Loren G. Yamamoto

Joint policy statement - Guidelines for care of children in the emergency department

Children who require emergency care have unique needs, especially when emergencies are serious or life-threatening. The majority of ill and injured children are brought to community hospital emergency departments (EDs) by virtue of their geography within communities. Similarly, emergency medical services (EMS) agencies provide the bulk of out-of-hospital emergency care to children. It is imperative, therefore, that all hospital EDs have the appropriate resources (medications, equipment, policies, and education) and staff to provide effective emergency care for children. This statement outlines resources necessary to ensure that hospital EDs stand ready to care for children of all ages, from neonates to adolescents. These guidelines are consistent with the recommendations of the Institute of Medicines report on the future of emergency care in the United States health system. Although resources within emergency and trauma care systems vary locally, regionally, and nationally, it is essential that hospital ED staff and administrators and EMS systems administrators and medical directors seek to meet or exceed these guidelines in efforts to optimize the emergency care of children they serve. This statement has been endorsed by the Academic Pediatric Association, American Academy of Family Physicians, American Academy of Physician Assistants, American College of Osteopathic Emergency Physicians, American College of Surgeons, American Heart Association, American Medical Association, American Pediatric Surgical Association, Brain Injury Association of America, Child Health Corporation of America, Childrens National Medical Center, Family Voices, National Association of Childrens Hospitals and Related Institutions, National Association of EMS Physicians, National Association of Emergency Medical Technicians, National Association of State EMS Officials, National Committee for Quality Assurance, National PTA, Safe Kids USA, Society of Trauma Nurses, Society for Academic Emergency Medicine, and The Joint Commission.

Management of pediatric trauma

Injury is the number 1 killer of children in the United States. In 2004, injury accounted for 59.5% of all deaths in children younger than 18 years. The financial burden to society of children who survive childhood injury with disability continues to be enormous. The entire process of managing childhood injury is complex and varies by region. Only the comprehensive cooperation of a broadly diverse group of people will have a significant effect on improving the care and outcome of injured children. This statement has been endorsed by the American Association of Critical-Care Nurses, American College of Emergency Physicians, American College of Surgeons, American Pediatric Surgical Association, National Association of Childrens Hospitals and Related Institutions, National Association of State EMS Officials, and Society of Critical Care Medicine.

Rapid sequence anesthesia induction for emergency intubation.

Emergency intubations are done for a variety of reasons in the emergency department (ED). In some patients, a rapid, controlled induction of anesthesia is useful to facilitate intubation and to reduce the complications of intubation. This is referred to as rapid sequence induction (RSI) in the anesthesia literature. Atropine, thiopental, fentanyl, diazepam, ketamine, vecuronium, succinylcholine, other drugs and their applications for RSI are described. The purpose of this article is to describe the use of RSI in the airway management of ED patients. Nineteen pediatric patients requiring emergency intubation were intubated using RSI with vecuronium and thiopental. Actual intubation difficulty using RSI was significantly less than the anticipated intubation difficulty without RSI. There were no complications caused by intubation or RSI that had a significant impact on patient outcome. We feel that a sedative in combination with vecuronium represents the most optimal means of achieving RSI in the ED setting. Although the induction of general anesthesia is best done by anesthesiologists, emergency physicians are often the most experienced physicians immediately available to manage an airway in a critical emergency. An objective protocol such as that described will make it easier for emergency physicians to perform this procedure when needed.

Characteristics of frequent pediatric emergency department users

The purpose of this study was to examine the medical and demographic characteristics of patients who frequently seek emergency care at a pediatric emergency department (ED). Registration information of ED visits during the study period from 11/1/87 to 5/31/92 (4.6 years) was stored in a data base. Patients with 10 or more ED visits during this study period were considered to be “frequent” ED users. Outpatient and inpatient medical records of these patients were manually reviewed. Demographics, chronic conditions, and the acute conditions for each ED visit were coded and analyzed. During the study period, there were 79,049 ED patient visits under 21 years of age. Of the patients born after 1970, there were 47,451 visits by patients seen one or two times, 25,883 visits by patients seen three to nine times, and 5178 visits by 357 patients seen in the ED ten times or more. Ninety-nine patients were seen more than 15 times, 39 patients were seen more than 20 times, 17 patients were seen more than 25 times, and 10 patients were seen more than 30 times. Two hundred sixty-five of the 357 frequent ED users (74%) had chronic disease conditions. Two hundred and twenty-three of them had good functional status, 25 had mild or moderate impairment in carrying out activities of daily living, and 17 had severe impairment of function. The most common chronic medical conditions were recurrent wheezing (226), neurologic conditions (33), gastrointestinal conditions (13), cardiac conditions (12), and endocrine conditions (9). The other 92 were assessed as healthy children. Patients immunization status were up to date as of the last ED visit during the study period in 329 patients (92%). Pediatricians were the primary care providers in 339 patients (95%). Medical insurance status of patients follows: private insurance (38%), military (0.3%), Medicaid or state assistance (60%), and no insurance (1.4%). Polynesian ethnic groups were overrepresented in the cohort of frequent ED users. We conclude that cultural differences appeared to be an important factor associated with frequent ED use by healthy persons. Medical care resources as measured by immunizations, insurance, and identification of a primary care physician did not appear to be deficient in this cohort of frequent ED users. Since recurrent

