PEDIATRIC EMERGENCIES

Rachel Tkaczyk

Overview

In 2010, the Centers for Disease Control and Prevention (CDC) database reported a total of 129.8 million emergency department visits in the United States. Of those visits, 25.5 million visits consisted of patients younger than 15 years, and an additional 20.7 million visits were patients between 15 and 24 years (Centers for Disease Control and Prevention, 2012). When it comes to the emergency room setting, there is no one universal definition as to what constitutes a “pediatric emergency.” Subsequently, levels of care and the associated acuity in the emergency setting often differ among various institutions. Despite varying definitions and management techniques, the approach to identifying, assessing, and treating a pediatric emergent situation must be systematic. To achieve successful outcomes, the medical staff must be equipped with the knowledge to appropriately recognize and treat all pediatric emergency scenarios.

Background

Pediatric patients, who accounted for 17.4% of the emergency room visits in 2010 in the United States, present unique challenges that can ultimately hinder an emergency room’s ability to provide the best possible care (Macias, 2013). Obtaining a complete history and performing a thorough assessment in the pediatric population can be accompanied by many unique challenges. Particularly in the emergency setting, the time constraint alone can elicit a sense of urgency that affects the overall quality of the patient intake and triage. This section explores several challenges that may be encountered during the evaluation and treatment of pediatric emergencies.

One identified difficulty when attempting to obtain an accurate history is the lack of an established rapport with the patient and his or her family. This can contribute to an incomplete, and often inadequate, extraction of critical information. Often the history taking is not given enough devoted time, and a therapeutic relationship is not established. This is problematic as the health history typically provides 85% of the information that is needed for the medical team to make a diagnosis (Reuter-Rice & Bolick, 2012). As stated earlier, another barrier is the element of time, and possibly the lack thereof. In the trauma scenario, resuscitation takes precedence over the acquisition of a health history. However, it is important to realize that this does not negate the significance of the health history. Rather it is necessary to recognize the limitation and employ strategies to overcome it (Reuter-Rice & Bolick, 2012).

There are several key elements of the pediatric emergent intake. Although obtaining a history is significant, another key element is the pediatric assessment and physical examination (Scott et al., 2014). Both components are used 93to answer the critical questions: Is there an immediate life threat? Regarding severity, where does the patient fall? Will the patient need admission? What evidence supports the providers’ differential diagnoses? In summary, the goal of assessing the pediatric patient in the emergent setting is to determine the severity of the situation and whether treatment is indicated. Often, this requires the initial assessment but also reassessment. When it comes to the overall treatment of a seriously ill or injured child, the goal is to provide a systematic approach that is consistent across all institutions. The recommended model for all pediatric life support courses consists of the general assessment, secondary assessment, and tertiary assessment (American Heart Association, 2015).

For example, in the case of a pediatric patient who presents with concern for sepsis, four physical examination signs are recommended for early detection of pediatric septic shock, before hypotension occurs. They include alteration in mental status, decreased capillary refill, cold extremities, and peripheral pulse quality (Scott et al., 2014). These changes can be subtle, particularly with the provider who does not have an established baseline for a patient as a primary care provider may have had (Reuter-Rice & Bolick, 2012). Research has shown that several barriers to this practice of frequent reassessment exist and include a lack of time, increased workload, and at times a lack of nursing knowledge specific to the situation (Pretorius, Searle, & Marshall, 2015). This again reinforces the need to provide a systematic and standardized approach to the assessment of the pediatric patient. With those skills, the medical team is equipped with the tools to recognize signs of impending respiratory distress, failure, and shock. Without the ability to assess and intervene quickly, pediatric patients are at greater risk and can progress to cardiopulmonary failure, which can lead to an arrest (AHA, 2015).

Clinical Aspects

ASSESSMENT

To meet the need for high-quality care in this population, several health care systems have integrated quality improvement methods to improve access, safety, and ultimately better the care delivered to this patient population (Macias, 2013). As discussed, one of the barriers to obtaining a thorough history from the beginning of the medical course is the lack of a developed therapeutic relationship with the patient and family. The American Academy of Pediatrics (AAP) and the American College of Emergency Physicians (ACEP) continually recognize the patient and family as significant decision makers in the patient’s overall care. Patient- and family-centered care is a method of health care that recognizes the essential role of the patient and family. The goal is to focus and implement collaboration among the patient, family, and medical professionals (AAP Committee on Pediatric Emergency Medicine & ACE Physicians Pediatric Emergency Medicine Committee, 2006).

94NURSING INTERVENTIONS, MANAGEMENT, AND IMPLICATIONS

The AAP and ACEP have issued several recommendations to improve the patient and medical team therapeutic relationship, which comes with its emergency room specific challenges. They continue to reinforce the necessity to validate a family and patient’s concerns. Family members should be given the option to be present for all aspects of their child’s care while in the emergency room. It is also essential that information is provided to the family during all interventions, regardless of the family’s decision to be present or not (AAP Committee on Pediatric Emergency Medicine & ACE Physicians Pediatric Emergency Medicine Committee, 2006).

OUTCOMES

In addition to information gathering, one of the key elements to improved outcomes in the pediatric emergency setting is early recognition and intervention. As stated previously, the sense of urgency and time constraint, increased work load, and inadequate knowledge can contribute to poor outcomes. The objective observation was recently studied to assess strengths and weaknesses during a pediatric resuscitation. The overall goal was to assess how well the medical providers in a pediatric emergency room adhered to cardiopulmonary resuscitation (CPR) guidelines during a resuscitation. During this study, 33 children received CPR under video recording. The results demonstrated appropriate compression rate, duration of pauses, and compression depth. It did show that there tended to be hyperventilation as well as the inability to coordinate the compression–ventilation ratio during the resuscitation. The overall recommendations included various training modalities for CPR among staff and evaluation of its effectiveness (Donoghue et al., 2015). This particular study is only one example of how a pediatric institution implemented a quality initiative to assess potential limitations and areas that required additional education. It demonstrates an overall approach to identify barriers to care, assess any shortcomings, and ultimately provide education to correct and improve certain practices.

Summary

The pediatric population is unique in many aspects when compared to the adult population, particularly in the emergency care setting. There are several challenges that the medical team faces, beginning from the moment the patient enters into their care and extends throughout treatment. Several strategies can be used to overcome those challenges and provide optimal care. It is of paramount importance that the medical team identifies any barriers to obtaining a thorough history and performing an in-depth assessment. Continued focus on ever evolving education is also essential. With a consistent and systematic approach to pediatric emergency care, outcomes continue to improve.

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