Children constitute one of the most diverse and challenging patient populations facing the emergency physician. While comprising almost 30% of emergency department patients, critical illness and injury are present in only approximately 5%. The majority of pediatric emergency visits are evaluated not in pediatric hospitals, but community emergency departments. Early recognition and aggressive management of illnesses and injuries effecting pediatric patients is of utmost importance.
The epidemiology of pediatric emergency medicine changes with the clinical setting. In the prehospital environment, the common presenting complaints are trauma, seizures, respiratory distress, and toxicologic emergencies. In the emergency department, the most common complaints are fever, trauma, injury, respiratory distress, vomiting, diarrhea, or upper respiratory tract infection.
Assessment of the pediatric patient in the emergency department requires an age-specific approach. A calm, reassuring, and gentle manner on the physician's part will facilitate information collection and encourage patient cooperation in examining and testing.
Knowledge of the child's growth and development often is required for the diagnosis, management, and disposition of the pediatric patient. Severity of acute pediatric illness and injury is often difficult to discern. Recognition of anatomic and physiologic differences remind the examiner of large surface area to weight ratio leading to heat loss and trauma to internal organs may exist with little signs of external injury. Airway differences are important to understand in order to manage respiratory distress and failure. Observational methods of assessment may be more sensitive to illness and injury acuity in children taking into account such variables as quality of cry, reaction to parent stimulation, state variation, skin color, hydration status, and response social overtures such as talking and smiling. Such observations appear to be more predictive of serious illness than anatomic physical examination using standard palpation, percussion, and auscultation techniques.
Assessment and management of the distressed pediatric patient requires appropriately sized equipment. Table 50–1 provides equipment sizes for invasive procedures in children of different age groups.
Table 50–1. Pediatric Procedural Equipment Sizing. |Favorite Table|Download (.pdf)
Table 50–1. Pediatric Procedural Equipment Sizing.
|Age||Weight (Kg)||Endotrachel Tube||Laryngoscope Blade||Chest Tube (F)||Nastrostic Tube (F)||Foley Catheter (F)||Femoral IV|
|Premie 32 week gestation||2||2.5–3.0||1 straight||8||5||5||3 F, 8 cm|
|Newborn||3||3.5||1 straight||10||5||8||3 F, 8 cm|
|1 month||4||3.5||1 straight||10||5||8||3 F, 8 cm|
|3–5 months||6–7||3.5||1 straight||10–12||5–8||8||3 F, 8 cm|
|6–11 months||8–10||3.5–4.0||1 straight||10–12||8||8–10||3 F, 8 cm|
|1 year||10–11||4.0||1 straight||16–20||8–10||8–10||3 F, 8 cm|
|2–3 years||12–14||4.5||1.5–2 straight||20–24||10||8–10||5 F, 15 cm|
|4–5 years||15–18||5.0||2 straight or curved||20–28||10–12||10–12||5 F, 15 cm|
|6–8 years||20–28||5.5–6.0||2 straight or curved||30–32||14–18||10–12||5 F, 15 cm|
|10–12 years||35–50||6.5–7.0||3 straight or curved||32–38||18||12||5–7 F, 15–20 cm|
|14 years||60||7.0–7.5||3–4 straight or curved||38–40||18||12||7 F, 20 cm|
Vital signs may vary by age (Table 50–2). A rapid formula for estimating normal systolic blood pressure is 80 + (2 × age [in years]). The maximum effective heart rate in infants is 200 beats/min, in young children 150 beats/min, and in school-aged children 120 beats/min. Respiratory rate decreases with advancing age (Table 50–2). The use of vital signs to assess vital functions in pediatric patients, however, is hazardous. Appropriate-sized measuring equipment is imperative, techniques must be applied carefully, and interpretation must be age-related. Furthermore, even accurately obtained, age-adjusted vital signs may be insensitive and are often affected by fever, pain, and ambient features of the emergency department environment. Instead, other measures of cardiopulmonary function, such as skin color, temperature, and capillary refill, are often better triage and assessment tools.
