Triage Pediatric Considerations in Prehospital Care

6/1/2016
Pediatricconsiderationsinprehospitalcare
OfficialreprintfromUpToDate
www.uptodate.com2016UpToDate
Authors
PaulESirbaugh,DO
ManishIShah,MD
SectionEditors
RichardDZane,MD
GeorgeAWoodward,MD
DeputyEditor
JamesFWiley,II,MD,MPH
Alltopicsareupdatedasnewevidencebecomesavailableandourpeerreviewprocessiscomplete.
Literaturereviewcurrentthrough:Dec2015.|Thistopiclastupdated:May08,2014.
INTRODUCTIONAppropriateprehospitalassessmentandmanagementofchildrenischallengingandrequires
dedicatedresourcestoensurethebestoutcomes[1].Inthepast,itwascommonforemergencymedicalservice
(EMS)agenciestoemploytheloadandgophilosophywhenprovidingprehospitalcaretoanillorinjuredchild
withoutstrongemphasisontheprovisionofpediatricspecificstabilization.Morerecently,manyagencieshave
improvedthelevelofprehospitalpediatriccareandinvestedintrainingandequipmentfortheirprehospital
providers(eg,emergencymedicaltechnicians,paramedics).
IntheUnitedStates,thefederallysupportedEmergencyMedicalServicesforChildren(EMSC)programhasbeen
amajorfactorinpromotingmoreintensiveprehospitalcarewithinexistingEMSsystems[2].TheEMSCprogram
hassupportedprehospitalpediatricresearch,developededucationaltoolsforprehospitalproviders,andassessed
theavailabilityofequipment,onlinemedicaldirection,andofflineprotocolsforpediatricpatients[3].Asaresult,
pediatricfocusedofflineprotocolswhereproviderscanreferenceassessmenttools,managementpathways,or
pediatricmedicationdosingorequipmenttypesandsizingaremorewidelyavailable.Inaddition,onlinemedical
directionbypediatricemergencymedicinespecialistswithexpertiseinprehospitalcareisoccurringinselected
EMSagencieswithintheUnitedStates.
Thegeneralapproachtoprovidingonlinemedicaldirectionandpediatricprehospitalcareconsiderations,including
management,fieldtriage,andtransportdecisionswillbereviewedhere.Ageneralunderstandingofthe
componentsofaneffectiveEMSsystemforchildren,includingpersonnelrolesandcapabilitiesandnecessary
preparationandequipmentforprovidingprehospitalpediatriccarearediscussedseparately.(See"Prehospital
pediatricsandemergencymedicalservices(EMS)".)
ONLINEMEDICALCONTROLOnlinemedicalcontrolconsistsofphysiciandirection,supervision,and
authorizationofprehospitaltreatmentbyphone,radio,oratthesceneinrealtime.Thephysicianisoftenlocated
atabasestationthatoftenisnotlocatedatthefacilitythatwilleventuallyreceivethepatient.Insomesettings,
onlinemedicalcontrolimplies24houravailabilityofphysicianstoprovideprehospitalmedicaldirection.(See
"Prehospitalpediatricsandemergencymedicalservices(EMS)",sectionon'Basestationpersonnel'.)
Physicianswhowillprovideonlinemedicalcontrolshouldhavepediatricemergencymedicineknowledgeand
skills,specifictraining,agoodunderstandingofthegeneralapproachtodirectionofprehospitaltreatment,and
detailedknowledgeofthepediatricprotocolsinuseintheirregion.Medicalcontrolphysiciansshouldalsohavea
clearunderstandingoftheabilitiesoftheprehospitalproviders,theirlimitations,andoverallsystemconstraints.
Whileonlinemedicalcontroldoesallowforcustomizedprehospitalmedicalcare,itmaydelaytransportto
definitivecareandislaborintensive.Inmanysystems,themajorityofprehospitalcareisprovidedthrough
standardprotocols.(See'Offlinemedicalcontrol'below.)
MedicaldirectiontrainingTobemosteffective,physicianswhowillprovideonlinepediatricmedicalcontrol
shouldhaveaproperunderstandingofhowtofulfillthatroleaswellasspecificknowledgeoftheirlocaland
regionalemergencymedicalservices(EMS).Keyactionstooptimizetheironlinemedicaldirectioninclude(see
'Additionalresources'below):
Maintainpediatricemergencymedicineknowledgeandskillswithemphasisonthespecifictypesofcritical
http://www.uptodate.com.pbidi.unam.mx:8080/contents/pediatricconsiderationsinprehospitalcare?topicKey=EM%2F13870&elapsedTimeMs=0&source=m
1/43
6/1/2016
illnessandinjurythatcommonlyrequireprehospitalintervention(eg,respiratorydiseases,seizures,trauma,
poisoning).(See"Prehospitalpediatricsandemergencymedicalservices(EMS)",sectionon'Epidemiology'.)
DevelopageneralunderstandingofthestructureofEMSintheirregionincludinghowtheEMSsystemis
accessed(eg,UnitedStates:911EuropeanUnion:112Australia:000),dispatchprotocols,andthescope
ofpracticeofspecifictransportpersonnel.(See"Prehospitalpediatricsandemergencymedicalservices
(EMS)",sectionon'TheEMSsystem'and"Prehospitalpediatricsandemergencymedicalservices(EMS)",
sectionon'Dispatchpersonnel'and"Prehospitalpediatricsandemergencymedicalservices(EMS)",section
on'Scopeofpractice'.)
Obtainspecificeducationonhowtoprovideonlinemedicaldirection.Manyemergencyphysiciansreceive
specifictraininginonlinemedicaldirectionduringtheiremergencymedicineresidencyorfellowshipin
pediatricemergencymedicineorprehospitalmedicine.Othersmaytakeonlinemedicaldirectioncourses
providedbyvariousorganizations(eg,theNationalAssociationofEMSPhysicians).
Understandthelocalsystemorsystemsinwhichtheypracticeincludingthefollowing:
Typeofsystem(eg,public,privateorvolunteersystems)(see"Prehospitalpediatricsandemergency
medicalservices(EMS)",sectionon'TypesofEMSsystems')
Organizationofthedispatchsystemandprehospitalresponsetoanemergencycall(eg,tieredversus
nontiered).InthecontextofEMS,tieredresponsereferstolevelofprovidertrainingandtimingto
dispatchofproviderstoascene.Forexample,tieredsystemsmaybesingletiered(advancedlife
supportresponse[ALS]orbasiclifesupport[BLS]responseonly),twotiered(basiclifesupport[BLS]
andALS),orthreetiered(physician).Exceptformultiplecasualtyincidents,itremainsrareformedical
directorsinNorthAmericatobeincludedinthedispatchprotocol.Thisisincontrasttosomecountries
inEuropewherephysiciansmaybedispatcheddirectlytothescenetoprovidecareforthecriticallyill
orinjuredpatient[4].
Levelofpreparednessforpediatricencountersbaseduponinitialandongoingprehospitalprovider
education,training,andexperience
Thepolicies,capabilitiesandcapacityoftheregionsEMSagenciesandhospitals.Forexample,some
hospitalsmaybemorecapablethanothersofhandlingtheacutelyillorinjuredchild.
TheregionallawsgoverningEMSandemergencydepartment(ED)operations.Forexample,consent
anddonotresuscitatelawsarenotconsistentacrossjurisdictionsandignoranceofthelawdoesnot
protecttheclinicianfromprosecution[5].
Communicationchannelsandequipmentusedtoconnectprovidersonscenewithmedicaldirectors
andhospitals
Policyandproceduresforhospitalpatientdeliveryandhandoffs(eg,SBARSituation,Background,
AssessmentandRecommendation)
GeneralapproachTheapproachtoeveryprehospitalnotificationoftransportshouldbeorganizedand
consistent.Themedicalcontrolphysicianshouldalwaysbecordialduringprehospitalcommunicationsand
availableforupdatesduringprehospitaltransport.Medicalcontrolphysiciansshould:
Identifythemselvestothecallerasamedicalcontrolphysician
Identifythecallersandclarifytheircapabilities(ie,scopeofpractice)Themedicalcontrolphysicians
maybecontactedbydifferentprehospitalpersonnelincluding:
Dispatcher,basestation,EMSmedicaldirector,orprovideronscene.(See"Prehospitalpediatricsand
emergencymedicalservices(EMS)",sectionon'Dispatchpersonnel'.)
2/43
6/1/2016
Basiclifesupport(BLS)personnel(eg,emergencymedicalresponder[EMR],firstresponder[FR],
emergencymedicaltechnician[EMT]),advancedlifesupport(ALS)providers(advancedEMT,
paramedic,supervisor,nurseorphysician)Ifnotalreadyestablished,themedicalcontrolphysician
needstoassesstheprehospitalprovidersabilitytorespondtomedicaldirectionforpatient
managementandsocial,legal,oradministrativeissuesduringthetransport.(See"Prehospital
pediatricsandemergencymedicalservices(EMS)",sectionon'Scopeofpractice'.)
RequestpatientinformationKeyinformationincludesage,briefhistory,physicalassessment,treatment
provided,andresponsetointerventions.Prehospitalprovidersoftenusephysicalassessmenttoolsand
scoressuchasthepediatricassessmenttriangle,thepediatricGlasgowcomascale(table1),ortrauma
triagescores(table2)torapidlycommunicatetheseverityofillness.(See"Initialassessmentand
stabilizationofchildrenwithrespiratoryorcirculatorycompromise",sectionon'Pediatricassessment
triangle'and"Classificationoftraumainchildren".)
Thelengthofthisexchangewilldependuponmanyvariablesincludingthesafetyofthescene,theproviders
leveloftraining,andtheconditionofthepatient.Itmaybenecessarytointerrupttheprehospitalprovider
duringthecommunicationtoreorienttheprioritiestostabilizationoftheairway,breathing,andcirculation.For
example,afieldreportthatthechildisintubateddoesnotinsurethattheendotrachealtube(ETT)isproperly
placed.Theclinicianmayneedtostopandasktheproviderwhatconfirmationmeasureshaveoccurredto
provethattheETTisinthetrachea,suchasqualitativeendtidalcarbondioxidemeasurementor
auscultation,beforeproceedingwiththerestoftheexchange.
Whentimepermits,itisoftennecessarytoremindtheprehospitalprovidertoinvolvethecaregiverinthe
patientsassessment,especiallywhenthepatientisachildwithspecialhealthcareneeds.Oftenthe
