exist/
The critically ill child stresses the entire health care system, which must be ready to recognize life-threatening events, initiate care, and provide for appropriate referral for definitive management. All components of the health care system must work together to focus on the needs of children. The primary care physician can play a central role in this process by serving as an important advocate for children to assure that a high level of expertise and responsiveness is present within the system. The first step must be for primary care physicians to be well trained in treating pediatrie emergencies themselves and to make certain that their office is properly equipped and their personnel properly trained.
BASIC COMPONENTS OF A PEDIATRIC EMS SYSTEM
The vast majority of emergency pediatrie conditions are either preventable or reversible if treated quickly and appropriately. Today, accidents and injuries are the major cause of morbidity and mortality of children after infancy. Each year, more than 10 000 children succumb to accidental death, for each child who dies, four others sustain severe morbidity. The combination of motor vehicle- and bicycle-related injuries, drownings, and poisonings account for the vast majority of injuries.
These injuries carry specific problems:
* Most are preventable.
* They present as emergencies, generating rapid physiologic derangement, the treatment of which must be immediately instituted to be successful.
* They are frequently managed by minimally trained providers.
The solution to these problems is the establishment of an emergency medical service system responsive to pediatrie emergencies. Initial priorities of the EMS system were adult trauma and heart disease, with the creation of trauma centers and advanced cardiac life support systems. In 1973, the Emergency Medical Services Act outlined the system's components: prehospital transport agencies; imerfacility transport agencies; dispatch and communication systems; triage, treatment, transfer, and transport protocols; receiving facilities; specialty care units; training programs; financing methods; auditing and quality assurance overviews; public education programs; mutual aid methodologies; and disaster planning. Only recently has special attention to the needs of critically ill or injured children been seen as an integral element of the EMS system.1-7
The components of the system currently do not fall under any master structure, but function independently, the result is fragmentation of individual services, so the system does not ensure proper linkages between its components and continuity of care is often sacrificed. Only when all participants carry out their respective roles appropriately can problems be solved. The basic elements of a pediatric-oriented EMS system are discussed below.
Prevention plays a major role in reducing morbidity. This should be coordinated by primary care physicians. Primary care physicians should direct accident prevention information to parents about infant and child car seats (starting with their use with newborns on discharge from the nursery), seat belts for older children, bicycle safety (including the use of helmets), toy safety standards, home safety, (eg, electrical outlet covers, stair gates, proper poison and medication storage, hot water heater temperature control, and the use of smoke detectors). First aid information, including the use of ipecac, should also be provided. Informed parents can orchestrate community-wide, public awareness and educational efforts directed to prevention of childhood accidents and ingestions, and can lobby for legislative support for these initiatives. Access to care is often best achieved by using the 911 system, which should be universal. Unfortunately, it is not uncommon for people to spend precious time attempting to contact a primary care physician when a child suffers a major injury, or conversely, to access a paramedic unit for a trivial problem. An uneducated decision in either direction can jeopardize patient care by creating an unnecessary delay in obtaining emergency treatment. Effective medical direction must be provided so dispatch and hospital destination policies address the needs of children.
Field treatment involves emergency medicine technicians (EMTs) and the lay public. Bystander cardiopulmonary resuscitation has been shown to increase survival for the adult patient with myocardial infarction. Results in the pediatrie population are less favorable, however, because of the nature of pediatrie cardiac arrest and its uniformly bad prognosis. The care of critically ill children must be increased in paramedic and EMT training programs. Educational emphasis must reflect the problems encountered on the scene, including multiple trauma, seizures, and respiratory distress, particularly airway management.
