Caring for Children in the ED

Meet FCEP's Pediatric Committee

By John Misdary, MD, FACEP and Todd Wylie, MD | FCEP Pediatric Committee Chairs

This is the introductory update from the Pediatric Committee, which was initially started by Dr. Dennis Hernandez as a task force about 10 years ago. After much hard work and with little help, he transformed the group into a committee and, in 2014, turned the committee over to Dr. John Misdary. In 2017, Dr. Todd Wylie became co-chair. Though we are both EM/PEM trained, we embrace the dichotomy of emergency medicine with Dr. Wylie, being an academician as both fellowship director and medical director of the division of pediatric emergency medicine at the UF–Jacksonville Health Sciences Center, and Dr. Misdary, being a private practice physician who practices both general and pediatric emergency medicine in community and tertiary care centers in Tampa Bay.

Since 2013, the committee has grown exponentially with pediatric EM physicians from all over the state. Our main goal has been to increase pediatric education throughout Florida in all aspects of medical care. We have successfully completed a webinar lecture series for prehospital personnel and have hosted a pediatric track at Symposium by the Sea for the last three years. The strength of our educational endeavors has been in simulation; Dr. Shiva Kalindindi from Nemours Childrens Hospital and Drs. Chrissy Zeretzke and Tricia Swan from UF– Gainesville have been invaluable with their staff delivering the highest quality of high-fidelity medical simulation.

As we look forward to 2019, we will be conducting another pediatric track at Symposium by the Sea with a concentration in pediatric trauma. I would like to thank all members of the committee that have made this a success. Most of all, I would like to thank the staff at EMLRC who have worked tirelessly to obtain the committee grants and funding in order to put on the educational events. As a committee, will we continue moving forward with the goal of educating first responders, nurses, APPs and physicians on pediatric emergency care. ■

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New Recommendations on Emergency Care for Children

By Madeline Joseph, MD, FACEP, FAAP

On November 1, 2018, ACEP, the American Academy of Pediatrics (AAP) and the Emergency Nursing Association (ENA) announced the publication of updated joint guidelines, “Pediatric Readiness in the Emergency Department.” This marks an important landmark that highlights ACEP’s continuous dedication to improving the emergency care of children. [1]

The majority of children (83%) present to general emergency departments (EDs) versus specialized pediatric EDs. [2] With 69% of EDs providing care for fewer than 15 pediatric patients per day, it is crucial that all EDs have appropriate resources and capable staff to provide safe and effective emergency care for children.

In the 2006 report, “Emergency Care for Children: Growing Pains,” the National Academy of Medicine (formerly the Institute of Medicine) used the word “uneven” to describe the current status of pediatric emergency care in the U.S. [3] This is due to the fact that resources within emergency and trauma health care systems vary locally, regionally and nationally.

Launched in 2013, the National Pediatric Readiness Project is an ongoing quality improvement initiative among the federal EMSC program, AAP, ACEP and ENA to ensure pediatric readiness of EDs. [4] In phase 1, hospital ED leaders in the U.S. were asked to complete a comprehensive assessment of their readiness to care for children. The assessment was based on the 2009 joint Policy Statement. [5-6] The response rate was 83%, representing more than 4,000 EDs. [2] The data reveals that while much progress has been made to improve pediatric readiness across communities, there remains a significant opportunity for further progress nationwide and in Florida. [4]

The recommendations in the 2018 “Pediatric Readiness in the Emergency Department” policy statement 1 include current information on equipment, medications, supplies and personnel that are considered critical for managing pediatric emergencies in EDs. There are also recommendations for the administration and coordination of pediatric care in the ED; pediatric emergency care quality improvement (QI), performance improvement (PI) and patient safety activities; policies, procedures and protocols for pediatric care; and key ED support services. It is believed that all EDs in the U.S. can meet or exceed these recommendations, and that some hospitals, such as those with pediatric critical care capabilities or children’s hospitals with greater resources, will develop even more comprehensive recommendations and share their expertise.

An important first step in ensuring readiness is the identification of a pediatric emergency care coordinator (PECC). PECC includes a physician and nurse coordinator for pediatric emergency care who are identified by the ED’s medical and nurse directors. The 2018 recommendations include the qualifications and responsibilities of PECC to assist in pediatric preparedness, along with competencies for physicians, APPs, nurses and other health care providers.

In addition, the 2018 recommendations highlight the need for the ED’s QI and/or PI plan to include pediatric-specific indicators, some of which were identified in the recommendations for system-based or disease-specific measures. Examples include measuring weight in kilogram, identifying age-based abnormal pediatric vital signs and administration of systemic steroids for pediatric asthma. Resources are available to assist ED staff with implementing QI and/or PI activities.

The relatively low frequency of exposure of hospital-based, emergency care professionals to critically ill and injured children and children with special health care needs is a barrier to the maintenance of skills and clinical competencies. These updated recommendations are intended to serve as a resource for clinical and administrative leadership as EDs strive to improve their readiness for children of all ages.

Thank you all for what you do every day and for your commitment to improving emergency care for children. ■

References

1. Remick K, Gausche-Hill M, Joseph MM, et al; AAP Committee on Pediatric Emergency Medicine and Section on Surgery, ACEP Pediatric Emergency Medicine Committee, ENA Pediatric Committee. Pediatric Readiness in the Emergency Department. Pediatrics. 2018;142(5): e20182459

2. Gausche-Hill M, Ely M, Schmuhl P, et al. A national assessment of pediatric readiness of emergency departments. JAMA Pediatr. 2015;169(6):527–534.