caregiversassessmentofmentalstatus,respiratoryeffort,orcolorrelativetothechildsnormalbaselineis
essentialtodetermineproperprehospitalinterventions.
EnsureprovidersafetyTheenvironmentinwhichemergencymedicalservices(EMS)providerspractice
israrelyassafeandcontrolledasthatofthemedicalcontrolphysician.Theproviderswilltypicallyensure
thattheirsurroundingsaresafefromphysicalharmbeforeproceedingwithpatientassessmentand
management.However,occasionallythemedicalcontrolphysicianmayrecognizeriskthatwasnotnotedby
theprovider(eg,exposuretotransmittableinfectiondiseasesortoxins)andcanremindtheprovidertodon
appropriatepersonalprotectiveequipment.Whenaseriousinfectiousdiseaseexposurehasoccurred,the
EMSagencysinfectioncontrolofficershouldalsobecontactedoncepatienttransporthasbeencompleted.
ProvidepatientcarerecommendationsWhenmakingpatientcarerecommendations,theclinicianmust
understandthecapabilitiesandconstraintsoftheprehospitalproviderandthemedicationsandequipment
availabletothem.Forexample,itisnotappropriatetoorderabasiclifesupportprovidertoperform
endotrachealintubationbecausetheyarenotlicensedortrainedtodothisprocedure.Prehospitalproviders
alsotypicallyoperateunderprotocolsthathavebeenapprovedbytheirofflinemedicaldirector.Depending
uponthejurisdiction,theymayormaynotbeabletoperformactionsthatarenotpartoftheirprotocolunless
theirmedicaldirectorgivesonlineapproval.(See'Offlinemedicalcontrol'below.)
Whenthemedicalcontrolphysicianisunsureabouttheprehospitalproviderscapabilities,medications,or
supplies,thebestcourseofactionistodirectlyasktheprovider.
Additionalconsiderationswhenmakingprehospitalcarerecommendationsinclude:
Requestlengthbasedweightestimateswhentheactualweightisnotknowntoprovideappropriate
pediatricdrugdosing.(See"Initialassessmentandstabilizationofchildrenwithrespiratoryor
circulatorycompromise",sectionon'Estimationofweight'.)
Askfortheconcentrationofthemedicationtobedeliveredandordertherecommendeddosebyweight
3/43
6/1/2016
(eg,mg/kg)andvolume(eg,mL).Theprehospitalprovidershouldrepeatthedruganddosebacktothe
medicalcontrolphysiciantoensuretheorderhasbeenreceivedandproperlyunderstood.
Recognizethattheavailabilityofequipmentthatisspecifictochildrenisoftenlimitedintheprehospital
environment.IntheUnitedStates,arecommendedlistofpediatricsizedequipmentforambulances
hasbeendeveloped(table3andtable4).Unfortunately,notallUnitedStatesEMSagenciescomply
withthoserecommendations.
Balancethedelayintransportwiththebenefitsofperformingarecommendation.(See'Timingof
prehospitalinterventions'below.)
Allowtimefortherecommendationtobecarriedoutbeforerequestingastatusupdate.
Remindtheprovidertoreassessthechildforchangesinconditionthroughouttransport.
Determinethereceivinghospitalandestimatedtimeofarrival(ETA)Insomecircumstances(eg,level
1traumapatients(algorithm1)),thereceivinghospitalispredeterminedbylocalorregionaljurisdictions.In
manysystems,theprehospitalprovidershaveagoodunderstandingofthefacilitieswiththebestpediatric
resources.Otherwise,themedicalcontrolphysicianshouldselectthereceivinghospitalthatwillprovidethe
bestcareforthepediatricpatientsconditionwhilealsolimitingambulancetransporttime.(See'Hospital
destination'below.)
PerformadministrativedutiesThemedicalcontrolphysicianshouldensuredocumentationof
communicationwiththeprehospitalproviderincludingthecorrecttranscriptionofanymedicationordersor
recommendedinterventions.Keepinmindthatsystemsmayvaryontherequirementsfordocumentingthe
inputofinternalandphysiciandirectionandmedicalmanagement.
IntheUnitedStates,thephysicianmaybillforonlineadvancedlifesupport(ALS)medicaldirection.The
physicianmustbelocatedinahospitalemergencydepartmentorcriticalcareunitbutneitherafacetoface
servicenordocumentationoftheserviceisrequiredalthoughdocumentationtosupportthebillingisprudent.
Billingcannotoccurforofflinemedicalcontrol.Thephysiciancansendabillindependentlyfromanyother
EDevaluationandmanagementservices(eg,EMSALSonlinedirectionisdoneatasiteotherthanthe
receivinghospital)[6].
EnsurecompliancewithlegalrequirementsThemedicalcontrolphysicianshouldprovidethe
prehospitalproviderwithrecommendationsthatareinaccordancewithprevailinglawsinagivenjurisdiction
regardingthereportingofchildabuse,honoringofdonotresuscitateorders,abilityofapatienttorefuse
treatment,andactionstotakeifalegalguardianrefusesmedicaltransport.(See'Difficultsituations'below.)
OFFLINEMEDICALCONTROLOfflinemedicalcontrolrefers,inpart,totheadministrationofemergency
medicalservices(EMS)byanemergencymedicalservicesphysiciandirectorthroughtheuseofstandardized
prehospitalcareprotocols[7].Theseprotocolsareinplacetodirectprehospitalcareandauthorizespecific
medicaltreatmentswithinafieldprovidersscopeofpracticewithouttheneedforrealtimecommunication.The
prehospitalprovidertypicallyalsohastheabilitytodirectlycontactamedicalcontrolphysicianduringprehospital
treatmentfortheprovisionofcareoutsideofstandardprotocol,ifquestionsarise,orifaprotocoldoesnot
specificallyapplytothepatientscondition.(See"Prehospitalpediatricsandemergencymedicalservices(EMS)",
sectionon'Basestationpersonnel'and"Prehospitalpediatricsandemergencymedicalservices(EMS)",section
on'EMSdirection'.)
Offlineprehospitalprotocolsfacilitaterapidandeffectivetreatment,standardizemanagementactionsfor
prehospitalprovidersandprovideareferenceforEMSpracticestandards[8,9].Theuseofpatientcareprotocols
hasalsobeenshowntobeaneffectivewayofmonitoringprocessesinmedicalcareandprovidingamechanism
toprovidefeedbacktoemergencymedicalservicespersonnel[10].
4/43
6/1/2016
Manypediatricprehospitalprotocolsexistbutmayvaryfromregiontoregion.IntheUnitedStates,nationalmodel
pediatricprehospitalprotocolshavebeendeveloped[11].However,adoptionisvoluntaryandhasnotoccurredin
manyjurisdictions.
MostprotocolsthatEMSsystemsuseareformulatedbaseduponexpertopinionorconsensus.Thelackofhigh
qualityevidencefromrandomizedtrialsintheprehospitalsettingreflectsalimitednumberofprehospital
researchersandthechallengesassociatedwithobtainingconsentintheprehospitalsettingthisisespeciallytrue
inthepediatricpopulation[12,13].
TIMINGOFPREHOSPITALINTERVENTIONSOnscenerecommendationsshouldincludethosetreatments
thataretimesensitive,haveclearbenefit,aregenerallyeasyandfasttoperformandcouldbelifesaving.Itis
essentialforaprehospitalprovidertorespondtolifethreateningconditions(eg,apnea,hypoxemia,hypoglycemia,
orexternalhemorrhage).However,itisnotappropriateforthecliniciantodelaythetransportofastablepatientso
thatelectiveprocedures(eg,intravenousaccess)canbeperformed[14].
Examplesofappropriateonsceneprehospitalinterventionsareshowninthetable(table5).
Enrouterecommendationsshouldincludetheinitiationorcontinuationofthosetreatmentsindicatedforonscene
deliveryandthosethatmayaddadditionalbenefitwithoutdelayingtransporttimeorfurtherinjurytochild.
Examplesinclude:
Establishingvascularaccess(see"Vascular(venous)accessforpediatricresuscitationandotherpediatric
emergencies"and"Intraosseousinfusion")
Administrationofcorticosteroidsormagnesiumsulfateforstatusasthmaticus(see"Acuteasthma
exacerbationsinchildren:Emergencydepartmentmanagement",sectionon'Pharmacotherapy')
Administrationofmethylprednisoloneforallergicreactionsoranaphylaxis(see"Anaphylaxis:Rapid
recognitionandtreatment",sectionon'Pharmacologictreatments')
PREHOSPITALINTERVENTIONS
MedicalandsurgicalemergenciesEvidenceforimprovedoutcomeswithspecificinterventionsinthe
prehospitalsettingislimited[12].ExamplesofadultandpediatricprotocolsdevelopedforalargeEMSregionare
availableathttp://www.miemss.org/home/default.aspx?tabid=10.
Althoughprimarilydesignedforthehospitalsetting,thefollowingrapidoverviewsandalgorithmsprovideguidance
fordiseasespecificprehospitaltreatmentplansandcanassisttheonlinemedicalcontrolphysicianwith
recommendationsduringfieldcareofthecriticallyillorinjuredchildrenasfollows:
PediatricbasiccardiopulmonaryresuscitationTheapprovedinternationalpediatricbasiclifesupport
algorithmsareavailablehere(singlerescuer)andhere(2ormorerescuers).
Pediatrictachycardia(algorithm2)
Pediatriccardiacarrest2015PediatricCardiacArrestAlgorithm
Pediatricbradycardia(algorithm3)
Anaphylaxis(table6)
Statusasthmaticus(algorithm4)
Statusepilepticus(table7)
Shock(algorithm5)
Pediatrictrauma(figure1)
5/43
6/1/2016
Pediatrichypoglycemia(table8)
PediatricproceduresCommonprehospitalpediatricproceduresincludecervicalspineimmobilization,basic
andadvancedairwaymanagement,andvascularaccess.
CervicalspineimmobilizationChildrenwithpotentialorsuspectedcervicalspineinjurybyhistory,
physicalexam,ormechanismofinjuryshouldundergoimmobilizationinacervicalcollarandplacementona
rigidbackboard.Theprehospitalprovidermustensuretheuseofappropriatelysizedpediatricequipmentto
avoidexcessmotionofthecervicalspineandpotentialairwaycompromisefrominadequatepaddingunder
theshouldersorimproperlysizedcervicalspinecollars.Youngathleteswearinghelmetsandshoulderpads