Table 50–2. Age-Related Vital Signs. |Favorite Table|Download (.pdf)
Table 50–2. Age-Related Vital Signs.
|Age||Mean Weight (kg)||Minimum Systolic Blood Pressure||Normal Heart Rate||Normal Respiratory Rate|
Concept of the Distressed Family
The emergency department physician must appreciate the intimate relationship of the child to the family. Acute pediatric illness and injury are inextricably part of the family environment and dynamics. The child as well as the entire nuclear and extended family may experience major psychological, emotional, and financial consequences of pediatric emergencies. Effective care requires appropriate consideration of the child within the distressed family, enlistment of parental assistance in evaluation and management, and provision of psychological support.
Too often, the inexperienced physician neglects pain control or procedural sedation because of misunderstanding the significance of pain in the young child, unwarranted fear of addicting children to narcotic agents, or ignorance of appropriate agents. When a painful procedure is necessary, an effective approach integrates careful explanation directly to the child and enlistment of parental understanding and assistance. Whenever conscious or deep sedation procedures are performed, the emergency department physician must ensure patient's safety by strict adherence to the guidelines of monitoring. This includes preparation for any potential airway complications, such as aspiration or apnea. In general, only previously healthy or mildly chronically ill children should be considered candidates for sedation procedures in the emergency department. Sometimes a restraint apparatus will facilitate the procedure.
The guidelines for a variety of clinical situations are given next.
Table 50–3. Common Topical Local Anesthetics. |Favorite Table|Download (.pdf)
Table 50–3. Common Topical Local Anesthetics.
|Drug||Components||Applied To||Effect (min)||Cautions|
|EMLA (Eutectic Mixture of Local Anesthetics)||Intact skin||90|
|Both intact and non intact skin||30|
- Tetracaine 0.25–0.5%
- Adrenaline 0.025–0.05%
- Cocaine 4%–11.8%
|Both intact and nonintact skin||15|
- Cocaine toxicity
- Reapplication Contraindicated
- Max dose: cocaine 3 mglk
|Viscous Lidocaine||Lidocaine 2%||Both intact and and nonintact skin||10||Max dose: 5 mglk Lidocaine|
The formulation LET (2% lidocaine, 1:1000 epinephrine, and 2% tetracaine) is easily applied and has a favorable safety profile. It is available as gel or solution. The onset of action is approximately 30 minutes; thus it should be applied early in the laceration evaluation process. TAC (tetracaine, adrenaline, and cocaine) is occasionally used as well; however caution should be used as seizures have been reported secondarily to systemic cocaine absorption. Any anesthetic containing epinephrine (such as LET or TAC) should be avoided on end-arterial structures, such as the ears, nose, digits, or penis. (See Table 50–3.)
For IV Line Placement, Blood Draws
Eutectic mixture of local anesthetics (EMLA) or Elamax 4%, ethyl chloride spray preparations, J-tip lidocaine applicators have been advocated for local analgesic use on intact skin.
Sedation and Analgesia for Painful Procedures
There are numerous agents (Table 50–4) which are useful in sedation and pain management in the pediatric patient. Familiarity with several of these is useful for the emergency physician, allowing tailoring of the most appropriate agent to the clinical situation. The most commonly used agents are discussed next.
