Chapter 23. Emergency department management of children
Liz Gormley-Fleming, Julie Flaherty and E. Alan Glasper
LEARNING OUTCOMES
• Develop the specialist knowledge required to safely administer medicines to children.
• Understand how the triage process is operationalised in paediatric emergency departments.
• Explore how children presenting with fits are managed in emergency departments.
• Appreciate positive attributes of the environment of care in emergency departments in the overall care of children.
• Review pain management for children in emergency departments.
• Consider how the philosophy of family-centred care is promoted in emergency departments.
• Appreciate the role of paediatric emergency nurse practitioners.
The national picture
A 1997 report of national trends in the UK between 1979 and 1997 identified that in one year alone 459 children died as a result of accidents. Approximately 3.5 million children attend local A&E departments for their injuries each year and 10,000 children become permanently disabled every year. The cost to the NHS has been estimated at £100 million per annum; the personal cost is unquantifiable.
Since the inception of the NHS, medical care has been comprehensively provided for all. In the early 1960s the term ‘casualty’ became synonymous with that part of the NHS receiving and stabilising acutely ill and injured patients. The portal of entry into the hospital setting for the ill and injured was through the ‘casualty’ department. At the same time as the acutely ill and injured attended, those members of the public who felt their physical and mental health need required urgent medical attention took advantage of the casualty department’s ever open door.
In 1961, the Standing Medical Advisory Committee of Central Health Services undertook an investigation into NHS acute hospital arrangements for receiving and stabilisation of acutely ill and injured patients. The subsequent report for the first time formally recognised the concept of ‘casual attendees’ within the casualty department. Within the report, acknowledgement was given to the very skilful and important work undertaken in casualty departments. In recognition that this work should continue to develop, the concepts of ‘casualty’ and ‘casual attendees’ needed to be refocused and the term Accident and Emergency (A&E) department was created.
Many subsequent reports, including the Court report ‘Fit for the future’ (Department of Health and Social Services (DHSS) 1976), ‘Welfare of children and young people in hospital’ (Department of Health (DoH) 1991), ‘Children first. A study of hospital services’ (Audit Commission 1993) and ‘The patient’s charter – services for children and young people’ (DoH 1996), all advocated and determined recommendations and standards for health services, with specific reference to A&E services for children. Furthermore, there is now evidence that some of the recommendations of the many working groups are now taking shape, although slowly. Within the current climate of the modernising NHS (Department of Health (DoH), 2000 and Department of Health (DoH), 2004) there is now greater emphasis than ever on recognising and meeting the needs of families and children requiring A&E services.
There are currently many avenues to emergency services for children and young people. Importantly there are nine active children’s A&E departments in the UK. Alternatively, there are 259 other A&E departments accommodating health needs of all ages either in teaching or district general hospitals. The general A&E departments vary tremendously from integrated child and family services, audiovisual separation of adults and children to co-location of child and adult services.
In an average year, 50% of children under 1 year of age will attend an emergency department, and 25% of older children. Additionally, one in 11 children will be referred to a hospital outpatient department (NHS Confederation 2003). Additionally, an important change has occurred in the utilisation of emergency departments in recent years, with increasing numbers of children seeking hospital assessment, largely via self-referrals, but not requiring hospital admission (Boyle et al 2000).
Given the high profile that children have within an emergency department and Watson (2000) indicates that this client group makes up 30% of all attendees to emergency departments every year, it is not surprising to note that the National Service Framework (NSF) for children, young people and maternity services (DoH 2003) includes specific recommendations for accident and emergency departments. These include physical separation between children and adult areas within emergency departments and environments that are accessible, safe and suitable for babies, children and families.
Partridge (2001) has highlighted that children attending emergency departments have not generally been either treated or seen in separate facilities by registered children’s nurses. This situation will begin to change in light of the NSF recommendations, which will be audited by the Care Quality Commission. Furthermore, Partridge argues that nurses who work in emergency departments must recognise that the treatment of children and adults within the same space is fraught with difficulties. This sharing of facilities such as waiting rooms ensures that at least some children will be exposed unnecessarily to hostile sights and hostile sounds. It is, however, to be hoped that the token obligatory box of broken toys in a dark corner of the waiting room of some emergency departments, as described by Glasper (1995), is a thing of the past. However, nurse managers within emergency departments recognise these important aspects of care and are increasingly requiring registered nurses not holding a recognised children’s nursing qualification to undertake shortened child branch courses at local universities.