(eg,Americanfootballplayers)shouldhavethehelmetleftonwiththefacemaskremovedduringcervical
spineimmobilization.Childrenwearinghelmetswithoutshoulderpads(eg,dirtbikeriders,cyclists)should
havethehelmetremovedpriortocervicalspineimmobilization.(See"Pediatriccervicalspineimmobilization"
and"Fieldcareandevaluationofthechildoradolescentathletewithacuteneckinjury",sectionon'Helmet
removal'.)
Experiencesuggeststhatmanyinfantsandchildrenwhoundergospinalimmobilizationforminortrauma
couldbetransportedsafelywithoutcervicalspineprecautions.Althoughrulesforclinicalclearancewithout
imaginghavebeendevelopedforhospitaluse(algorithm6),consensuscriteriatoidentifychildrenwhodonot
requirecervicalspineimmobilizationintheprehospitalsettingarelacking.(See"Evaluationofcervicalspine
injuriesinchildrenandadolescents",sectionon'Radiologicevaluation'.)
BasicairwaymanagementMedicalcontrolphysiciansshouldemphasizeappropriatebasicairway
maneuversincludingjawthrust(traumapatients),chinlift(patientswithouttrauma),andbagmaskventilation
augmentedbyoralairway(unconsciouspatients)ornasopharyngealairway(semiconsciouspatients)forthe
prehospitalcareofchildrenwithrespiratorycompromise.(See"Basicairwaymanagementinchildren".)
Inurbanemergencymedicalservicessystemswherepatienttransporttimesaretypicallylessthan20
minutes,bagmaskventilationappearsequivalenttoendotrachealintubationwithfewerseriousadverse
events.Asanexample,inatrialof820childrenrequiringprehospitalairwaymanagementinLosAngeles
County,bagmaskventilationwasassociatedwithsimilarsurvivalandneurologicoutcomeswhencompared
withendotrachealintubation(survival30versus26percent,respectivelygoodneurologicoutcome23versus
20percent,respectively)[15].Esophagealintubationorunrecognizeddislodgementoftheendotrachealtube
occurredin15patientswhowereintubated,ofwhom14subsequentlydied.
AdvancedairwaymanagementTheroleofprehospitalendotrachealintubationinthepediatricpatientis
unclear.Asnotedabove,bagmaskventilationappearsasefficaciouswithfewerseriousadverseevents
thanendotrachealintubationwhenpatienttransporttimesareshort[15].Insystemswheretransporttimes
arelongandwhenrigoroustrainingandmaintenanceofintubationskillsbyparamedicscanbeassured,
endotrachealintubationmaybebeneficialinselectedpatients.
Preliminarystudiesinsimulationmodelssuggestthatalternativepediatricemergencyairwaydevices,such
asthelaryngealmaskairway,maypermitmorerapidestablishmentofeffectiveventilationwithfewer
adverseeventsthanendotrachealintubation[1618].However,furtherstudyofprehospitaluseofthese
devicesinchildrenisneededtodeterminewhethertheyprovideanyadditionalbenefitoverbagmask
ventilation.(See"Emergencyrescuedevicesfordifficultpediatricairwaymanagement".)
VascularaccessPrehospitalvascularaccesspermitsadministrationofmedicationsthatmayimprovethe
patientsconditionpriortoarrivalatthereceivinghospital(eg,patientswithseizures,anaphylaxis,or
hypoglycemia).However,establishingperipheralintravenous(IV)accesscanbedifficultintheprehospital
setting,especiallyinyounger,lesscooperativechildren.Atthescene,twopatientcareprovidersare
available,onetoperformvascularaccessandtheothertoassistwithholdingandsecuringtheintravenous
line.Whenenroute,typicallyonlyoneproviderisavailabletoperformandsecurevascularaccess.
6/43
6/1/2016
Incontrast,intraosseouscannulationallowsformorerapidprehospitalvascularaccesswithsimilarratesof
success.Insituationswhereimmediatevascularaccessisnecessarytoaddresslifethreateningillness,
intraosseouscannulationshouldbeadvisedforprehospitalproviderswhohavetheappropriatetrainingand
scopeofpractice.(See"Intraosseousinfusion",sectionon'Indications'.)
Difficultsituations
DisagreementwithprehospitalproviderWhentheprehospitalproviderdisagreesorrefusestocomply
withthemedicalcontrolphysiciansrecommendation,thephysicianshouldattempttofurtherunderstandthe
situationandifneededrequestimmediatecommunicationwiththeemergencymedicalservicesagencysmedical
director.Themedicalcontrolphysicianmustunderstandthattypicallytheprehospitalproviderislicensedto
practicesolelyunderthemedicallicenseoftheiractingmedicaldirectorandcanrefusedirectionbyother
physiciansthatfalloutsideofstandardprotocolsunlessthemedicaldirectoriscontactedanddirectsthemto
comply.
PatientrefusestreatmentAnunemancipatedorimmatureminorcannotrefuseemergencymedical
treatmentandthebestapproachwhenalegalguardiancannotbeidentifiedistoprovideprehospitaltreatmentand
transportation[7].However,theageofconsentandrefusalfortreatmentvariesdramaticallyindifferent
jurisdictions[5].
Incontrast,mostjurisdictionsrecognizeaminortobeemancipatedandcapableofrefusingemergentevaluation
andtreatmentiftheyaremarried,selfsupportingandnotlivingathomeoronactivedutystatusinthemilitary[5].
Furthermore,somegovernmentalstatutesrecognizeamatureminorexceptionthatallowsminorsoveracertain
age,usually14years,tomakemedicaldecisions.However,thespecificaspectsoftheseexceptionsvary
accordingtoregion.Thus,itiscriticalthatallphysiciansbefamiliarandincompliancewiththelawsofthelocality
inwhichtheypractice.
TransportrefusalbylegalguardianPediatricnontransportsshouldbeavoidedinmostcases.EachEMS
systemshoulddeveloppoliciesthataddressthissituationinaccordancewithlegalstatutes[5].Insituations
wherelackoftreatmentposesasignificantriskofharmordeathtoachild,assistancefromlawenforcement
shouldbeobtainedtopermitplacementinprotectivecustody.
Inpatientsforwhommedicaltransportandtreatmentisadvisedbutnoimminenthealththreatispresent,medical
harmtothepatientandmedicolegalriskcanbediminishedifthefollowingaretrue:
Thoroughassessmentandevaluation(medicalscreeningexamination)hasbeencompletedbythe
prehospitalproviderandnoabnormalitiesarenotedinadevelopmentallynormalchild.
Mechanismofinjuryishistoricallyinconsequentialtooutcome.
Notreatmentswereadministeredbyanyprehospitalprovider.
Thereisnohistoryorperceivedriskofabuseorneglectinvolvinganyindividualonscene.
Thechiefcomplaintisunrelatedtoanychronicmedicalcondition(eg,wheezingandasthma).
Thepersonrefusingprehospitaltransportationhasthelegalauthoritytorefusetreatmentandstatesthatthey
willseekappropriatemedicaltreatment.
Thelegalguardianwhoisrefusingtransportationisnotintoxicatedorotherwiseincompetent.
Theprehospitalmedicalrecordisinitiatedandrecordedandadocumentequivalenttoanagainstmedical
adviceformissignedbythelegalguardian.
Observationalstudiesindicatethatupto89percentofchildrenwhosecaretakerrefusestransportreceivemedical
carewithinaweekoftherefusalandtypicallyhavegoodoutcomes[19,20].However,inanobservationalstudyof
7/43
6/1/2016
51childrenwhosoughtcarewithin48hoursofcontactwithEMS,9percentwereadmittedtothehospital.Thus,
prehospitalprovidersandonlinemedicalcontrolshouldmakeeveryefforttopersuadecaregiverstoallow
prehospitaltransport.
AdvanceddirectivesAdvancedirectives(ie,donotresuscitateorders)arebecomingmoreandmore
prevalentinpediatricpatients.IntheUnitedStates,moststatesrequirethatlegitimateadvanceddirectivesbe
honoredbyprehospitalpersonnelunlessthelegalguardianprovidesexplicitagreementtoallowresuscitation.In
somelocalities,healthcareproviderscanbesubjecttodisciplinaryactioniftheyfailtocomplywithadonot
resuscitateorder[21].
Insituationswhereanemergencycallhasbeenplacedandthepresenceofanadvanceddirectiveisverified(eg,
certifieddonotresuscitateorderor,inregionswherelegal,donotresuscitatemedicalbracelet),theprehospital
providerwithsupportfromonlinemedicalcontrolshouldattemptcommunicationwiththelegalguardianto
determinetheirwishes[7].Ofnote,thelegalguardianmayrevokeadvanceddirectivesverballyatanytime.
Possibleoutcomesinclude:
Notransportationorintervention
Transportationonlywithoutintervention
Transportationwithlimitedintervention
Transportationwithfullinterventionincludingcardiopulmonaryresuscitation.
Whenthepresenceofanadvancedirectivecannotbeverified,transportationwithallappropriateemergency
treatmentmeasuresisadvised.
SuspectedchildabuseWhenaprehospitalproviderreportsasuspicionofchildmaltreatment,themedical
controlphysicianmustensurethatallofthefollowingactionshavebeencompleted:
Appropriateprehospitaltreatmentandtransportisoccurringandthereceivingfacilityisawareofthe
prehospitalprovidersconcernforchildabuse.
Lawenforcementisnotifiedandresponding.
Whererequired,amandatoryreportismadetochildprotectionagenciesinaccordancewithprevailinglaws
ofthejurisdiction.(See"Childabuse:Socialandmedicolegalissues",sectionon'Reportingsuspected
abuse'.)
Insituationswherechildabuseissuspected,thecaregivershouldnotbeallowedtorefusetransport[5].Police
protectionmayberequiredtoensurethesafetyoftheprehospitalproviderandensurethatmedicaltransport
occurs.
WithholdingorstoppingresuscitationintraumaticcardiopulmonaryarrestInApril2014,theAmerican
AcademyOfPediatrics(AAP)CommitteeonPediatricEmergencyMedicine,NationalAssociationOfEMS
Physicians(NAEMSP),AmericanCollegeOfEmergencyPhysicians(ACEP)andAmericanCollegeOfSurgeons
