Arthur Cooper

A rapid noninvasive method of detecting elevated intracranial pressure using bedside ocular ultrasound: application to 3 cases of head trauma in the pediatric emergency department.

Abstract: Managing pediatric head trauma with elevated intracranial pressure in the acute setting can be challenging. Bedside ocular ultrasound for measuring optic nerve sheath diameters has been recently proposed as a portable noninvasive method to rapidly detect increased intracranial pressure in emergency department patients with head trauma. Prior study data agree that the upper limit of normal optic nerve sheath diameters is 5.0 mm in adults, 4.5 mm in children aged 1 to 15, and 4.0 mm in infants up to 1 year of age. We report the application of this technique to 3 cases of head trauma in the pediatric emergency department.

Priorities for Research in Emergency Medical Services for Children: Results of a Consensus Conference

STUDY OBJECTIVEnThe study objective was to arrive at a consensus on the priorities for future research in Emergency Medical Services for Children (EMSC).nnnMETHODSnA consensus group was convened using the Rand-UCLA Consensus Process. The group took part in a 3-phase process. Phase I involved reviewing a compendium of relevant research articles and answering a mailed questionnaire. Panel members were asked to prioritize topics based on the 1993 Institute of Medicine Report on Emergency Medical Services for Children. Participants were asked to rate each topic based on the significance of the research and whether the topic would (1) improve general knowledge, (2) change behavior, (3) improve health, (4) decrease the cost of care, or (5) change public policy. A 4-point Likert scale was used. They were also asked in the research would require a multicenter study and if the research were feasible. Round II of the study involved a meeting of the panel, where the results of Round I were discussed and the topics reprioritized. The topics were given a rank order and a final ranking was done in Round III.nnnRESULTSnThe panel considered a list of 32 topics and these were combined and reworded to give them more precise meaning. Several new topics were also added. Fifteen topics were given a rank order and placed within the 7 broad categories of the Institute of Medicine report. Clinical aspects of emergency care systems organization, configuration and operation and injury prevention were given high priority rankings. The first 5 topics were very close in point-rank order.nnnCONCLUSIONnThe panel was able to develop a list of important topics for future research in EMSC that can be used by foundations, governmental agencies, and others in setting a research agenda for EMSC.

The kendrick extrication device used for pediatric spinal immobilization

Immobilizing a child presents a unique challenge for emergency medical services (EMS) personnel in addition to those challenges faced when immobilizing an adult. Most equipment commonly carried by EMS personnel is sized for adult use and as a result does not routinely provide adequate static or dynamic immobilization of a child. In addition, children often resist immobilization and can free themselves from standard strapping techniques. These problems have led to the modification of existing equipment and the development of several pediatric-specific devices. An ideal pediatric immobilization device would be one that uses an existing piece of equipment, is of limited additional cost, is routinely used by EMS providers, could be easily modified to immobilize a child, could easily be taught to EMS providers, and provides excellent static and dynamic immobilization. The Kendrick extrication device (KED) used as the authors describe meets these goals of an ideal pediatric immobilization device.

Education of Out-of-Hospital Emergency Medical Personnel in Pediatrics: Report of a National Task Force

The Pediatric Education Task Force has developed a list of major topics and skills for inclusion in pediatric curricula for EMS providers Areas of controversy in the management of pediatric patients in the prehospital setting are outlined, and helpful learning tools are identified.

Priorities for research in emergency medical services for children: results of a consensus conference.