Scenario
ScenarioSheila Putman is 4 years and 6 months. She had a grand-mal convulsion in the school playground and sustained a laceration to the scalp, which bled profusely. She is dazed and confused after the convulsion, crying and asking for her mother. The teacher calls an ambulance and travels with Sheila to the local emergency department. Sheila’s mother is eventually located at her work address on the outskirts of the city. She arrives at the emergency department 30 minutes after Sheila’s arrival.
Transportation to the emergency department
By far the best way for critically ill and injured children to travel to hospital is by ambulance. However, parents and carers are often unaware of the severity of illness and injury that children suffer. Often because of their size, children are ‘scooped up’ and brought by people unaware of the risks they are taking escorting children in critical conditions by private car, public transport or taxi. Only 6% of children attend emergency departments by ambulance.
Taking this figure into account, it is important that A&E staff are aware that seriously ill and injured children often arrive in the emergency department ‘in arms’, and should receive early triage for this very reason. Conveying to the public the message about appropriate use of ambulances in urgent and emergency situations has been ongoing for years. There are, however, numerous accounts of situations when an ambulance has been called inappropriately by someone who has misjudged the situation. The nationally available NHS Direct telephone advice service is available for parents and carers (tel: 0845 46 47). The nurses can provide emergency advice about a child’s health status and mobilise an ambulance if necessary.
Ninety per cent of all children attending A&E do so between 8.00 a.m. and midnight; the remaining 10% attend between midnight and 8.00 a.m. The busiest period for children in A&E is between mid-day and 4.00 p.m., when over 55% children attend for unscheduled care; 80% of children with traumatic injury arrive between 4.00 p.m. and midnight.
MacFaul & Werneke (2001) conducted a study in which presenting problems were recorded in 842 admissions. Fifty-six per cent of children presented with one of three problems: breathing difficulty (25%), fit (16%), or feverish illness (15%). Feeding problems and diarrhoea together accounted for a further 21%. Seizures as a high cause of emergency admissions have come under considerable scrutiny by healthcare professionals working in such environments. The introduction of clinical guidelines (or care pathways) for the management of children presenting with fits in emergency departments is linked to improvements in the effectiveness of care delivery (Arnon et al 2004).
Activity
ActivityCritically review the Arnon et al (2004) paper. Access this online at: http://www.archdischild.com
Read the article by Watts et al (2003) and look at the Joanna Briggs Institute, Adelaide website. Access this at: http://www.joannabriggs.edu.au
What are fits, convulsions or seizures?
Many people in society suffer from fits, convulsions or seizures. One in 20 (5%) of all children will have a fit of some kind during childhood. About 1 in 200 (0.5%) children have epilepsy,
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i.e. a neurological condition in which the child has a predisposition to recurrent, unprovoked fits.
wwwThe following text is based on ‘About seizures’, a leaflet produced by the Royal Children’s Hospital Melbourne. Access the original document at:
Epileptic fits occur when there is a transient disarrangement of the electrical and chemical neurotransmitters in the brain, which results in brain cells discharging impulses in an abnormal fashion. This may create a temporary disturbance in the way the brain controls awareness and responsiveness, which commonly causes unusual sensations or abnormal movements and postures. What happens during a fit reflects what parts of the brain are involved.
There are many different types of fit. The following describes the classification of seizure types from the International League Against Epilepsy (ILAE). A major distinction that healthcare professionals try to make is between partial (focal) fits, where the abnormal activity arises in a localised part of the brain (usually on one side), and generalised fits, where epileptic activity begins all over the brain simultaneously.
Partial (focal) fits
Partial (focal) fits occur when the abnormal activity arises in a localised part of the brain, usually on one side, and consciousness may or may not be impaired. The manifestations of the seizure depend on the part of the brain involved with the abnormal electrical discharge. Partial fits are classified according to whether there is impairment of consciousness:
• Simple partial fits: arise in parts of the brain not responsible for maintaining consciousness, typically the movement or sensory areas. Consciousness is not impaired and the effects of the fit relate to the part of the brain involved. If the site of origin is the motor area of the brain, bodily movements may be abnormal (e.g. limp, stiff, jerking). If sensory areas of the brain are involved, the person may report experiences such as tingling or numbness, changes to what he or she sees, hears or smells, or very unusual feelings that may be hard to describe. Young children might have difficulty describing such sensations or may be frightened by these.