CommitteeOnTrauma(COT),coauthoredapolicystatementtitledWithholdingOrTerminationOfResuscitation
InPediatricOutOfHospitalTraumaticCardiopulmonaryArrest[22].
Thispolicysuggeststhefollowing[22]:
Ifthereisanydoubtastothecircumstancesortimingofthetraumaticcardiopulmonaryarrest
resuscitationshouldbeinitiatedandcontinueduntilarrivaltotheappropriatefacility.
Thewithholdingofresuscitativeeffortsiswarrantedinpediatricvictimsofpenetratingorblunttraumawith
thefollowingfindings:
Injuriesobviouslyincompatiblewithlife,suchasdecapitationorhemicorporectomy.
Evidenceofasignificanttimelapseafterpulselessness,includingdependentlividity,decomposition
8/43
6/1/2016
andintheabsenceofseverehypothermia,rigormortis.
Ifthepatienthasarrested,resuscitationhasalreadyexceeded30minutes,andthenearestfacilityismore
than30minutesaway,involvementofparentsandfamilyofthesechildreninthedecisionmakingprocess
withassistanceandguidancefrommedicalprofessionalsshouldbeconsideredaspartofanemphasison
familycenteredcarebecausetheevidencesuggeststhateitherdeathorapooroutcomeisinevitable.
Patientswhosufferatraumaticcardiopulmonaryarrestinthefieldandwhoreceiveatleast30minutesof
resuscitativeeffortsusuallyhaveverypooroutcomes(deathorpersistentvegetativestate).Thus,
terminationofresuscitationisareasonableoptionforsuchpatientsinjurisdictionswheresuchfielddecisions
arepermittedbylawandwhenappropriatemeasuresareinplacetosupportthefamilyintheprehospital
setting.
FIELDTRIAGEANDTRANSPORTDECISIONS
GroundversusairtransportThedecisiontotransportachildbyairorgrounddependsupontheconditionof
thechild,theseverityoftheemergencycondition,thetypeandlocationoftheemergencyfacility,localresources,
safety,andweatherconditions[23].Asageneralrule,groundtransportismorereadilyavailableifanemergency
facilityiswithin20to30minutesofthescene,andairtransportisbetterifthereisroughterrainoralongdistance
betweenthesceneandtheemergencyfacility.Sometimesacombinationofairandgroundtransportisused.
Thetypicalstaffing(eg,emergencymedicaltechnicianorparamedic)andequipmentforbasiclifesupport(table3)
andadvancedlifesupport(table4)ambulancesandtherelativeadvantagesofgroundversusairprehospital
transportationarediscussedindetailseparately.(See"Prehospitalpediatricsandemergencymedicalservices
(EMS)",sectionon'Airversusgroundtransport'.)
HospitaldestinationSelectionofanappropriatereceivinghospitalisfacilitatedbydetailedknowledgeofthe
pediatriccapabilitiesofdifferentfacilitieswithinaregion.Designatingfacilitiescapableofhandlingpediatric
emergenciesaspartofaregionalsystemofemergencymedicalservicesforchildrenisdesirable[24].Asan
example,atraumafieldtriagealgorithmwithspecificpediatriccomponentshasbeendevelopedbyanational
expertpanelorganizedbytheCentersforDiseaseControl(algorithm1).Becauseoptimalcareandoutcomes
occurwhenthecriticallyinjuredchildisinitiallyresuscitatedandsubsequentlymanagedinapediatrictrauma
center,itispreferabletodirectlytransportchildrentosuchfacilitiesfromthefield,wheneverpossible.(See
"Traumamanagement:Approachtotheunstablechild",sectionon'Definitivecare'.)
Ingeneral,theoptimalreceivingfacilityforacriticallyillorinjuredchildshouldhavelargepediatricvolumeand
availabilityofexpertiseintheintensivecareofchildrenaswellasphysicianstrainedinpediatricsubspecialties,
suchaspediatricemergencymedicine,pediatriccriticalcaremedicine,andpediatricsurgery[25].General
emergencydepartmentsaretypicallycapableofmanagingacuteairwayemergenciesandstabilizationofother
criticalpediatricconditionspriortotransferfordefinitivecare.Otherfactorsthatmayimpactthebestdestination
include:
Hospitaldiversionstatusandsurgecapacity
Hospitalcapability
Pediatricsubspecialtiesavailable
Suspectedabuseandtheavailabilityofasuspectedchildabuseandneglectteam
Needformanagementinatertiarypediatriccarefacility
Parentalorpatientchoice(eg,historywithparticularinstitution)
Distancetothedefinitivecarefacility
Safetransport
LightsandsirensObservationalstudiesindicatethattheuseoflightsandsirenbyambulancesshortens
patienttransporttimeonaveragebyonlyonetothreeminutes[2628].Furthermore,improvedmedicaloutcomes
9/43
6/1/2016
forpatientsundergoingtransportwithlightsandsirenhasnotbeenshowninlimitedobservationalstudies[2931].
Theriskfortrafficcollisionsduringtransportwithlightsandsirenstocircumventorexceedtrafficlawsis
increasedwithsignificantpotentialforseriousinjuriesanddeathoftheprehospitalprovidersandpatient[7,3236].
Thus,theuseoflightsandsirensshouldbelimitedtothemostcriticallyillpatientswhoremainunstabledespite
prehospitaltreatmentandtoadviseotherdriversthatanemergentsituationexistswhiletheambulanceattempts
toadheretotrafficrules.
ChildrestraintTheUnitedStatesNationalHighwayTrafficSafetyAdministrationhasdevelopeddetailed
guidelinesonhowchildrenshouldbesafelytransportedaccordingtotheirdegreeofillnesswithspecific
recommendationsregardingthetypeofrestraintdeviceandhowtohandmultiplepatientswithinthesamefamily
whorequiretransportasshowninthetable(table9)[37].
DecisionnottotransportAllowingprehospitalpersonneltorefusetransportofchildrenafteremergency
medicalservices(EMS)contactiscontroversial.Observationalstudiesinvariousemergencymedicalsystems
(EMS)reportthatapproximately13to27percentofallpediatricEMSencountersresultinnotransportoccurring
[3841].Observationalstudiesthatevaluatedrefusalbaseduponaprehospitalprotocolorproviderclinical
judgmentsuggeststhattheycannotreliablydeterminewhichadultpatientsdonotneedambulancetransport[42
44].Incontrast,limitedobservationalevidenceinchildrensuggeststhatparamedicswiththesupportofonline
medicalcontrolcansafelyidentifypediatricpatientswhodonotrequireambulancetransportation[39,45].
InEMSsystemsthatallowprehospitalproviderstorefusetransportationofchildrenonthebasisofanonurgent
complaint,thefollowingkeycomponentsareessential[39]:
Appropriatetrainingofprehospitalpersonnelwithanemphasisonaccuratepediatricassessment
Clearpoliciesandprocedurestoguideprehospitaltriagedecisions
Requiredonlinemedicaloversight
Capacityinthelocalprimarycarenetworktoprovideearlyfollowupforchildrenwhoarenottransported
Ongoingqualityimprovement
ADDITIONALRESOURCESThefollowingresourcesareavailabletoaugmentonlineandofflineprehospital
pediatriccare:
EmergencyMedicalServiceforChildren(EMSC)http://www.childrensnational.org/emsc
Physicianprehospitalpediatricscoursehttp://www.moodlemedce.com/pemeducation/login/index.php
NationalAssociationofEmergencyMedicalServices(EMS)Physiciansmodelpediatricprotocols
http://www.kdheks.gov/cphp/download/cacs_template/ModelPediatricProtocols.pdf
NationalAssociationofEMSPhysiciansbasestationcoursehttp://www.naemsp.org/Pages/Products.aspx
SUMMARY
Onlinemedicalcontrolconsistsofphysiciandirection,supervision,andauthorizationofprehospitaltreatment
byphone,radio,oratthesceneinrealtime.Thephysicianislocatedatabasestationthatoftenisnot
locatedatthefacilitythatwilleventuallyreceivethepatient.(See'Onlinemedicalcontrol'above.)
Physicianswhowillprovideonlinemedicalcontrolshouldhavepediatricemergencymedicineknowledgeand
skills,specifictraining,agoodunderstandingofthegeneralapproachtodirectionofprehospitaltreatment,
anddetailedknowledgeoftheregulationsandpediatricprotocolsinuseintheirregion.Medicalcontrol
physiciansshouldalsohaveaclearunderstandingoftheabilitiesoftheprehospitalproviders,their
limitations,andoverallsystemconstraints.(See'Medicaldirectiontraining'above.)
Thegeneralapproachtocommunicationwithandmedicaldirectionofaprehospitalproviderisdiscussedin
detailabove.(See'Generalapproach'above.)
http://www.uptodate.com.pbidi.unam.mx:8080/contents/pediatricconsiderationsinprehospitalcare?topicKey=EM%2F13870&elapsedTimeMs=0&source=
10/43
6/1/2016
Offlinemedicalcontrolrefers,inpart,totheadministrationofemergencymedicalservices(EMS)byanEMS
physiciandirectorthroughtheuseofstandardizedprehospitalcareprotocols.Theseprotocolsareinplaceto
directprehospitalcareandauthorizespecificmedicaltreatmentswithinafieldprovidersscopeofpractice
withouttheneedforrealtimecommunication.Examplesofadultandpediatricprotocolsdevelopedforalarge
EMSregionareavailableathttp://www.miemss.org/home/default.aspx?tabid=10.(See'Offlinemedical
control'aboveand'Medicalandsurgicalemergencies'above.)
Onscenerecommendationsshouldincludethosetreatmentsthataretimesensitive,haveclearbenefit,are
generallyeasyandfasttoperformandcouldbelifesaving(table5).Commonprehospitalpediatric
proceduresincludecervicalspineimmobilization,basicandadvancedairwaymanagement,andvascular
access.Difficultprehospitalsituationsthatfrequentlywarrantonlinemedicalcontrolorcommunicationwith
theEMSagencysmedicaldirectorincludedisagreementwithaprehospitalprovider,treatmentrefusal,
advanceddirectives,andsuspectedchildabuse.(See'Timingofprehospitalinterventions'aboveand
'Pediatricprocedures'aboveand'Difficultsituations'above.)
Whendecidingthemodeoftransportanddestinationhospital,keyfactorsincludethechildscondition,the
