George L. Foltin

Recommended Guidelines for Uniform Reporting of Pediatric Advanced Life Support: The Pediatric Utstein Style A Statement for Healthcare Professionals From a Task Force of the American Academy of Pediatrics, the American Heart Association, and the European Resuscitation Council

This consensus document is an attempt to provide an organized method of reporting pediatric ALS data in out-of-hospital, emergency department, and in-hospital settings. For this methodology to gain wide acceptance, the task force encourages development of a common data set for both adult and pediatric ALS interventions. In addition, every effort should be made to ensure that consistent definitions are used in all age groups. As health care changes, we will all be challenged to document the effectiveness of what we currently do and show how new interventions or methods of treatment improve outcome and/or reduce cost. Only through collaborative research will we obtain the necessary data. For these reasons, and to improve the quality of care and patient outcomes, it is the hope of the task force that clinical researchers will follow the recommendations in this document. It is recognized that further refinements of this statement will be needed; these recommendations will improve only when researchers, clinicians, and EMS personnel use them, work with them, and modify them. Suggestions, emendations, and other comments aimed at improving the reporting of pediatric resuscitation should be sent to Arno Zaritsky, MD, Eastern Virginia Medical School, Childrens Hospital of The Kings Daughter, Division of Critical Care Medicine, 601 Childrens Lane, Norfolk, VA 23507.

Rapid-Sequence Intubation of the Pediatric Patient

Airway compromise is the most common cause of death and severe morbidity in acutely ill and injured children. Rapid-sequence intubation (RSI) is a technique for emergency airway control designed to maximize successful endotracheal intubation while minimizing the adverse physiologic effects of this procedure. RSI requires familiarity with patient evaluation, airway-management techniques, sedation agents, neuromuscular blocking agents, additional adjunctive agents, and postintubation management techniques. Emergency physicians should use RSI techniques in the endotracheal intubation of critically ill children.

Epidemiology of Psychiatric-Related Visits to Emergency Departments in a Multicenter Collaborative Research Pediatric Network

Objectives: Describe the epidemiology of pediatric psychiatric-related visits to emergency departments participating in the Pediatric Emergency Care Applied Research Network. Methods: Retrospective analysis of emergency department presentations for psychiatric-related visits (International Classification of Diseases, Ninth Revision, codes 290.0-314.90) for years 2003 to 2005 at 24 participating Pediatric Emergency Care Applied Research Network hospitals. All patients who had psychiatric-related emergency department visits aged 19 years or younger were eligible. Age, sex, race, ethnicity, insurance status, mode of arrival, length of stay, and disposition were described for psychiatric-related visits and compared with non-psychiatric-related visits. Results: Pediatric psychiatric-related visits accounted for 3.3% of all participating emergency department visits (84,973/2,580,299). Patients with psychiatric-related visits were older (mean ± SD age, 12.7 ± 3.9 years vs. 5.9 ± 5.6 years, P < 0.001), had a higher rate ambulance arrival (19.4% vs 8.2%, P < 0.0001), had a longer median length of stay (3.2 vs 2.1 hours, P < 0.0001), and had a higher rate of admission (30.5% vs 11.2%, P < 0.0001) when compared with non-psychiatric-related patient presentations. Older age, female sex, white race, ambulance arrival, and governmental insurance were factors independently associated with admission or transfer from the emergency department for psychiatric-related visits in multivariate regression analyses. Conclusions: Pediatric psychiatric-related visits require more prehospital and emergency department resources and have higher admission/transfer rates than non-psychiatric-related visits within a large national pediatric emergency network.

Children requiring psychiatric consultation in the pediatric emergency department: epidemiology, resource utilization, and complications.

Methods: A cohort of children younger than 18 years presenting to an urban pediatric emergency department (PED) who underwent psychiatric consultation was analyzed. A standardized data collection sheet was prospectively completed and included: patient characteristics, extent of medical evaluation and findings, ancillary diagnostic studies, resources utilized, dangerous behaviors, and disposition. Results: Two hundred ten patients required psychiatric evaluation. Median age was 14 years; 51.9% were boys; 71.9% had a past psychiatric history; 39.0% had prior psychiatric admission(s), and 40.5% were on psychiatric medications. The admission rate was 49.5%. Patients spent a median of 5.7 hours in the PED. Hospital police monitored 51.9% patients. Forty-five patients had 91 dangerous behaviors. Those patients presenting with a complaint of aggressive behavior (P = 0.00006), a past psychiatric history (P = 0.003), or a history of prior psychiatric hospitalization (P = 0.005) were more likely to have dangerous behaviors. Two hundred nine patients underwent a complete medical evaluation, and 207 were considered medically cleared. Patients who had diagnostic evaluations for medically indicated reasons were significantly more likely to have abnormal results than those requested by the psychiatric consultant for screening purposes (43.6% vs. 9.2%; relative risk, 2.33; 95% confidence interval, 1.33-4.08) but were not statistically more likely to result in medical intervention (5.4% vs. 0%, P = 0.243). Conclusions: PED patients requiring psychiatric consultation and psychiatric admission had a prolonged PED stay and a high incidence of dangerous behaviors requiring intervention. History and physical examination adequately identified medical illness. Laboratory evaluation obtained for psychiatric transfer or admission purposes was of low yield.