STUDY OBJECTIVEnTo arrive at a consensus on the priorities for future research in emergency medical services for children.nnnMETHODSnA consensus group was convened using the Rand-UCLA Consensus Process. The group took part in a 3-phase process. Round 1 involved reviewing a compendium of relevant research articles and answering a mailed questionnaire. Panel members were asked to prioritize topics on the basis of the 1993 Institute of Medicine Report on Emergency Medical Services for Children. Participants were asked to rate each topic based on the significance of the research, and whether the topic would (1) improve general knowledge, (2) change behavior, (3) improve health, (4) decrease the cost of care, or (5) change public policy. A 4-point Likert scale was used. Participants were also asked if the research would require a multicenter study and if the research were feasible. Round 2 of the study involved a meeting of the panel, where the results of Round 1 were discussed and the topics were reprioritized. The topics were given a rank order and a final ranking was done in Round 3.nnnRESULTSnThe panel considered a list of 32 topics; these were combined and reworded to give them more precise meaning. Several new topics were also added. Fifteen topics were given a rank order and placed within the 7 broad categories of the Institute of Medicine report. Clinical aspects of emergency care, systems organization, configuration, and operation and injury prevention were given high priority rankings. The first 5 topics were very close in point-rank order.nnnCONCLUSIONnThe panel was able to develop a list of important topics for future research in emergency medical services for children that can be used by foundations, governmental agencies, and others in setting a research agenda for such services.

Withholding or Termination of Resuscitation in Pediatric Out-of-Hospital Traumatic Cardiopulmonary Arrest

This multiorganizational literature review was undertaken to provide an evidence base for determining whether recommendations for out-of-hospital termination of resuscitation could be made for children who are victims of traumatic cardiopulmonary arrest. Although there is increasing acceptance of out-of-hospital termination of resuscitation for adult traumatic cardiopulmonary arrest when there is no expectation of a good outcome, children are routinely excluded from state termination-of-resuscitation protocols. The decision to withhold resuscitative efforts in a child under specific circumstances (decapitation or dependent lividity, rigor mortis, etc) is reasonable. If there is any doubt as to the circumstances or timing of the traumatic cardiopulmonary arrest, under the current status of limiting termination of resuscitation in the field to persons older than 18 years in most states, resuscitation should be initiated and continued until arrival to the appropriate facility. If the patient has arrested, resuscitation has already exceeded 30 minutes, and the nearest facility is more than 30 minutes away, involvement of parents and family of these children in the decision-making process with assistance and guidance from medical professionals should be considered as part of an emphasis on family-centered care because the evidence suggests that either death or a poor outcome is inevitable.

Assessment of pediatric patients by emergency medical technicians-basic.

Objective To determine whether emergency medical technicians-basic can accurately assess children and whether this ability varies with the patient’s age or diagnosis. This determination is important for educational program design for emergency medical technicians in pediatrics and for evaluation of the possibility of expanding their scope of practice. Design Retrospective chart review. Setting Pediatric emergency department in a large, urban hospital. Participants Patients (n = 2430) presenting to the pediatric emergency department via basic life support ambulance during a 12-month period. Measurements Data collected were name, age, field assessment (FA), and emergency department (ED) diagnosis. Patient’s ages were organized into five groups: infant (0–1 y), toddler (1–3 y), preschool (3–6 y), school-aged (6–11 y), and adolescent (> 11 y), and the ED diagnoses were divided into seven categories. The accuracy of the FA was compared with the ED diagnosis. We then analyzed FA accuracy by patient’s age and type of diagnosis. The χ2 contingency table analysis was used for dichotomous variables (P < 0.05). In addition, logistic regression and stratified analysis were used. Both ambulance and hospital charts were available for 2064 patients. Age ranged from birth to 19 years with a bimodal distribution at the extremes of patient age and a mean age of 8.25 (SD, 5.64). The distribution was 11.7% (241) infants, 14.7% (303) toddlers, 14.9% (307) preschool, 21.2% (437) school-aged, and 37.6% (776) adolescents. Results Overall emergency medical technician-basic assessment was accurate 81.5% (1683) of the time. There was a statistically significant variation in accuracy with both age group (χ2 = 40.07, P < 0.05) and diagnostic category (χ2 = 185.7, P < 0.05). By age group, the accuracy of field assessment was 69.7% (168) infants, 75.9% (230) toddlers, 82.7% (254) preschool, 86.7% (379) school-aged, and 84.0% (652) adolescents. By category of diagnosis, the accuracy of the field assessment was 92.4% (292) major trauma, 91.4% (478) minor trauma, 88.9% (112) psychologic and social, 85.1% (229) major medical, 81.1% (180) wheezing-associated respiratory illness, 65.4% (350) minor medical, and 57.5% (42) nonwheezing-associated respiratory illness. Conclusions Emergency medical technicians-basic were highly successful in assessing children with wheezing, serious illness, injuries, and psychologic and social conditions. Consideration should be given to expanding their scope of practice in these areas. They were less successful in assessing minor medical conditions and respiratory emergencies other than wheezing. They require additional training in these areas.