typeandlocationofthebestemergencyfacilityforprovidingdefinitepediatriccare,safety,andweather
conditions.Ingeneral,theoptimalreceivingfacilityforacriticallyillorinjuredchildshouldhavelarge
pediatricvolumeandavailabilityofexpertiseintheintensivecareofchildrenaswellasphysicianstrainedin
pediatricsubspecialties,suchaspediatricemergencymedicine,pediatriccriticalcaremedicine,andpediatric
surgery.Generalemergencydepartmentsaretypicallycapableofmanagingacuteairwayemergenciesand
stabilizationofothercriticalpediatricconditionspriortotransferfordefinitivecare.(See'Groundversusair
transport'aboveand'Hospitaldestination'above.)
Duringambulancetransport,theuseoflightsandsirensshouldbereservedforthemostcriticallyillpatients
whoremainunstabledespiteprehospitaltreatmentasameansofreducingtheriskoftrafficcollisionsandto
adviseotherdriversthatanemergentsituationexistswhileremainingwithintrafficrules.(See'Lightsand
sirens'above.)
Childrenshouldberestrainedduringambulancetransportasdeterminedbytheirmedicalcondition(table9).
(See'Childrestraint'above.)
UseofUpToDateissubjecttotheSubscriptionandLicenseAgreement.
REFERENCES
1. CommitteeontheFutureofEmergencyCareintheUnitedStatesHealthSystem.Summary.In:Emergency
CareforChildren:GrowingPains,TheNationalAcademiesPress,Washington2007.p.1.
2. EMSCNationalResourceCenter.http://www.childrensnational.org/emsc(AccessedonApril18,2012).
3. BallJW,LiaoE,KavanaughD,TurgelC.TheEmergencyMedicalServicesforChildrenProgram:
AccomplishmentsandContributions.ClinicalPediatricEmergencyMedicine.20067:614.
http://www.clinpedemergencymed.com/article/S15228401(06)000024/abstract(AccessedonSeptember21,
2011).
4. DickWF.AngloAmericanvs.FrancoGermanemergencymedicalservicessystem.PrehospDisasterMed
200318:29.
5. CommitteeonPediatricEmergencyMedicineandCommitteeonBioethics.Consentforemergencymedical
servicesforchildrenandadolescents.Pediatrics2011128:427.
6. Referencepersonalcommunication:JeffreyF.Linzer,MD(jlinzer@emory.edu)762011.
7. WoodwardGA,GarrettAL,KingBR,BakerMD.Emergencymedicalservicesandtransportmedicine.In:
TextbookofPediatricEmergencyMedicine,6thedition,FleisherGR,LudwigS.(Eds),Lippincott,Williams
&Wilkins,Philadelphia2010.p.85.
8. EMSCPartnershipforChildren/NationalAssociationofEMSPhysiciansmodelpediatricprotocols:2003
11/43
6/1/2016
revision.PrehospEmergCare20048:343.
9. ConeDC.Knowledgetranslationintheemergencymedicalservices:aresearchagendaforadvancing
prehospitalcare.AcadEmergMed200714:1052.
10. GrimmRHJr,ShimoniK,HarlanWRJr,EstesEHJr.Evaluationofpatientcareprotocolusebyvarious
providers.NEnglJMed1975292:507.
11. Modelpediatricprotocols.EMSCpartnershipforchildren.NationalAssociationofEMSPhysicians,2003.
http://www.kdheks.gov/cphp/download/cacs_template/ModelPediatricProtocols.pdf(AccessedonApril24,
2012).
12. CallahamM.Quantifyingthescantyscienceofprehospitalemergencycare.AnnEmergMed199730:785.
13. FoltinGL,DayanP,TunikM,etal.Prioritiesforpediatricprehospitalresearch.PediatrEmergCare2010
26:773.
14. GonzalezRP,CummingsGR,PhelanHA,etal.Onsceneintravenouslineinsertionadverselyimpacts
prehospitaltimeinruralvehiculartrauma.AmSurg200874:1083.
15. GauscheM,LewisRJ,StrattonSJ,etal.Effectofoutofhospitalpediatricendotrachealintubationon
survivalandneurologicaloutcome:acontrolledclinicaltrial.JAMA2000283:783.
16. YoungquistS,GauscheHillM,BurbulysD.Alternativeairwaydevicesforuseinchildrenrequiring
prehospitalairwaymanagement:updateandcasediscussion.PediatrEmergCare200723:250.
17. RitterSC,GuyetteFX.PrehospitalpediatricKingLTDuse:apilotstudy.PrehospEmergCare2011
15:401.
18. ChenL,HsiaoAL.Randomizedtrialofendotrachealtubeversuslaryngealmaskairwayinsimulated
prehospitalpediatricarrest.Pediatrics2008122:e294.
19. KahalJ,OsmondMH,NesbittL,StiellIG.Whatarethecharacteristicsandoutcomesofnontransported
pediatricpatients?PrehospEmergCare200610:28.
20. SeltzerAG,VilkeGM,ChanTC,etal.Outcomestudyofminorsafterparentalrefusalofparamedic
transport.PrehospEmergCare20015:278.
21. TexasStatute166Healthandsafetycode:AdvanceDirectives.
22. AmericanCollegeofSurgeonsCommitteeonTrauma,AmericanCollegeofEmergencyPhysiciansPediatric
EmergencyMedicineCommittee,NationalAssociationofEmsPhysicians,etal.Withholdingortermination
ofresuscitationinpediatricoutofhospitaltraumaticcardiopulmonaryarrest.Pediatrics2014133:e1104.
23. AmericanAcademyofPediatrics,SectiononTransportMedicine.AirandGroundTransportofNeonataland
PediatricPatients,3rdedition,WoodwardGA,InsoftRM,KleinmanME.(Eds),AmericanAcademyof
Pediatrics,ElkGroveVillage,Illinois,USA2006.
24. NationalAssociationofStateEMSOfficials.Regionalizationofcare:PositionstatementoftheNational
AssociationofStateEMSOfficials.PrehospEmergCare201014:403.
25. AmericanAcademyofPediatrics.CommitteeonPediatricEmergencyMedicine.AmericanCollegeof
CriticalCareMedicine.SocietyofCriticalCareMedicine.Consensusreportforregionalizationofservices
forcriticallyillorinjuredchildren.Pediatrics2000105:152.
26. HuntRC,BrownLH,CabinumES,etal.Isambulancetransporttimewithlightsandsirenfasterthanthat
without?AnnEmergMed199525:507.
27. BrownLH,WhitneyCL,HuntRC,etal.Dowarninglightsandsirensreduceambulanceresponsetimes?
PrehospEmergCare20004:70.
28. HoJ,CaseyB.Timesavedwithuseofemergencywarninglightsandsirensduringresponsetorequestsfor
emergencymedicalaidinanurbanenvironment.AnnEmergMed199832:585.
29. KupasDF,DulaDJ,PinoBJ.Patientoutcomeusingmedicalprotocoltolimit"lightsandsiren"transport.
PrehospDisasterMed19949:226.
30. BledsoeBE.TheGoldenHour:factorfiction?EmergMedServ200231:105.
31. LernerEB,MoscatiRM.Thegoldenhour:scientificfactormedical"urbanlegend"?AcadEmergMed2001
8:758.
32. MaguireBJ,HuntingKL,SmithGS,LevickNR.Occupationalfatalitiesinemergencymedicalservices:a
hiddencrisis.AnnEmergMed200240:625.
33. WhitingJD,DunnK,MarchJA,BrownLH.EMTknowledgeofambulancetrafficlaws.PrehospEmergCare
12/43
6/1/2016
19982:136.
34. ChapleauW.Lights&sirens.EmergMedServ200231:59.
35. WolfbergD.Lights,sirensandliability.JEMS199621:38.
36. CharalambousN.Sirenstobelimitedtoemergencies.AndersonIndependentMail(November21,2002).
37. NationalHighwayTrafficSafetyAdministration(NHTSA).RecommendationsfortheSafeTransportationof
ChildreninEmergencyGroundAmbulances.Publicmeeting.August5,2010.
http://www.nhtsa.gov/staticfiles/nti/ems/pdf/EMSconference05aug2010.pdf(AccessedonSeptember21,
2011).
38. GerlacherGR,SirbaughPE,MaciasCG.Prehospitalevaluationofnontransportedpediatricpatientsbya
largeemergencymedicalservicessystem.PediatrEmergCare200117:421.
39. HainesCJ,LutesRE,BlaserM,ChristopherNC.Paramedicinitiatednontransportofpediatricpatients.
PrehospEmergCare200610:213.
40. KannikeswaranN,MahajanPV,DunneRB,etal.Epidemiologyofpediatrictransportsandnontransportsin
anurbanEmergencyMedicalServicessystem.PrehospEmergCare200711:403.
41. MossST,ChanTC,BuchananJ,etal.Outcomestudyofprehospitalpatientssignedoutagainstmedical
advicebyfieldparamedics.AnnEmergMed199831:247.
42. SchmidtTA,AtchesonR,FederiukC,etal.Hospitalfollowupofpatientscategorizedasnotneedingan
ambulanceusingasetofemergencymedicaltechnicianprotocols.PrehospEmergCare20015:366.
43. HauswaldM.Canparamedicssafelydecidewhichpatientsdonotneedambulancetransportoremergency
departmentcare?PrehospEmergCare20026:383.
44. SilvestriS,RothrockSG,KennedyD,etal.Canparamedicsaccuratelyidentifypatientswhodonotrequire
emergencydepartmentcare?PrehospEmergCare20026:387.
45. SeldenBS,SchnitzerPG,NolanFX.Medicolegaldocumentationofprehospitaltriage.AnnEmergMed
199019:547.
Topic13870Version6.0
13/43
6/1/2016
GRAPHICS
GlasgowComaScaleandPediatricGlasgowComaScale
Sign
Eye
opening
Verbal
Glasgow
Coma
Scale [1]
PediatricGlasgowComaScale [2]
Score
Spontaneous
Spontaneous
Tocommand
Tosound
Topain
Topain
None
None
Oriented
Ageappropriatevocalization,smile,ororientationto
response
sound,interacts(coos,babbles),followsobjects
Confused,
disoriented
Cries,irritable
Inappropriate
words
Criestopain
Incomprehensible
Moanstopain
None
None
Obeyscommands
Spontaneousmovements(obeysverbalcommand)
Localizespain
Withdrawstotouch(localizespain)
Withdraws
Withdrawstopain
Abnormalflexion
topain
Abnormalflexiontopain(decorticateposture)
Abnormal
extensiontopain
Abnormalextensiontopain(decerebrateposture)
None
None
sounds
Motor
response
Besttotalscore
15
TheGlasgowComaScale(GCS)isscoredbetween3and15,3beingtheworst,and15the
best.Itiscomposedofthreeparameters:besteyeresponse(E),bestverbalresponse(V),
andbestmotorresponse(M).ThecomponentsoftheGCSshouldberecordedindividuallyfor
example,E2V3M4resultsinaGCSof9.Ascoreof13orhighercorrelateswithmildbrain
injuryascoreof9to12correlateswithmoderateinjuryandascoreof8orlessrepresents
severebraininjury.ThepediatricGlasgowcomascale(PGCS)wasvalidatedinchildrentwo
yearsofageoryounger.
Datafrom:
1. TeasdaleG,JennettB.Assessmentofcomaandimpairedconsciousness.Apracticalscale.Lancet
