The Pediatric Education for Prehospital Professionals Course and the Pediatric Assessment Triangle: A 25-Year Retrospective.

The American Academy of Pediatrics established the Pediatric Education for Prehospital Professionals (PEPP) Course in 1998. A national PEPP Task Force rolled out the first courses in 2000, and PEPP rapidly became a foundational pediatric knowledge source in prehospital education. The backbone of the PEPP course is the pediatric assessment triangle (PAT), a simple assessment tool to help determine if an infant or child is "sick" or "not sick", to identify the likely type of pathophysiology, and to gauge the urgency for intervention. The PAT has been validated in multiple studies as a reliable tool for emergency triage and for guiding initial management of children in both prehospital and emergency settings. Over 400,000 emergency medical services clinicians have taken the PEPP course, and the PAT has been integrated into life support courses, emergency pediatrics training, and pediatric assessment protocols worldwide. We describe the creation and successful implementation of the first national prehospital pediatric emergency care course, including the integration and widespread dissemination of an innovative assessment paradigm for pediatric emergency care education and training.

Outpatient Treatment of Lyme Disease.

ABSTRACT: Lyme disease, also called Lyme borreliosis, is caused by the spirochete Borrelia burgdorferi sensu stricto (B burgdorferi) in the Upper Atlantic Coast and Borrelia mayonii in the Upper Midwest and West Coast. It can cause a range of manifestations including erythema migrans, cranial nerve palsies, meningitis, carditis, and arthritis. Recent guidelines advocate for outpatient treatment for many of these conditions. Scenarios will be presented that outline treatment of these manifestations.

Tick-Borne Infections.

ABSTRACT: There are many tick-borne infections that affect children and adolescents in the United States. These illnesses often begin with non-specific flulike symptoms such as fever, chills, headache, and myalgia, so obtaining a good travel history is important. Most people do not even realize that they were bitten by a tick, so identification of the specific tick is not necessary. Often, treatment should commence before formal illness identification, as delays may cause more severe disease, and rapid laboratory confirmation is difficult. One of the most important issues is prevention of tick bites with insect repellents, accompanied by thorough tick checks after being outdoors in a tick-infested region.

Tourniquets in Major Extremity Trauma.

Much has been learned about hemorrhage control using tourniquets from wartime experiences, and recent mass casualty events. The use of tourniquets for extremity hemorrhage is a lifesaving skill for all providers to learn.

Gastrostomy Tubes: Care and Feeding.

Parents often bring their children to the emergency department for adverse events with their child's gastrostomy tube or button. This review will discuss the possible complications and the methods to handle them.

An Evidence-based Guideline for Pediatric Prehospital Seizure Management Using GRADE Methodology.

OBJECTIVE: The objective of this guideline is to recommend evidence-based practices for timely prehospital pediatric seizure cessation while avoiding respiratory depression and seizure recurrence. METHODS: A multidisciplinary panel was chosen based on expertise in pediatric emergency medicine, prehospital medicine, and/or evidence-based guideline development. The panel followed the National Prehospital EBG Model using the GRADE methodology to formulate questions, retrieve evidence, appraise the evidence, and formulate recommendations. The panel members initially searched the literature in 2009 and updated their searches in 2012. The panel finalized a draft of a patient care algorithm in 2012 that was presented to stakeholder organizations to gather feedback for necessary revisions. RESULTS: Five strong and ten weak recommendations emerged from the process; all but one was supported by low or very low quality evidence. The panel sought to ensure that the recommendations promoted timely seizure cessation while avoiding respiratory depression and seizure recurrence. The panel recommended that all patients in an active seizure have capillary blood glucose checked and be treated with intravenous (IV) dextrose or intramuscular (IM) glucagon if <60 mg/dL (3 mmol/L). The panel also recommended that non-IV routes (buccal, IM, or intranasal) of benzodiazepines (0.2 mg/kg) be used as first-line therapy for status epilepticus, rather than the rectal route. CONCLUSIONS: Using GRADE methodology, we have developed a pediatric seizure guideline that emphasizes the role of capillary blood glucometry and the use of buccal, IM, or intranasal benzodiazepines over IV or rectal routes. Future research is needed to compare the effectiveness and safety of these medication routes.

Creation and Delphi-method refinement of pediatric disaster triage simulations.