Emergency care of children has continued to improve with enhanced training of emergency physicians and standardization of equipment appropriate for infants and children. There are now guidelines for enhancing the ability of general emergency departments to care for children. Emergency department treatment protocols, continuing medical education, and quality assurance must reflect pediatrie needs. Transfer agreements that provide rapid access to specialized pediatrie tertiary care centers need to be in place.5
COMPREHENSIVE FEATURES OF A PEDIATRIC EMS SYSTEM
EMS systems are designed to treat both children and adults, rather than having separate systems for each because they are costly and, particularly in small cities and rural areas, the number of children requiring emergency medical services is too small to justify a separate pediatrie EMS system. In recent years a few statewide and regional emergency medical services for children (EMSC) have been developed,8,9 some with federally funded srate demonstration grants. These efforts represent the integration of pediatrie care into the existing EMS system. Mailer has re' cently described seven factors intrinsic to EMS-C systems.10
1. Initial and continuing educational programs for EMTs conducted by neonatologists, emergency physicians, pediatrie emergency physicians, pedi' atric surgeons, and anesthesiologists, that include training in the emergency care of infants and children, incorporating placement of intravenous and intraosseous infusions and endotracheal tubes in infants and young children.
2. Two-way radio communication between EMTs at the scene of an emergency and a centrally based emergency physician to obtain advice on emergency care to determine to which emergency treatment facility the child should be transported, in accordance with the child's particular needs for special care.
3. A dependable transport system that will take the child to the appropriate treatment center via a specially equipped and staffed ambulance or helicopter in radio contact with the emergency medical relay center and the referral treatment center.
4. Hospital-based emergency departments appropriate for pediatrie care (EDAPs), fully equipped and staffed by emergency medicine specialists for assessing, stabilizing, and treating critically ill infants and children either to resolve the problem or to prepare transfer to a pediatrie intensive care unit (PICU) or a pediatrie trauma center, when the patient's initial condition precludes transport.
5. Centrally located pediatrie intensive care units and pediatrie trauma centers equipped with multiple-channel monitors, ventilators, and an on-site blood gas laboratory staffed by appropriately trained critical care pediatricians, pediatrie surgeons, neurosurgeons, orthopedists and other surgical subspecialists, nurses, and respiratory therapists.
6. Local intermediate care units capable of caring for less critically ill patients who do not require initial treatment in a PICU or where recuperating PICU patients may be transferred to relieve PICU census problems and enable primary care physicians and parents to contribute to the patient's management and recovery more easily.
7. A pediatrie rehabilitation unit staffed by specialists in rehabilitation medicine and nursing, neurology, psychiatry, psychology, education, behavioral pediatrics, orthopedics, and physiotherapy and occupational therapy, is capable of providing all services required to assure maximum recovery from the physical, emotional, and cognitive effects of critical illnesses and severe trauma.
Certainly, these comprehensive features of an EMS-C system define ideal pediatrie critical care management. This system was evaluated and discussed at a recent meeting of experts in the field.11 Whether such a system can be instituted in all areas of the United States is not known. Certainly, we will have to invest extensive resources in training and professional support needed to build and equip all components of the system.
1. Fifield. et al. Pediatrie emergency care in a metropolitan area. J Emerg MeJ. 1984; 1 1:495.
2. Seidel JS. Emergency medical service! and the pédiatrie patient: are the needs being met.' II. Training and equipping emergency medical service providers for pediatrie emergencies. Pediatrici. 1986;78:808.
3. Ramenofsky ML. Emergency medical services for children and pediatrie trauma system components. J Pediarr Sing. 1989;2:153.
4. Applebaum D. Advanced prehospital care lot pediatric emerRencies. Ann Emerg Mal 1985;14:656.
5. Wagner D. Pediatrie emergency care: where Ai we gu from hcrcf An emergency physician's perspective. Pediatr Emerg Care. 1986:2:261.
6. Harris BH. Creating pediarric trauma systems. J Peditr Surg. 1989;M49.
7. Creating pediatrie trauma systems. ) Pe&atr Surg. 1989;24:149-152.
8. Mailer JA, Beaver B. A model: systems management of I ite -threatening injuries in children for the state of Maryland, USA. Intensnx Care MoJ. 1989; 15:553-550.
9. Haller JA. Toward 3 comprehensive emergency medical system tor children. Pediatria. 1990;T6:?2(?22.
10. Halkr JA, ed. Emergency medical services for children. Riiss Laboratories; Reptirt (if the 97th Ross. Contttence on Pediatric Research; 1989-, CulumW. Ohio.