19742:81.
2. HolmesJF,PalchakMJ,MacFarlaneT,KuppermannN.PerformanceofthepediatricGlasgowcoma
scaleinchildrenwithbluntheadtrauma.AcadEmergMed200512:814.
14/43
6/1/2016
Graphic59662Version11.0
15/43
6/1/2016
Traumatriagescoringsystemsforchildren
Revisedtraumascore*
Clinical
Parameter
RR
SBP
GCS
Parameter
Category
Pediatrictraumascore
Clinical
Parameter
Score
1024
2535
Weight(kg)
ParameterCategory
Score
20
1020
>35
<10
<10
Normal
Maintainable
>90
Unmaintainable
7090
90
5069
5090
<50
<50
Awake
1415
1113
Obtunded/Lossof
consciousness
810
Comaordecerebrate
57
None
34
Minor
Major/penetrating
None
Closedfracture
Open/multiplefractures
Airway
SBP
Centralnervous
system
Openwound
Skeletal
*Therevisedtraumascoreutilizesrespiratoryrate,systolicbloodpressure,andGlasgowcomascore.
Unlikethetraumascore,itdoesnotincludesubjectivevariablessuchasrespiratoryeffortandcapillary
refill.Therevisedtraumascoreisthesumofthevaluesgivenforeachparameter.Triagetoatrauma
centerisrecommendedforpatientswithascoreof11.
Thepediatrictraumascoreisthesumofthevaluesgivenforeachparameter.Triagetoatrauma
centerisrecommendedforpatientswithascoreof8.
AdaptedwithpermissionfromFurnival,RA,Schunk,JE.PediatrEmergCare199915:215.
16/43
6/1/2016
Pediatricequipmentforbasiclifesupport(BLS)ambulancesinthe
UnitedStates
Required*
Airwayandventilation
Portableandfixedsuctionwithregulatorandwideboresuctiontubing
Suctioncatheters:tonsiltipandflexible(1flexiblebetween6and10F,1between10Fand
16F)
Fixedandportablemeteredflowoxygenandoxygentubingwithvariableflowregulator
Oxygenmasks(valvelessandnonrebreathing):adultandchildsizes
Nasalcannulas:adultandchildsizes
Bagvalvemaskresuscitator:handoperated,selfreexpandingbagforadult(1000mL)and
child(450750mL)withoxygenreservoir/accumulator,valve,andmask(neonatal,infant,
child,andadultsizes)
Airways:oropharyngeal(sizes05)nasopharyngeal(16F34F,adultandchildsizes)
Pulseoximeterwithpediatricandadultprobes
Salinedropsandinfantnasalbulbsyringe
Monitoringanddefibrillation
Automaticexternaldefibrillatorwithadultandpediatricpadsandcables
Immobilizationdevices
Rigidcervicalcollarsforchildrenaged2yearsorolder
Headimmobilizationdevice,eg,firmpaddingorcommercialdevice(notsandbags)
Upperandlowerextremityimmobilizationdevicesforchildren
Backboards
Obstetricalkit
Miscellaneous
Accesstopediatricprotocols
LengthbasedresuscitationtapeORreferencematerialtoguidepediatricdrugdosingand
equipmentsizingbaseduponlengthORage
Pediatricsphygmomanometer
Optionalbasicpediatricequipment
Infantoxygenmask
Infantselfinflatingresuscitationbag
Infantairways(nasopharyngeal12F,14Foropharyngealsize00)
BPcuffs,neonatalandinfant
Pediatricstethoscope
Infantcervicalimmobilizationdevice
17/43
6/1/2016
Pediatricbackboardandextremitysplints
Femurtractiondeviceforchildren
F:French.
*Inadditiontostandardequipmentandsuppliesasdeterminedbystateandlocalregulations.
Datafrom:JointpolicystatementEquipmentforgroundambulances.AmericanAcademyofPediatrics,
AmericanCollegeofEmergencyPhysicians,AmericanCollegeofSurgeonsCommitteeonTrauma,
EmergencyMedicalServicesforChildren,EmergencyNursesAssociation,NationalAssociationofEMS
Physicians,NationalAssociationofStateEMSOfficials.PrehospEmergCare201418:92.
18/43
6/1/2016
Pediatricequipmentandsuppliesforadvancedlifesupport(ALS)
ambulancesintheUnitedStates
ALSambulances
Required*
Airwayandventilation
Laryngoscopehandle,extrabatteriesandbulbs
Laryngoscopeblades:straight(Miller)sizes04curved(MacIntosh)sizes24
Endotrachealtubes:cuffedand/oruncuffedsizes2.55.5mmcuffed68mm(1ofeachsize
andtype)
10mLnonLuerlocksyringes
Stylettesforendotrachealtubes:adultandpediatric
Magill(Rovenstein)forceps,adultandpediatric
Lubricatingjelly(watersoluble)
EndtidalCO 2 detector(adultandpediatriccolorimetricorquantitativecapnometry)
Vascularaccess
Intravenouscatheters,14to24gauge
Intraosseousneedlesordevicesappropriateforchildren
Pediatricintravenousarmboards
Monitoringanddefibrillation
Portable,batteryoperatedmonitor/defibrillatorwithtapewriteout/recorder,defibrillator
pads,quicklookpaddlesorelectrodesorhandsfreepatches,ECGleads,adultandpediatric
chestattachmentelectrodes,adultandpediatricpaddles
Transcutaneouscardiacpacemakerwithpediatricpadsandcables(standaloneorintegrated
intomonitor/defibrillator)
Optionaladvancedequipment
Respirator(volumecycled,on/offoperation,100percentoxygen,4050psipressure
(child/infantcapabilities))
Pediatricbloodsampletubes
Nasogastrictubes,pediatricfeedingtubesizes5Fand8F,sumptubesizes8F16F
Pediatriclaryngoscopehandles
Size1curved(MacIntosh)laryngoscopeblades
Rescueairwaydevicesforchildren(eg,laryngealmaskairwaysinpediatricsizes)
Needlecricothyrotomycapability
Atomizersforadministrationofintranasalmedications
CO 2 :carbondioxideECG:electrocardiogrampsi:poundspersquareinchF:French.
*Inadditiontothestandardequipmentandsuppliesasdeterminedbystateandlocalregulations.
Inadditiontoitemsforbasiclifesupportambulances.
19/43
6/1/2016
Datafrom:JointpolicystatementEquipmentforgroundambulances.AmericanAcademyofPediatrics,
AmericanCollegeofEmergencyPhysicians,AmericanCollegeofSurgeonsCommitteeonTrauma,
EmergencyMedicalServicesforChildren,EmergencyNursesAssociation,NationalAssociationofEMS
Physicians,NationalAssociationofStateEMSOfficials.PrehospEmergCare201418:92.
20/43
6/1/2016
US2011traumafieldtriagealgorithm
21/43
6/1/2016
EMS:emergencymedicalservices.
*Theupperlimitofrespiratoryrateininfantsis>29breathsperminutetomaintainahigherlevelof
overtriageforinfants.
TraumacentersaredesignatedLevelIIV.ALevelIcenterhasthegreatestamountofresourcesand
personnelforcareoftheinjuredpatientandprovidesregionalleadershipineducation,research,and
preventionprograms.ALevelIIfacilityofferssimilarresourcestoaLevelIfacility,possiblydifferingonlyin
continuousavailabilityofcertainsubspecialtiesorsufficientprevention,education,andresearchactivitiesfor
LevelIdesignationLevelIIfacilitiesarenotrequiredtoberesidentorfelloweducationcenters.ALevelIII
centeriscapableofassessment,resuscitation,andemergencysurgery,withseverelyinjuredpatientsbeing
transferredtoaLevelIorIIfacility.ALevelIVtraumacenteriscapableofproviding24hourphysician
coverage,resuscitation,andstabilizationtoinjuredpatientsbeforetransfertoafacilitythatprovidesahigher
leveloftraumacare.
AnyinjurynotedinSteptwoormechanismidentifiedinStepthreetriggersa"yes"response.
Age<15years.
Intrusionreferstointeriorcompartmentintrusion,asopposedtodeformationwhichreferstoexterior
damage.
Includespedestriansorbicycliststhrownorrunoverbyamotorvehicleorthosewithestimatedimpact
>20mphwithamotorvehicle.
Localorregionalprotocolsshouldbeusedtodeterminethemostappropriateleveloftraumacenterwithin
thedefinedtraumasystemneednotbethehighestleveltraumacenter.
**Age>55years.
Patientswithbothburnsandconcomitanttraumaforwhomtheburninjuryposesthegreatestriskfor
morbidityandmortalityshouldbetransferredtoaburncenter.Ifthenonburntraumapresentsagreater
immediaterisk,thepatientmaybestabilizedinatraumacenterandthentransferredtoaburncenter.
PatientswhodonotmeetanyofthetriagecriteriainStepsonethroughfourshouldbetransportedto
themostappropriatemedicalfacilityasoutlinedinlocalEMSprotocols.
Reproducedfrom:SasserSM,HuntRC,FaulM,etal.Guidelinesforfieldtriageofinjuredpatients:
RecommendationsoftheNationalExpertPanelonFieldTriage,2011.MMWR201261:1.
22/43
6/1/2016
Appropriateonscenepediatricprehospitalinterventions
Assessment
Initiatecardiacmonitoring
Measurepulseoximetry
Airwayandcervicalspineimmobilization
Openandmaintaintheairway
Suctiontheairwaytoremovesecretions
Applycervicalcollarandbackboardimmobilizationforsuspectedspinalinjury
AdministerracemicorLepinephrineforsevereinspiratorystridor(eg,severecroup)
Placeanadvancedairway,ifunabletomaintainairwaybyothermeans
Breathing
Performbagmaskventilation
Administerbetaagonisttherapyforreactiveairwaydisease
Performneedledecompressionfortensionpneumothorax
Circulation
Controlexternalhemorrhage(eg,penetratingtraumatoextremity)
Providecardiopulmonaryresuscitationifindicatedatleastthreecycles
Performsynchronizedcardioversionanddefibrillation
Obtainintravenousorintraosseousaccessifbenefitoutweighsdelayintransport
Administermedicationsindicatedforcardiopulmonaryarrestatleastonecycle
AdministerIVfluidsforshock
Disability
Administerglucoseforhypoglycemia
Administermedicationstocontrolseizures
Splintextremities
Performeyeirrigation
Other
Administermedications(eg,epinephrine,diphenhydramine,andsteroids)forallergicor
anaphylacticreactions
Administerhydroxocobalaminforcyanidepoisoning(eg,homefires)
Administerpainmedication
23/43
6/1/2016
Pediatrictachycardiaalgorithm(withapulseandpoorperfusion)
PALS:pediatricadvancedlifesupportIO:intraosseousIV:intravenousECG:electrocardiogramHR:heart
rate.
*Vagalmanuevers:Ininfantsoryoungchildren,placeaplasticbagfilledwithiceandcoldwateroverthe
24/43
6/1/2016