Priorities for Pediatric Prehospital Research

Up to 3 million US children are cared for by emergency medical services (EMSs) annually. Limited research exists on pediatric prehospital care. The Pediatric Emergency Care Applied Research Network (PECARN) mission is to perform high-quality research for children, including prehospital research. Our objective was to develop a pediatric-specific prehospital research agenda. Methods: Representatives from all 4 PECARN nodes and from EMS agency partners participated in a 3-step process. First, participants ranked potential research priorities and suggested others. Second, participants reranked the list in order of importance and scored each priority using a modified Hanlon method (prevalence, seriousness, and practicality of each research area were assessed). Finally, the revised priority list was presented at a PECARN EMS summit, and consensus was sought. Results: Forty-two representatives participated, including PECARN representatives, EMS agency leaders, and nationally recognized prehospital researchers. Consensus was reached on the priority ranking. The prioritization processes resulted in 2 ranked lists: 15 clinical topics and 5 EMS system topics. The top 10 clinical priorities included (1) airway management, (2) respiratory distress, (3) trauma, (4) asthma, (5) head trauma, (6) shock, (7) pain, (8) seizures, (9) respiratory arrest, and (10) C-spine immobilization. The 5 EMS system topics identify methods to improve prehospital care on the system level. Conclusions: PECARN has identified high-priority EMS research topics for children using a consensus-derived method. These research priorities include novel EMS system topics. The PECARN EMS pediatric research priority list will help focus future pediatric prehospital research both within and outside the network.

The Role of Emergency Medical Services in Primary Injury Prevention

Injury is a leading cause of death and disability. Preventing injuries from ever occurring is primary injury prevention (PIP). The objective of this statement is to present the consensus of a 16-member panel of leaders from the out-of-hospital emergency medical services (EMS) community on essential and desirable EMS PIP activities. Essential PIP activities for leaders and decision makers of every EMS system include: protecting individual EMS providers from injury; providing education to EMS providers in PIP fundamentals; supporting and promoting the collection and utilization of injury data; obtaining support for PIP activities; networking with other injury prevention organizations; empowering individual EMS providers to conduct PIP activities; interacting with the media to promote injury prevention; and participating in community injury prevention interventions. Essential PIP knowledge areas for EMS providers include: PIP principles; personal injury prevention and role modeling; safe emergency vehicle operation; injury risk identification; documentation of injury data; and one-on-one safety education.

A National Assessment of Knowledge, Attitudes, and Confidence of Prehospital Providers in the Assessment and Management of Child Maltreatment

OBJECTIVE. The goal was to assess the knowledge and confidence in recognition, management, documentation, and reporting of child maltreatment among a representative sample of emergency medical services personnel in the United States. METHODS. A questionnaire was developed and pilot-tested, with the input of experts in emergency medical services and child maltreatment, to assess knowledge, attitudes, confidence, and training needs regarding assessment and treatment of child maltreatment. The questionnaire was distributed nationally to a random sample of prehospital providers by using a previously validated sampling plan. RESULTS. Of 2863 surveys sent to prehospital providers, 1237 (43%) were returned. Most prehospital providers reported receiving ≤1 hour of continuing medical education regarding child maltreatment. Most (78%) asked for additional educational opportunities, with only 3% stating that they required no additional training. Participants lacked knowledge regarding the developmental abilities of children, management of families in which child maltreatment is suspected, key elements of the history that should be noted, and the degree of suspicion necessary for reporting. CONCLUSIONS. Prehospital providers expressed confidence in their abilities to recognize and to manage cases of child abuse and neglect; however, significant deficiencies were reported in several critical knowledge areas, including identification of child maltreatment, interviewing techniques, and appropriate documentation.

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.

Alcohol use by pedestrians who are struck by motor vehicles: How drinking influences behaviors, medical management, and outcomes

BACKGROUND Injuries to pedestrians struck by motor vehicles represent a significant public health hazard in large cities. The purpose of this study is to investigate the demographics of alcohol users who are struck by motor vehicles and to assess the effects of alcohol on pedestrian crossing patterns, medical management, and outcomes. METHODS Data were prospectively collected between December 2008 to September 2010 on all pedestrians who presented to a Level I trauma center after being struck by a motor vehicle. Variables were obtained by interviewing patients, scene witnesses, first responders, and medical records. RESULTS Pedestrians who used alcohol were less likely to cross the street in the crosswalk with the signal (22.6% vs. 64.7%) and more likely to cross either in the crosswalk against the signal (22.6% vs. 12.4%) or midblock (54.8% vs. 22.8%). Alcohol use was associated with more initial computed tomography imaging studies compared with no alcohol involvement. Alcohol use was associated with a higher Injury Severity Score (8.82 vs. 4.85; p < 0.001) and hospital length of stay (3.89 days vs. 1.82 days; p < 0.001) compared with those with no alcohol involvement. Patients who used alcohol had a lower average Glasgow Coma Scale score (13.80 vs. 14.76; p < 0.001) and a higher rate of head and neck, face, chest, abdomen, and extremity/pelvic girdle injuries (based on Abbreviated Injury Scale) than those with no alcohol involvement. CONCLUSION Alcohol use is a significant risk factor for pedestrians who are struck by motor vehicles. These patients are more likely to cross the street in an unsafe manner and sustain more serious injuries. Traffic safety and injury prevention programs must address irresponsible alcohol use by pedestrians.

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.