Table 50–4. Pediatric Sedation and Analgesia. |Favorite Table|Download (.pdf)
Table 50–4. Pediatric Sedation and Analgesia.
|Commonly Used Sedative/Analgesic Agents|
|Propofol||IV||1 mg/kg bolus: followed by 0.5 mg/kg every 3–5 min||30–45 s||<15 min|
- Max dose 4.5 mg/kg
- Contraindicated in egg, soy allergies
- No analgesia
- 3–5 mg/kg
- 0.5–2 mg/kg
- 0.5 mg/kg
- Laryngospasm occurs in 2%
- Vomiting in up to 20%
- May use atropine or glycopyrrolate to decrease secretions
- Contraindicated in patients with increased intraocular or intracranial pressure
- 0.05–0.1 mg/kg
- 0.1–0.2 mg/kg
- 0.5 mg/kg
- 0.2–0.5 mg/kg
- 2–3 min
- 10–20 min
- 15–30 min
- 10–15 min
|Nitrous Oxide||Inhaled||50–70% Concentration||1–2 min||5 min||Vomiting in up to 10%|
|Acetaminophen||20–40 min||4 h|
- No anti-inflammatory effects
- Max 1 g
- Use with caution in hepatic disease
|Ibuprofen||PO||10 mg/kg||20–30 min||6h|
- Beware in ASA allergic
- Use with caution in renal or hepatic disease
|Hydrocodone||PO||0.15–0.2 mg/kg||10–30 min||4–6 h|
- 0.1–0.2 mg/kg
|Maximum dose 10 mg|
- 1.7 mcg/kg of 150 mcg/cc concentration
- 1–4 mcg/kg
|Chest wall rigidity with rapid infusion|
Midazolam is a relatively fast acting benzodiazepine providing anxiolysis, sedation, and antegrade amnesia, commonly used in emergency department sedation. It is commonly used in conjunction with a narcotic analgesic such as morphine or fentanyl. Some children will have a paradoxical excitation to midazolam and will experience agitation instead of sedation. There is some evidence that this unpleasant reaction may be reversed with flumazenil. Patients may also respond favorably to additional administration of benzodiazepines.
Ketamine, IM/ may be used for procedural situations involving children of any age, especially burn debridement, foreign body removal, deep wound care, abscess incision and drainage, or orthopedic reductions. Some clinicians recommend adding atropine, 0.01 mg/kg (maximum, 0.5 mg), or glycopyrrolate, 0.005 mg/kg (maximum 0.25 mg), to avoid hypersalivation, although current literature has not demonstrated a clear benefit. Intravenous administration is better for longer procedures. Ketamine may elevate intracranial and intraocular pressure, induce emesis, and occasionally precipitate laryngospasm. Ketamine use in older children may also cause an adverse behavioral reaction upon emergence from sedation. Some clinicians recommend the concomitant use of midazolam in children over 5 years. Studies, however, have not demonstrated a clear benefit to administering midazolam with ketamine to prevent emergence phenomenon.
Propofol, 0.5–1.0 mg/kg by slow IV injection over 3–5 minutes, followed by an infusion of up to 0.5 mg/kg over 2–3 minutes with at least 1 minute between infusions. The advantage to this drug is the rapid onset of sedation and quick recovery time. Propofol is easily titrated to appropriate level of sedation. As with other agents, respiratory depression can occur and therefore ability to manage the airway and assist ventilation is extremely important when using this agent. Common uses of propofol include sedation for orthopedic reduction and suturing. Because of the potential for allergic reaction, the drug is contraindicated in patients with egg or soy allergies. Although the clinical significance of the effect is often not apparent, blood pressure frequently drops during propofol infusion. For this reason, most clinicians avoid propofol in patients who have been hypotensive and/or are significantly hypovolemic.
Sedation for Imaging Studies
For individuals requiring imaging studies such as computed tomography (CT) scan or magnetic resonance imaging (MRI), pentobarbital intramuscularly, midazolam, etomidate , methohexital or dexmedetomidine are commonly and safely used with proper monitoring as for any procedural sedation.
Sedation agents should only be used by those with appropriate training and familiarity with the agents used. Proper precautions should be taken such as constant vital sign and pulse oximetry monitoring. End-tidal CO2 monitoring is advised to more closely assess the adequacy of a patient's ventilation. Rescue airway equipment and reversal agents such as naloxone, 0.01–0.1 mg/kg IV, and flumazenil, 0.01 mg/kg IV should be readily available.