facefor15to30secondsorstimulatetherectumwithathermometer.Inolderchildren,encouragebearing
down(Valsalvamaneuver)for15to20seconds.Carotidmassageandorbitalpressureshouldnotbe
performedinchildren.
Reprintedwithpermission.PediatricAdvancedLifeSupport:2010.AmericanHeartAssociationGuidelinesfor
CardiopulmonaryResuscitationandEmergencyCardiovascularCare.2010AmericanHeartAssociation,
Inc.Thisalgorithmremainsunchangedinthe2015update.
25/43
6/1/2016
Pediatricbradycardiaalgorithm(withapulseandpoor
perfusion)
PALS:pediatricadvancedlifesupportCPR:cardiopulmonaryresuscitationIO:
intraosseousIV:intravenousHR:heartrateAV:atrioventricularABCs:airway,
breathing,circulation.
Reprintedwithpermission.PediatricAdvancedLifeSupport:2010.AmericanHeart
AssociationGuidelinesforCardiopulmonaryResuscitationandEmergencyCardiovascular
Care.2010AmericanHeartAssociation,Inc.Thisalgorithmremainsunchangedin
the2015update.
26/43
6/1/2016
Rapidoverview:Emergentmanagementofanaphylaxisininfants
andchildren*
Diagnosisismadeclinically:
Themostcommonsignsandsymptomsarecutaneous(eg,suddenonsetofgeneralized
urticaria,angioedema,flushing,pruritus).However,10to20%ofpatientshavenoskin
findings.
Dangersigns:Rapidprogressionofsymptoms,evidenceofrespiratorydistress(eg,
stridor,wheezing,dyspnea,increasedworkofbreathing,retractions,persistent
cough,cyanosis),signsofpoorperfusion,abdominalpain,dysrhythmia,hypotension,
collapse.
Acutemanagement:
Thefirstandmostimportanttherapyinanaphylaxisisepinephrine.ThereareNOabsolute
contraindicationstoepinephrineinthesettingofanaphylaxis.
Airway:Immediateintubationifevidenceofimpendingairwayobstructionfromangioedema.
Delaymayleadtocompleteobstruction.Intubationcanbedifficultandshouldbeperformedby
themostexperiencedclinicianavailable.Cricothyrotomymaybenecessary.
IMepinephrine(1mg/mLpreparation):Epinephrine0.01mgperkilogramshouldbe
injectedintramuscularlyinthemidouterthigh.Forlargechildren(>50kilograms),the
maximumis0.5mgperdose.Ifthereisnoresponseortheresponseisinadequate,the
injectioncanberepeatedin5to15minutes.IfepinephrineisinjectedpromptlyIM,patients
respondtoone,two,oratmostthreeinjections.Ifsignsofpoorperfusionarepresentor
symptomsarenotrespondingtoepinephrineinjections,prepareIVepinephrineforinfusion(see
below).
Placepatientinrecumbentposition,iftolerated,andelevatelowerextremities.
Oxygen:Give8to10litersperminuteviafacemask,orupto100%oxygenasneeded.
Normalsalinerapidbolus:Treatpoorperfusionwithrapidinfusionof20mLperkilogram.
Reevaluateandrepeatfluidboluses(20mLperkilogram)asneeded.Massivefluidshiftswith
severelossofintravascularvolumecanoccur.Monitorurineoutput.
Albuterol:ForbronchospasmresistanttoIMepinephrine,givealbuterol0.15mgperkilogram
(minimumdose:2.5mg)in3mLsalineinhaledvianebulizer.Repeatasneeded.
H1antihistamine:Considergivingdiphenhydramine1mgperkilogram(max40mg)IV.
H2antihistamine:Considergivingranitidine1mgperkilogram(max50mg)IV.
Glucocorticoid:Considergivingmethylprednisolone1mgperkilogram(max125mg)IV.
Monitoring:Continuousnoninvasivehemodynamicmonitoringandpulseoximetrymonitoring
shouldbeperformed.UrineoutputshouldbemonitoredinpatientsreceivingIVfluid
resuscitationforseverehypotensionorshock.
Treatmentofrefractorysymptoms:
Epinephrineinfusion :PatientswithinadequateresponsetoIMepinephrineandIVsaline,
giveepinephrinecontinuousinfusionat0.1to1mcgperkilogramperminute,titratedtoeffect.
Vasopressors :PatientsmayrequirelargeamountsofIVcrystalloidtomaintainblood
pressure.Ifresponsetoepinephrineandsalineisinadequate,dopamine(5to20mcgper
27/43
6/1/2016
kilogramperminute)canbegivenwiththedosetitratedtoeffectoncontinuouslymonitored
bloodpressure,cardiacrate,andfunction.
IM:intramuscularIV:intravenous.
*Achildisdefinedasaprepubertalpatientweighinglessthan40kg.
Allpatientsreceivinganinfusionofepinephrineand/oranothervasopressorrequirecontinuous
noninvasivemonitoringofbloodpressure,heartrateandfunction,andoxygensaturation.Wesuggest
thatpediatriccentersprovideinstructionsforpreparationofstandardconcentrationsandalsoprovide
chartsforestablishedinfusionrateforepinephrineandothervasopressorsininfantsandchildren.
28/43
6/1/2016
Managementofmoderateasthma
MDI:metereddoseinhalerIM:intramuscular.
*ConsiderIMmethylprednisoloneorIMdexamethasoneifthechildvomits
prednisoneordexamethasone.
CourtesyofRichardScarfone,MD,FAAP.
29/43
6/1/2016
Initialmanagementofstatusepilepticusinchildren
Timeline*
0to5
minutes
Assessment
Obtaininitialvitalsigns,
includingtemperature
Supportivecare
Openairway
Suctionsecretions
Administer100percent
O2
Identifyairway
obstructionand
hypoxemia
Placecontinuous
cardiorespiratory
monitorsandpulse
oximetry
Identifyimpaired
oxygenationor
ventilation
Performbagvalvemask
ventilation,asneeded
Obtainrapidbedside
bloodglucoseandother
studies,asindicated
EstablishIVorIOaccess
Evaluateforsignsof
sepsis/meningitis
Treathypoglycemia(IV
dextrose0.25to0.5
gram/kg)
PrepareforRSI*
Seizuretherapy
Benzodiazepine(first
line):
Lorazepam0.1mg/kgIV
orIO,maximum4mg
OR
Diazepam0.2mg/kgIVor
IO,maximum8mg
IVorIOaccessnot
achievedwithin3
minutes:
Buccalmidazolam0.2
mg/kg,maximum10mg
OR
IMmidazolam0.10.2
mg/kg,maximum10mg
OR
Rectaldiazepam(Diastat
gelorinjectionsolution
givenrectally)0.5mg/kg,
maximum20mg
Evaluateforsignsofhead
trauma
Treatfever
(acetaminophen15
mg/kgrectally)
Reevaluatevitalsigns,
airway,breathing,and
circulation
Maintainmonitoring,
ventilatorysupport,and
vascularaccess
Evaluateforsignsof
trauma,sepsis,
meningitis,or
encephalitis
Giveantibioticsifsignsof
sepsisormeningitis
10to15
Maintainmonitoring,
Fosphenytoin(second
minutes
circulation
vascularaccess
line):
5to10
minutes
Benzodiazepine:
seconddose
20mgPEperkgIVor
IO
OR,iftoxininduced
seizure,
15to30
minutes
PlacesecondIV
Phenobarbital:
RSIpotentiallyindicated*
20mg/kgIVorIO,
maximum1gram,
(expectrespiratory
depressionwithapnea)
Maintainmonitoring,
Phenobarbital(third
line):
30/43
6/1/2016
circulation
vascularaccess
20mg/kgIVorIO,
maximum1gram,(10
mg/kgifphenobarbital
givenassecondline)
OR
Valproicacid20to40
mg/kgIVorIO
AND
ObtaincontinuousEEG
monitoring,ifavailable
Pyridoxine100mgIVor
IOininfants<1yearof
age
Pyridoxine70mg/kgIVor
IO,maximum5grams,if
INHpoisoningsuspected
Obtainpediatric
neurologyconsultation
IV:intravenousIO:intraosseousIM:intramuscularO2:oxygenRSI:rapidsequenceendotracheal
intubationPE:phenytoinequivalentsEEG:electroencephalogramINH:isoniazid.
*Rapidsequenceintubationshouldbeperformedifairway,ventilation,oroxygenationcannotbe
maintainedandiftheseizurebecomesprolonged.
Referto"Ancillarystudiesinchildrenwithstatusepilepticus"(partofthisdocument).
Empiricantibioticregimensvarydependingonpatientsusceptibilityandlikelypathogen.
Donotexceed3mg/kgperminute(maximumrate:150mgperminute).Fosphenytoinmaybe
ineffectivefortoxininducedseizuresandmayintensifyseizurescausedbycocaineandotherlocal
anesthetics,theophylline,orlindane.Iffosphenytoinnotavailable,mayusephenytoin20mg/kgIV,do
notexceed1mg/kgperminute(maximumrate:50mgperminute)withECGmonitoring.
Donotexceed1mg/kgperminute.
31/43
6/1/2016
Initialmanagementofshockinchildren
*Forpossiblecardiogenicshockwithhypovolemia,give5to10mL/kgofisotonicfluids(eg,
normalsalineorRingerslactate),infusedover10to20minutes.Evaluatetargetendpointsand
slowlygiveanother5to10cc/kgiftherehasbeenimprovementornochange.Forpatientswith
diabeticketoacidosis,give10mL/kgofisotonicfluidsoveronehour.
32/43
6/1/2016
Suchasinotropesorvasodilators.Fornewborns,prostaglandinE1.
ForpatientswithDKAwhodonotimprovewith20mL/kg,lookforanothercauseofshock
beforeadministeringadditionalcrystalloid.Forpossiblecardiogenicshock,slowlygiveanother5to
10mL/kgiftherehasbeenimprovementornochange.
Dopamineifnormotensive,norepinephrineifhypotensiveandvasodilated,andepinephrineif
hypotensiveandvasoconstricted.
Adaptedfrom:CarcilloJA,FieldsAI.Clinicalpracticeparametersforhemodynamicsupportof
pediatricandneonatalpatientsinsepticshock.CritCareMed200230:1365.
33/43
6/1/2016
Initialtraumamanagementinchildrenwithseveremultipletrauma
34/43
6/1/2016
35/43
6/1/2016
pCO2:partialpressureofcarbondioxideO2:oxygenGCS:GlasgowcomascaleFAST:focused
abdominalsonographyfortrauma.
*CliniciansshouldalwaysperformactionsinRED.
Administer20mL/kgofwarmednormalsalineorRinger'slactateover10to20minutes.
Signsofherniationincludecoma,unilateralpupillarydilationwithoutwardeyedeviationfollowedby
hemiplegia,hyperventilation,CheyneStokesrespirations,and/ordecerebrateordecorticateposturing.
36/43
6/1/2016
Rapidoverviewforhypoglycemiainadolescentsandchildren,other
thanneonates
Clinicalfeatures
Anypatientwithacutelethargyorcomashouldhaveanimmediatemeasurementofbloodglucose
todetermineifhypoglycemiaisapossiblecause
Otherfindingsofhypoglycemiaarenonspecific*andvarybyage:
Infants
Irritability
Lethargy
Jitteriness
Feedingproblems
Hypothermia
Hypotonia
Tachypnea
Cyanosis
Apnea
Seizures
Olderchildrenandadolescents