Mass critical care: pediatric considerations in extending and rationing care in public health emergencies.

This article applies developing concepts of mass critical care (MCC) to children. In public health emergencies (PHEs), MCC would improve population outcomes by providing lifesaving interventions while delaying less urgent care. If needs exceed resources despite MCC, then rationing would allocate interventions to those most likely to survive with care. Gaps between estimated needs and actual hospital resources are worse for children than adults. Clear identification of pediatric hospitals would facilitate distribution of children according to PHE needs, but all hospitals must prepare to treat some children. Keeping children with a family member and identifying unaccompanied children complicate PHE regional triage. Pediatric critical care experts would teach and supervise supplemental providers. Adapting nearly equivalent equipment compensates for shortages, but there is no substitute for age-appropriate resuscitation masks, IV/suction catheters, endotracheal/gastric/chest tubes. Limitations will be encountered using adult ventilators for infants. Temporary manual bag valve ventilation and development of shared ventilators may prolong survival until the arrival of ventilator stockpiles. To ration MCC to children most likely to survive, the Pediatric Index of Mortality 2 score meets the criteria for validated pediatric mortality predictions. Policymakers must define population outcome goals in regard to lives saved versus life-years saved.

Developing consensus on appropriate standards of disaster care for children

BACKGROUNDnNeither professional consensus nor evidence exists to guide the choice of essential hospital disaster interventions. The objective of our study was to demonstrate a method for developing consensus on hospital disaster interventions that should be regarded as essential, quantitatively balancing needs and resources.nnnMETHODSnA panel of pediatric acute care practitioners developed consensus using a modified Delphi process. Interventions were chosen such that workload per staff member would not exceed the previously validated maximum according to the Therapeutic Intervention Scoring System. Based on published models, it was assumed that the usual numbers of staff would care for a disaster surge of 4 times the usual number of intensive care and non-intensive care hospital patients.nnnRESULTSnUsing a single set of assumptions on constrained resources and overwhelming needs, the panel ranked and agreed on essential interventions. A number of standard interventions would exceed crisis workload constraints, including detailed recording of vital signs and fluid balance, administration of vasoactive agents, invasive monitoring of pressures (central venous, intraarterial, intracranial), dialysis, and tube feedings.nnnCONCLUSIONSnThe quantitative methodology and consensus development process described in the present report may have utility in future planning. Groups with appropriate expertise must develop action plans according to authority within each jurisdiction, addressing likely disaster scenarios, according to the needs in each medical service region, using available regional resources, and accounting for the capabilities of each institution.

Pediatric nerve agent poisoning: medical and operational considerations for emergency medical services in a large American city.

Abstract: Most published recommendations for treatment of pediatric nerve agent poisoning are based on standard resuscitation doses for these agents. However, certain medical and operational concerns suggest that an alternative approach may be warranted for treatment of children by emergency medical personnel after mass chemical events. (1) There is evidence both that suprapharmacological doses may be warranted and that side effects from antidote overdosage can be tolerated. (2) There is concern that many emergency medical personnel will have difficulty determining both the age of the child and the severity of the symptoms. Therefore, the Regional Emergency Medical Advisory Committee of New York City and the Fire Department, City of New York, Bureau of Emergency Medical Services, in collaboration with the Center for Pediatric Emergency Medicine of the New York University School of Medicine and the Bellevue Hospital Center, have developed a pediatric nerve agent antidote dosing schedule that addresses these considerations. These doses are comparable to those being administered to adults with severe symptoms and within limits deemed tolerable after inadvertent nerve agent overdose in children. We conclude that the above approach is likely a safe and effective alternative to weight-based dosing of children, which will be nearly impossible to attain under field conditions.