Outpatient analgesia ordinarily includes a nonsteroidal, anti-inflammatory drug such as ibuprofen, 10 mg/kg every 6–8 hours. This drug can also be used in combination with oral narcotic agents for the treatment of severe pain. Acetaminophen, 10–15 mg/kg every 4–6 hours, can also be used for the treatment of mild pain on an outpatient basis. Narcotics as hydrocodone/acetaminophen combination or codeine/acetaminophen every 4–6 hours may be used for severe pain.
Drug and Fluid Administration
All parenterally and orally administered agents should be given strictly on a per-kilogram basis, until maximum adult doses and volumes are reached. Over dosing and over hydration are dangerous errors in emergency pediatrics. Under dosing is also frequent, especially in infants and small children. Initial treatment of dehydration should include isotonic fluids (normal saline or lactated Ringer's). Physicians and nurses should meticulously review drug and fluid orders to ensure that they are age and weight corrected.
Vascular access is often the rate-limiting step in provision of life-saving therapy to critically ill and injured children. The emergency department physician must be familiar with a variety of techniques for access into the cardiopulmonary system.
In critically ill, intubated patients, the endotracheal route is an effective conduit for administration of a variety of life-saving drugs, including epinephrine, atropine, lidocaine, naloxone, and diazepam. Epinephrine is by far the most commonly used. When administered through the endotracheal tube, higher doses, up to 10 times the IV dose, must be used to obtain adequate serum concentrations. The pharmacokinetics of endotracheal epinephrine administration may be optimized by delivery of the drug directly into the highly vascular trachea and proximal tracheobronchial tree instead of directly into the endotracheal tube. The preferred technique required is the insertion of a nasogastric tube or a size 5F umbilical catheter past the distal tip of the endotracheal tube with direct instillation of drugs through the tube. Because endotracheal drugs may be more effective if aerosolized, dilute the drug with normal saline to a maximum volume of 0.5–1.0 mL/kg, and then inject rapidly to achieve a partially aerosolized form.
In infants, the scalp is an ideal site for cannulation; use a size 24 gauge IV catheter. In children past the neonatal period, the dorsal veins of the hand, antecubital fossa, or dorsum of the foot are usually accessible with a 24 or 22-gauge IV catheter. The external jugular vein is a large vein, usually easily visualized and readily cannulated with a 20-gauge catheter if the child is properly restrained and the head is held in a dependent position.
(See also Chapter 8.) For patients under age 5 years in extremis and requiring life-saving drug and fluid administration, intraosseous infusion is an alternative method of administration. This method of access is also a viable alternative in older children and adults; however, successful cannulization is more difficult in this population. A short, thick needle with a trocar tip is inserted into the intramedullary space of the bone. The richly vascularized intramedullary space allows for direct entry of drugs into the central circulation through emissary veins. The easiest insertion sites are the medial proximal tibia or the distal midline femur. Intraosseous infusion is a rapid and effective technique of achieving therapeutic serum concentrations of almost all important drugs; moreover, a large fluid volume can be rapidly administered in injured or dehydrated patients. The most common complication of this procedure is osteomyelitis.
Death in the Emergency Department
The sudden and unexpected death of an infant or child in the emergency department constitutes one of the most difficult situations in emergency practice. Chaplin and social services should be made available to aid in support to the family. Careful and compassionate dialogue between the physician and parents, and between the physician and emergency department staff, is essential to minimize chaos in the clinical setting and to reduce confusion and anger among bereaved families and department personnel. Provide the parents with a hospital contact should questions arise after their return home. Debriefing for health-care workers may also be appropriate within 48–72 hours to alleviate stress that may impair work performance or cause psychological disability.
1This chapter is a revision of the chapter by Eric Yazel, MD, & Sandra Herr, MD from the 6th edition.