Autonomicresponse(tendstooccurwithbloodglucose<50to65mg/dL)
Sweating
Tachycardia
Palpitations
Tremor
Nervousness
Hunger
Paresthesias
Pallor
Neuroglycopenia
Irritability
Confusion
Uncharacteristicbehavior
Weakness
Seizures
Coma
Occasionally,transientfocalneurologicdeficits
Diagnosis
37/43
6/1/2016
Obtainrapidbedsidebloodglucoseconcentration(andhydroxybutyrate,ifavailableasapoint
ofcaremeasurement)
Confirmthepresenceofhypoglycemiawithasimultaneouslydrawnplasmaglucose
Treat,asoutlinedbelow,ifthebedsidevalueislow(<70mg/dL[3.89mmol/L])insymptomatic
patients
Obtainabloodsampleforadditionaldiagnosticstudiespriortoglucoseadministration,ifpossible,
andcollectthefirstvoidedurineafterthehypoglycemiceventinallinfantsandyoungchildren
whoarenotbeingtreatedfordiabetesmellitusordonothaveaknowncausefor
hypoglycemia
Treatment
Donotdelaytreatmentifsymptomatichypoglycemiaissuspected.However,everyreasonable
effortshouldbemadetoobtainarapidbloodglucosemeasurementpriortoadministering
glucose.
Giveglucosebaseduponthepatientslevelofconsciousnessandabilitytoswallow
safely(ie,alertenoughtodosoandwithintactgagreflex)asfollows:
Consciousandabletodrinkandswallowsafely:
Administer0.3grams/kg(10to20grams)ofarapidlyabsorbedcarbohydrate.15gramsis
suppliedby3glucosetablets,atubeofgelwith15grams,4oz(120mL)sweetenedfruit
juice,6oznondietsoda,oratablespoon(15mL)ofhoneyortablesugar.Mayrepeatin10
to15minutes.
Alteredmentalstatus,unabletoswallow,ordoesnotrespondtooralglucose
administrationwithin15minutes:
GiveaninitialIVbolusofglucoseof0.25grams/kgofdextrose(maximumsingledose25
grams). Thevolumeandconcentrationofglucosebolusisinfusedslowlyat2to3mLper
minuteandbaseduponage:
2.5mL/kgof10percentdextrosesolution(D10W)ininfantsandchildrenupto12
yearsofage(10percentdextroseis100mg/mL)
1mL/kgof25percentdextrose(D25W)or0.5mL/kgof50percentdextrose(D50W)
inadolescents(25percentdextroseis250mg/mL50percentdextroseis500mg/mL)
UnabletoreceiveoralglucoseandunabletoobtainIVaccess:
Giveglucagon0.03mg/kgIMorSQ(maximumdose1mg) :
Performbloodglucosemonitoringevery10to15minutesastheeffectsofglucagon
maybetransient
Establishvascularaccessassoonaspossible
Afterinitialhypoglycemiaisreversed,provideadditionalglucoseandtreatmentbasedupon
suspectedetiology:
GivechildrenandadolescentswithtypeIdiabetesmellitusanormaldiet
Givepatientswithanunknowncauseofhypoglycemiaintravenousinfusionofdextrose
10percent(6to9mg/kgperminute)titratedtomaintainbloodglucoseinasafeand
appropriaterange(70to150mg/dL[3.89to8.33mmol/L])
Givepatients,whohaveingestedasulfonylureaandhaverecurrenthypoglycemia,
octreotide(dose:1to1.5mcg/kgIMorSQ,maximumdose150mcgevery6hours)in
38/43
6/1/2016
additiontoglucose.(RefertoUpToDatetopiconsulfonylureapoisoning).
Measurearapidbloodandplasmaglucose15to30minutesaftertheinitialIVglucosebolus
andthenmonitorevery30to60minutesuntilstable(minimumoffourhours)toensurethat
plasmaglucoseconcentrationismaintainedinthenormalrange(>70to100mg/dL[>3.89to
5.55mmol/L])
Obtainpediatricendocrinologyconsultationforpatientswithhypoglycemiaofunknowncause
Obtainmedicaltoxicologyconsultationforpatientswithingestionoforalhypoglycemicagentsby
callingtheUnitedStatesPoisonControlNetworkat18002221222oraccesstheWorldHealth
Organization'slistofinternationalpoisoncenters
(www.who.int/gho/phe/chemical_safety/poisons_centres/en/index.html)
Admitthefollowingpatients:
Cannotmaintainnormoglycemiawithoralintake
Hypoglycemiaofunknowncause
Ingestionoflongactinghypoglycemicagents
Recurrenthypoglycemiaduringtheperiodofobservation
IV:intravenousIM:intramuscularSQ:subcutaneousD10W:10percentdextroseinwaterD25W:25
percentdextroseinwaterD50W:50percentdextroseinwater.
*Thesefindingsmayalsooccurininfantswithsepsis,congenitalheartdisease,respiratorydistress
syndrome,intraventricularhemorrhage,othermetabolicdisorders,andinchildrenandadolescentswith
avarietyofunderlyingconditions.
Specificlaboratorystudiestoobtaininchildrenincludebloodsamplesforglucose,insulin,Cpeptide,
betahydroxybutyrate,lactate(freeflowingbloodmustbeobtainedwithoutatourniquet),plasma
acylcarnitines,freefattyacids,growthhormone,andcortisol.
Higherdosesofglucose(eg,0.5to1g/kg[5to10mL/kgof10percentdextroseinwateror2to4
mL/kgof25percentdextroseinwater])maybeneededtocorrecthypoglycemiacausedbysulfonylurea
ingestion.(Formoredetail,refertoUpToDatetopiconsulfonylureaagentpoisoning).
Glucagonwillreversehypoglycemiacausedbyexcessendogenousorexogenousinsulinandwillnotbe
effectiveinpatientswithinadequateglycogenstores(prolongedfasting),ketotichypoglycemia,orare
unabletomobilizeglycogen(glycogenstoragediseases).Ofnote,childrenmayexhausttheirglycogen
storesinaslittleas12hours.Otherconditionsinwhichglycogencannotbeeffectivelymobilizedinclude
ethanolintoxicationinchildren,adrenalinsufficiency,andcertaininbornerrorsofmetabolism(eg,a
disorderofglycogensynthesisandglycogenstoragediseases).
39/43
6/1/2016
Guidelineforcervicalspineclearanceinthereliablepediatric
patient
cspine:cervicalspineAP:anteroposteriorD/C:discontinueMRI:magneticresonance
imagingCT:computedtomography.
*AwakeandalertwithGCS=15.
MeetsNEXUScriteria(nomidlinecervicalspinetenderness,nofocalneurologicdeficit,normal
alertness,nointoxication,andnopainful,distractinginjury)ANDmovesheadin
40/43
6/1/2016
flexion/extensionANDrotate45degreestobothsideswithnopain.
Changetolongtermcervicalspinecollarassoonasappropriate.
Reproducedwithpermissionfrom:ChungS,MikrogianakisA,WalesPW,etal.Trauma
AssociationofCanadaPediatricSubcommitteeNationalPediatricCervicalSpineEvaluation
Pathway:ConsensusGuidelines.JTrauma201170:873.Copyright2011LippincottWilliams
&Wilkins.
41/43
6/1/2016
Guidelinesforsafeprehospitaltransportation
Condition
Injured,butnotill
Restraintoptions
Transportinthefrontseatoftheambulancewiththeairbagsoff
TransportinaforwardorrearfacingEMSprovider'sseat
Considerdelayoftransportandcontinueonscenecareuntilanalternate
vehicleisavailable
Illorinjured,butnot
requiring
continuous/intensive
monitoringor
interventions
TransportintheEMSprovider'sseatinasizeappropriatechildrestraint
systemoranintegratedseatintheEMSprovider'sseatthatiscertifiedby
themanufacturertomeettheinjurycriteriaofFederalMotorVehicleSafety
Standards
Illorinjured,and
requiring
continuous/intensive
monitoringor
interventions
Transportthechildinasizeappropriatechildrestraintsystemthatcomplies
withtheinjurycriteriaofFederalMotorVehicleSafetyStandardssecured
appropriatelyonacot.Ifthisisnotfeasible,thefollowingalternativesare
recommended:
Conditionrequires
spinalimmobilization
orlyingflat
Transportwithasizeappropriatespineboardandsecureittothecot,head
first,withatetheratthefoottopreventforwardmovementANDthree
horizontalrestraintsacrossthechild'storso(chest/waist/knees)andone
verticalrestraintacrosseachofthechild'sshoulders.Ifthisisnotfeasible,
thefollowingalternativeisrecommended:
Transportonacotusingthreehorizontalrestraintsacrossthechild'storso
(chest/waist/knees)andoneverticalrestraintacrosseachofthechild's
shoulders
Transportonacot,headfirst,usingthreehorizontalrestraintsacrossthe
child'storso(chest/waist/knees)andoneverticalrestraintacrosseachof
thechild'sshoulders.Ifrestraintsmustberemoved,theyshouldbere
securedasquicklyaspossibleconsiderstoppingtheambulanceif
interventionsrequirerestraintremoval.
Transportwithastandardspineboardwithpaddingaddedtomakethe
devicefitthechildsecureasnotedabove.
Multipletransport
(newbornwith
motherormultiple
children)
Transporteachasasinglepatient.Ifthisisnotfeasible,thefollowing
alternativeisrecommended:
Usespaceavailableinanonemergencymode,drivingbelowthemaximum
legalspeedlimit.
NationalHighwayTrafficSafetyAdministration(NHTSA).RecommendationsfortheSafeTransportation
ofChildreninEmergencyGroundAmbulances.Publicmeeting.August5,2010.
http://www.nhtsa.gov/staticfiles/nti/ems/pdf/EMSconference05aug2010.pdf(AccessedonSeptember21,
2011).
42/43
6/1/2016
Disclosures
Disclosures:PaulESirbaugh,DONothingtodisclose.ManishIShah,MDNothingtodisclose.RichardDZane,MDNothingto
disclose.GeorgeAWoodward,MDNothingtodisclose.JamesFWiley,II,MD,MPHNothingtodisclose.
Contributordisclosuresarereviewedforconflictsofinterestbytheeditorialgroup.Whenfound,theseareaddressedbyvettingthrougha
multilevelreviewprocess,andthroughrequirementsforreferencestobeprovidedtosupportthecontent.Appropriatelyreferenced
contentisrequiredofallauthorsandmustconformtoUpToDatestandardsofevidence.
Conflictofinterestpolicy
43/43

Triage Pediatric Considerations in Prehospital Care

Transféré par

Informations du document

Copyright

Formats disponibles

Partager ce document

Partager ou intégrer le document

Options de partage

Avez-vous trouvé ce document utile ?

Ce contenu est-il inapproprié ?

Droits d'auteur :

Formats disponibles

Triage Pediatric Considerations in Prehospital Care

Transféré par

Droits d'auteur :

Formats disponibles

6/1/2016

Vous aimerez peut-être aussi