3. Institute of Medicine, Committee of the Future of Emergency Care in the US Health System. Emergency Care for Children: Growing Pains. Washington, DC: National Academies Press; 2006.

4. National Pediatric Readiness Project. 2014. Available at: http://ow.ly/Xw2g30mEHxM. Accessed November 1, 2018.

5. AAP, Committee on Pediatric Emergency Medicine; ACEP, Pediatric Committee; ENA, Pediatric Committee. Joint policy statement–guidelines for care of children in the emergency department. Pediatrics. 2009;124(4):1233–1243

6. AAP, Committee on Pediatric Emergency Medicine; ACEP, Pediatric Committee; ENA, Pediatric Committee. Joint policy statement–guidelines for care of children in the emergency department. Ann Emerg Med. 2009;54(4):543–552

Emergency Department Evaluation and Management of Bronchiolitis in Infants and Children

By Michael Tandlich MD Candidate, FSU College of Medicine, Class of 2020

Bronchiolitis is one of the leading causes of hospitalization in infants and young children that is often mistreated in the emergency department.

Bronchiolitis is clinically defined by wheezing or crackles in a child less than 2 years of age with history and physical exam findings characteristic of a lower respiratory tract infection (LRTI). A virus is thought to infect and cause damage to the bronchiolar epithelial lining, leading to an inflammatory response. The subsequent inflammatory debris and mucus directly blocks small airways and leads to atelectasis.

Respiratory syncytial virus is the leading cause of bronchiolitis in children less than age 1, as well as medically attended LRTIs in children less than age 5. Rhinovirus is another major cause. Most cases of bronchiolitis have a viral etiology. Additional viral causes may be parainfluenza virus, adenovirus, coronavirus and bocavirus. A significant number of young children hospitalized for bronchiolitis test positive for two or more viruses.

Bronchiolitis typically occurs in the colder months. Risk factors for increased disease severity include prematurity, age younger than 12 weeks, immunodeficiency, low birth weight, chronic lung disease, anatomic airway defects and hemodynamically significant heart disease.

In an otherwise healthy child, bronchiolitis typically presents with a history of 1-3 days of upper respiratory symptoms followed by the onset of fever and respiratory distress worsened with crying, coughing and agitation. Signs of a LRTI such as wheezing typically occur most prominently between 4-6 days after initial symptom onset. The disease is usually self-limited and resolves gradually between 1-2 weeks after initial symptom onset.

The diagnosis should be made clinically on the basis of history and physical exam findings. Routine labs and radiographic studies for diagnosis do not need to be ordered routinely unless clinical findings suggest other potential diagnoses.

A crucial step in evaluation of bronchiolitis is the assessment of disease severity. Mild severity is characterized by normal feeding, minimal respiratory distress and pulse oximetry above 95%. Moderate severity is characterized by signs of respiratory distress and mild hypoxemia corrected with oxygen. Severe bronchiolitis is characterized by inability to feed, signs of severe respiratory distress and hypoxemia that is not corrected with oxygen.

The presence of crepitus on chest auscultation and hypoxemia are sensitive predictors of the need for hospitalization. Patients with severe bronchiolitis often require close observation and immediate treatment, largely supportive. Providing adequate hydration, oxygen with respiratory support as indicated, and monitoring progression of disease are most important. With severe respiratory distress, IV fluids and intensive care unit consultation may be necessary.

Bronchodilators have not been shown to improve oxygen saturation. Corticosteroids are not effective in the immediate treatment of bronchiolitis symptoms. Antibiotics are not indicated as they have no action against viruses, and secondary bacterial infection in bronchiolitis is uncommon. In the emergency setting, nebulized 3% saline has not been shown to reduce hospitalization.

Infants may often develop one or more minor complication. Infants with fever, tachypnea and decreased oral intake are at risk for dehydration. Serious complications may include apnea and respiratory failure and occur more commonly among infants with a history of prematurity or congenital abnormalities. Secondary bacterial infection is unlikely in the absence of fever, but intubation and ventilation may increase the risk of bacterial pneumonia. Palivizumab is a monoclonal antibody against RSV reserved for prophylactic treatment of children at a very high risk for complications, although its use is debated. ■

References

1. AAP Subcommittee on, D., & Management of, B. (2006). Diagnosis and management of bronchiolitis. Pediatrics, 118(4), 1774-1793. doi:10.1542/ peds.2006-2223

2. Bordley, W. C., Viswanathan, M., King, V. J., Sutton, S. F., Jackman, A. M., Sterling, L., & Lohr, K. N. (2004). Diagnosis and testing in bronchiolitis: a systematic review. Arch Pediatr Adolesc Med, 158(2), 119-126. doi:10.1001/archpedi.158.2.119

3. Fitzgerald, D. A., & Kilham, H. A. (2004). Bronchiolitis: assessment and evidence-based management. Med J Aust, 180(8), 399-404.

4. Ralston, S. L., Lieberthal, A. S., Meissner, H. C., Alverson, B. K., Baley, J. E., Gadomski, A. M., AAP. (2014). Clinical practice guideline: the diagnosis, management, and prevention of bronchiolitis. Pediatrics, 134(5), e1474-1502. doi:10.1542/peds.2014-2742