• Complex partial seizures: arise in parts of the brain responsible for maintaining awareness, responsiveness and memory – typically parts of the temporal and frontal lobes. Consciousness is lost and the person may appear dazed or unaware of his or her surroundings. Sometimes the person experiences a warning sensation, or aura, before losing awareness, essentially the simple partial phase of the fit. Behaviour during a complex partial fit relates to the site of origin and spread of the fit. Often, the person’s actions are clumsy and the individual will not respond normally to questions and commands. Behaviour may be confused and the person might exhibit automatic movements and behaviours, e.g. picking at clothing, picking up objects, chewing and swallowing, trying to stand or run, appearing afraid and struggling with restraint. Colour change, wetting and vomiting can occur in complex partial fits. Following the fit, the person may remain confused for a prolonged period and may not be able to speak, see, or hear if these parts of the brain were involved. The person has no memory of what occurred during the complex partial phase of the fit and often needs to sleep.
• Partial seizures becoming secondarily generalised: fits that begin as simple or complex partial seizures may progress due to a spread of epileptic activity all over one or both sides of the brain, leading to a secondary generalised seizure. This part of the fit looks like a generalised tonic clonic seizure.
Generalised seizures
Generalised fits occur when epileptic activity begins all over the brain simultaneously and consciousness is always impaired in generalised seizures:
• Tonic clonic fit: sometimes called a ‘grand mal’ fit: produces a sudden loss of consciousness, with the person commonly falling to the ground followed by stiffening (tonic) and then rhythmic jerking (clonic) of the muscles. Shallow or jerky breathing, bluish tinge of the skin and lips, drooling of saliva and often loss of bladder or bowel control generally occur. The seizures usually last a couple of minutes and normal breathing and consciousness then returns. The person is tired following the seizure and may be confused. There is no aura prior to a tonic clonic seizure.
• Absence fit: sometimes called a ‘petit mal’ fit: produces a brief cessation of activity and loss of consciousness, usually lasting 5–30 seconds. Often, the momentary blank stare is accompanied by subtle eye blinking and mouthing or chewing movements. Awareness returns quickly and the person continues with the previous activity. Falling and jerking do not occur in typical absences.
• Myoclonic fit: sudden and brief muscle contractions that may occur singly, repeatedly or continuously. They may involve the whole body in a massive jerk or spasm, or may only involve individual limbs or muscle groups. If they involve the arms, the person might drop or spill what he or she was holding. If they involve the legs or body, the person may fall.
• Tonic fit: characterised by generalised muscle stiffening, lasting 1–10 seconds. Associated features include increased pulse, brief cessation of breathing, flushed face, bluish skin discoloration and drooling. If a tonic seizure occurs suddenly while the person is awake, he or she may fall violently to the ground, causing injury. Tonic seizures often occur during sleep. Fortunately, tonic fits are rare and usually only occur in severe forms of epilepsy.
• Atonic fit: produces a sudden loss of muscle tone, which, if brief, may only involve the head dropping forward (‘head nods’), but may cause sudden collapse and falling (‘drop attacks’).
From these descriptions, it can be appreciated that the exact type of fit may be difficult for a witness to determine. For example, a fit with stopping and staring could be a complex partial seizure or an absence seizure. A large, convulsive fit (grand mal) may be a generalised tonic clonic fit, a myoclonic fit, a tonic fit or a partial fit that became secondarily generalised. A sudden fall to the ground (‘drop attack’) can occur with a myoclonic, a tonic or an atonic fit or a partial fit involving the movement areas. Determination of the exact type of fit is important and is obtained from patient and observer descriptions, home video recordings, and EEG testing and sometimes video EEG monitoring.
It is also important to remember that many episodic behaviours and disorders in children can mimic epilepsy, including breath-holding spells, normal sleep jerks, daydreaming, fainting, migraine, heart and gastrointestinal problems, and psychological problems.