Commercial airline travel decreases oxygen saturation in children

Objective To investigate the degree of oxygen saturation decline occurring in children during prolonged commercial air travel. Methods Oxygen saturation and heart rate were measured with a pulse oximeter in healthy pediatric passengers at sea level before boarding a commercial aircraft. These measurements were repeated after 3 hours and 7 hours of flight. Cabin pressure, true altitude, and cabin fraction of inspired oxygen (Fio2) were also recorded at 3 hours and 7 hours. Results Eighty healthy children (43 boys) aged 6 months to 14 years were studied during eight flights between Honolulu, Hawaii, and Taipei, Taiwan. Oxygen saturation declined, and heart rate increased after 3 hours (95.7%, 105 beats per minute [BPM]) and 7 hours (94.4%, 108 BPM) of flight compared to preflight levels at sea level (98.5%, 100 BPM) (P < 0.001). The 3-hour to 7-hour oxygen saturation and heart rate means differed significantly (P < 0.001, P = 0.014, respectively). The significant drop in oxygen saturation was associated with the decreased cabin partial pressure of oxygen (Po2)—Po2 was 159 mm Hg at sea level, 126 mm Hg after 3 hours, and 124 mm Hg after 7 hours—but the 3-hour and 7-hour difference suggests that flight duration may also contribute to worsened oxygen desaturation. Conclusion Oxygen saturation declines significantly during commercial airline travel with reduced aircraft cabin pressure and concomitant reduced cabin Po2. We did not observe an “acclimation” of oxygenation as the length of travel increased; rather, the oxygen saturation decline worsened, although it may be partially a result of the lower cabin Po2. Although there were no clinically noticeable ill effects at the level of oxygen saturation decline in these relatively healthy passengers, patients with preexisting anemia or cardiopulmonary disease are likely to experience greater degrees of clinical compromise with similar degrees of oxygen saturation decline.

Policy statement - Consent for emergency medical services for children and adolescents

Parental consent generally is required for the medical evaluation and treatment of minor children. However, children and adolescents might require evaluation of and treatment for emergency medical conditions in situations in which a parent or legal guardian is not available to provide consent or conditions under which an adolescent patient might possess the legal authority to provide consent. In general, a medical screening examination and any medical care necessary and likely to prevent imminent and significant harm to the pediatric patient with an emergency medical condition should not be withheld or delayed because of problems obtaining consent. The purpose of this policy statement is to provide guidance in those situations in which parental consent is not readily available, in which parental consent is not necessary, or in which parental refusal of consent places a child at risk of significant harm.

A one-year prospective ED cohort of pediatric trauma

During a 12-month period ending on November 30, 1988, data were collected on 4623 pediatric patients visiting a pediatric emergency department with trauma (excluding burns). Sixty-one percent were male. Common causes of the trauma included suspected child abuse (4%), organized sports (6%), nonorganized sports (4%), pedestrian motor vehicle accidents (MVAs) (3%), bicycle MVAs (2%), and automobile MVAs (3%). However, most of the incidents had none of the identified associated activities surrounding the trauma (60%), Incidents took place at home (41%), on the street (11%), at school (10%), and at a playground or park (10%). Injuries involved the external body (59%), extremity (26%), head or neck (13%), face (4%), chest (1%), and abdomen (2%) and were more common during the summer. Injury severity scores had a mean of 1.8 and were grouped as: <3 (80%), 3–6 (19%), and >6 (1.6%). Factors associated with higher trauma severity included MVAs, water-related injuries, sports, streets, schools, parks, playgrounds, skateboards, skates, and alcohol.

Personal computer teleradiology interhospital image transmission to facilitate tertiary pediatric telephone consultation and patient transfer: Soft-tissue lateral neck and elbow radiographs

Although teleradiology systems are available commercially, they are expensive (

A one-year series of pediatric prehospital care. I, Ambulance runs. II, Prehospital communication. III, Interhospital transport services

30,000), and different makes are incompatible with each other, making them unusable for interhospital image transfers. Standard components were added to a personal computer (PC) to build a functional teleradiology unit capable of interhospital image transmission at a low cost (

The role of intravenous valproic acid in status epilepticus.

600 upgrade). This PC teleradiology system was studied to assess its accuracy in the interpretation of soft-tissue lateral neck x-rays with epiglottitis or retropharyngeal abscesses and elbow x-rays with joint effusions, fractures, or both. A radiologist and a pediatric emergency physician were asked to read the PC teleradiology images. Both physicians read 13 of 13 soft-tissue lateral neck x-rays and 15 of 15 elbow x-rays correctly. This study supports the premise that PC teleradiology can be used to facilitate telephone consultation and patient transfers between tertiary pediatric emergency centers by transmitting pertinent radiographic information over a phone line. Although verbal communication can often suffice in a telephone consultation or transfer, there are many instances when visualizing a radiographic image such as an x-ray or computed tomography scan can provide important information that cannot be optimally described verbally. Rural hospitals can form interhospital image transmission links with tertiary center resources. Tertiary centers may elect to organize interhospital image transmission and referral networks with their rural hospital sources.