Managing acute seizures and status epilepticus
ActivityThink about the management of a brief seizure by putting yourself into the position of witnessing a child, known to have epilepsy, who is having a seizure in school:
• What would you do?
• What would you not do?
wwwAdvice relating to seizure management can be readily found on the following websites:
• Epilepsy Action (British Epilepsy Association) search for seizure-first aid: http://www.epilepsy.org.uk
• National Society for Epilepsy search for first aid for epilepsy: http://www.epilepsynse.org.uk
Rapid treatment has the potential to minimise the morbidity and mortality associated with acute seizures and convulsive status epilepticus (Scott et al., 1998 and Scott and Neville, 1999). Although status epilepticus is described as a disorder in which epileptic activity, a seizure or series of seizures persists for 30 minutes or more, clinically, most seizures that do not stop spontaneously within 5 minutes progress for 30 minutes or more (Appleton et al., 2000, Scott et al., 1998 and Tasker, 1998). Seizure activity dramatically increases the brain’s demands for oxygen and glucose. After 30 minutes compensatory mechanisms fail, resulting in cerebral oedema, metabolic acidosis and circulatory collapse and an increasing risk of cerebral damage (Shovron 2001). Causes of acute seizures in children include:
• acute cerebral dysfunction:
• trauma
• infection
• tumours
• metabolic disturbances
• febrile seizures
• pre-existing epilepsy:
• drug withdrawal
• progression of underlying cause
• acute illness
• pre-existing neurological abnormality, e.g. cerebral palsy.
The aim of management is to control the seizure before cerebral damage and life-threatening sequelae occur (Scott et al., 1998 and Tasker, 1998). The neurological status should only be assessed after airway, breathing and circulation have been assessed and managed. Clear protocols with structured interventions are necessary to ensure prompt and consistent management of seizures and status epilepticus (Appleton et al., 2000, Scott and Neville, 1999, Shovron, 2001 and Tasker, 1998) (Table 23.1).
| BP, blood pressure; EEG, electroencephalogram; IV, intravenous. | ||
| Stage | Action | Rationale |
|---|---|---|
| Immediate assessment and stabilisation | Rapid cardiopulmonary assessment If necessary maintain and secure airway Give oxygen Monitor vital signs and pulse oximetry Confirmation/history of seizure/child’s past medical history | Recognise respiratory failure and shock Airway obstruction will compound hypoxia Ensure management is appropriate for the individual child |
| Immediate seizure control (5–10 minutes) | Administer first-line anticonvulsant: If IV access available, administer IV lorazepam If there is no venous access, administer either rectal diazepam or intramuscular midazolam or intramuscular paraldehyde Obtain IV or intraosseous access Obtain bloods for electrolytes and glucose Commence intravenous fluids. Repeat further IV dose of lorazepam if no response after 10 minutes Repeat cardiopulmonary assessment Prepare for intensive support | Lorazepam has longer duration of action compared with diazepam and lower risk of drug accumulation. It may be less effective in children taking regular benzodiazepine anticonvulsants Paraldehyde may result in abscess formation at injection site |
Second-stage treatment (15 minutes onwards) Intensive care management | If no response administer further anticonvulsants: Phenytoin infusion Intubate and ventilate, transfer to intensive care Ventilate, monitor pulse/BP/temperature/urine output, EEG Phenobarbitone infusion If no response consider IV bolus of midazolam or thiopentone | Phenytoin is effective within 10–30 minutes and has a long duration of action and may prevent recurrent seizures Phenobarbitone is effective but may take time to reach therapeutic levels and may cause lowering of the blood pressure Midazolam is water soluble and easy to administer, less irritant to veins and appears to be effective in stopping seizures that have been unresponsive to other drugs |
Children who have repeated episodes of convulsive epilepticus may need an adapted acute protocol to reflect their individual response to treatments and interactions with regular anticonvulsants (Scott and Neville, 1999 and Tasker, 1998). Individual protocols will require the inclusion of parental home treatment regimes.
Emergency care teams
Given that accidents are the foremost cause of death in children over 1 year of age, response to the care of the most seriously ill and injured children must be delivered speedily and following a professionally competent model backed up by the right facilities. A team approach allows critically ill and traumatised patients optimal chances for survival.
There has been a dramatic increase in the number of children attending hospital with head injuries in the last decade and this accounts for up to one-third of the incidence of accidental death in childhood. While there has been a marked improvement in the long-term outcome for children with traumatic brain injuries, there is an associated health impact for the child and their families (Parslow et al 2005). A systematic approach to the initial assessment and early management of head injuries is crucial to the long-term outcome (National Institute of Clinical Excellent (NICE) 2007).
The Royal College of Surgeons recommends that the emergency care team should include a team leader, usually the A&E consultant, a surgical consultant, a medical consultant, and an anaesthetic or intensivist consultant. Other team members will be registered nurses and allied health professionals (AHP); the numbers will vary but it has been suggested that the trauma team should include four senior doctors, five nurses and a radiographer. It was clearly stated in the National Confidential Enquiry into Perioperative Deaths (1989 p 7) that:
Consultants who take responsibility for the care of children … must be competent and must keep up to date in the management of children.
The Royal College of Paediatricians and Child Health stipulates that a nominated consultant anaesthetist, suitably trained in paediatric anaesthesia, should be responsible for children’s services. It is important to train the right team members, with the right skills and abilities; successful results in a trauma situation are determined by the training and abilities of the trauma team.
A paediatrician should be included in the emergency care team for seriously traumatised children. After initial resuscitation and stabilisation, children should be transferred to the care of paediatric surgeons in a specialist facility with paediatric intensive care back-up. More recently, a joint report from the Royal College of Surgeons and the British Orthopaedic Association (RCS/BOA 2000) recommended that:
Any hospital receiving and caring for the severely injured child must have on-site support from paediatricians and paediatric anaesthetists.
The Audit Commission (1993 p 48) highlights the fact that A&E departments do not always have or receive timely back-up from other specialists or allied health professionals to support diagnostic investigations. Further, the Audit Commission (1993 p 49) appraises a list of favourable specialists that should work synergistically with A&E services. Some specialty back-up seems obvious, such as anaesthesia, orthopaedics, general surgery and medicine. Support services that need to co-locate at A&E include critical care facilities, radiology, ultrasound, online CT scanner and 24-hour pathology services.
Disappointingly, the report ‘Better care for the seriously injured’ (RCS/BOA 2000) dedicates only one of 55 pages to the severely injured child. However, the report does acknowledge that there is a much higher frequency of serious head, chest and abdominal injuries in children than in adults. It berates less experienced doctors for their indecision and late intervention when managing a seriously injured child and is also the only report of all those mentioned above to relate and conclude that severely injured children present the greatest opportunity for organ salvage.
The Healthcare Commission 2009 identified that hospitals are still failing to provide adequate pain relief for children attending A&E Departments and that 74% of staff in emergency departments had not received basic training in resuscitation or in child protection. Staff working in emergency departments must be equipped with the appropriate skills and receive training to treat all children that attend the department.
Children’s nurses in emergency departments
The development of A&E nursing has been at the forefront of role extension within the UK and the development of a faculty of emergency nursing within the Royal College of Nursing (RCN) has allowed nurses working within the domain to agree and establish levels of clinical competencies (Endacott et al 1999). Bentley (1996) has defined role categories for children’s nurses who work in emergency departments, which include the development and use of protocols in the management of sick children. Despite this, Cleaver (2003) has highlighted the feelings of vulnerability experienced by children’s nurses who work in emergency departments, who are perceived by their adult/general nurse colleagues as being experts in the care of sick children. Cleaver’s study reveals that the children’s nurses themselves, having acquired and mastered new roles, move from feeling vulnerable to feeling frustrated when they are not allowed to develop autonomous practice. However the Emergency Nurse Practitioner is now becoming an established role in many Children’s A&E departments throughout the UK.
The environment in the A&E department
Often, the first point of contact or portal of entry to hospital is through the A&E department. The A&E department can be a distressing place, full of unfamiliar sights and sounds and little opportunity to prepare children for this experience (DoH 2003). Depending on their particular stage of cognitive development, children will interpret the situations into terms they can conceptualise. In turn, the child’s perceptions and experiences in the A&E or emergency room will affect future attendances; the right staff and the right environment can have a dramatic impact (Audit Commission 1993, Department of Health (DoH), 1991 and Department of Health (DOH), 2003).
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