OBJECTIVE: There is a need for rigorously designed pediatric disaster triage (PDT) training simulations for paramedics. First, we sought to design three multiple patient incidents for EMS provider training simulations. Our second objective was to determine the appropriate interventions and triage level for each victim in each of the simulations and develop evaluation instruments for each simulation. The final objective was to ensure that each simulation and evaluation tool was free of bias toward any specific PDT strategy. METHODS: We created mixed-methods disaster simulation scenarios with pediatric victims: a school shooting, a school bus crash, and a multiple-victim house fire. Standardized patients, high-fidelity manikins, and low-fidelity manikins were used to portray the victims. Each simulation had similar acuity of injuries and 10 victims. Examples include children with special health-care needs, gunshot wounds, and smoke inhalation. Checklist-based evaluation tools and behaviorally anchored global assessments of function were created for each simulation. Eight physicians and paramedics from areas with differing PDT strategies were recruited as Subject Matter Experts (SMEs) for a modified Delphi iterative critique of the simulations and evaluation tools. The modified Delphi was managed with an online survey tool. The SMEs provided an expected triage category for each patient. The target for modified Delphi consensus was ≥85%. Using Likert scales and free text, the SMEs assessed the validity of the simulations, including instances of bias toward a specific PDT strategy, clarity of learning objectives, and the correlation of the evaluation tools to the learning objectives and scenarios. RESULTS: After two rounds of the modified Delphi, consensus for expected triage level was >85% for 28 of 30 victims, with the remaining two achieving >85% consensus after three Delphi iterations. To achieve consensus, we amended 11 instances of bias toward a specific PDT strategy and corrected 10 instances of noncorrelation between evaluations and simulation. CONCLUSIONS: The modified Delphi process, used to derive novel PDT simulation and evaluation tools, yielded a high degree of consensus among the SMEs, and eliminated biases toward specific PDT strategies in the evaluations. The simulations and evaluation tools may now be tested for reliability and validity as part of a prehospital PDT curriculum.

Characteristics of the pediatric patients treated by the Pediatric Emergency Care Applied Research Network's affiliated EMS agencies.

OBJECTIVE: To describe pediatric patients transported by the Pediatric Emergency Care Applied Research Network's (PECARN's) affiliated emergency medical service (EMS) agencies and the process of submitting and aggregating data from diverse agencies. METHODS: We conducted a retrospective analysis of electronic patient care data from PECARN's partner EMS agencies. Data were collected on all EMS runs for patients less than 19 years old treated between 2004 and 2006. We conducted analyses only for variables with usable data submitted by a majority of participating agencies. The investigators aggregated data between study sites by recoding it into categories and then summarized it using descriptive statistics. RESULTS: Sixteen EMS agencies agreed to participate. Fourteen agencies (88%) across 11 states were able to submit patient data. Two of these agencies were helicopter agencies (HEMS). Mean time to data submission was 378 days (SD 175). For the 12 ground EMS agencies that submitted data, there were 514,880 transports, with a mean patient age of 9.6 years (SD 6.4); 53% were male, and 48% were treated by advanced life support (ALS) providers. Twenty-two variables were aggregated and analyzed, but not all agencies were able to submit all analyzed variables and for most variables there were missing data. Based on the available data, median response time was 6 minutes (IQR: 4-9), scene time 15 minutes (IQR: 11-21), and transport time 9 minutes (IQR: 6-13). The most common chief complaints were traumatic injury (28%), general illness (10%), and respiratory distress (9%). Vascular access was obtained for 14% of patients, 3% received asthma medication, <1% pain medication, <1% assisted ventilation, <1% seizure medication, <1% an advanced airway, and <1% CPR. Respiratory rate, pulse, systolic blood pressure, and GCS were categorized by age and the majority of children were in the normal range except for systolic blood pressure in those under one year old. CONCLUSIONS: Despite advances in data definitions and increased use of electronic databases nationally, data aggregation across EMS agencies was challenging, in part due to variable data collection methods and missing data. In our sample, only a small proportion of pediatric EMS patients required prehospital medications or interventions.

Access to Critical Health Information for Children During Emergencies: Emergency Information Forms and Beyond.

ABSTRACT: Children with chronic medical conditions rely on complex management plans for problems that cause them to be at increased risk for suboptimal outcomes in emergency situations. The emergency information form (EIF) is a medical summary that provides rapid access to critical information to physicians and other members of the health care team so that optimal emergency medical care can be provided. This statement describes an updated approach to EIFs and the information they contain. Essential common data elements are reviewed, integration with electronic health records is discussed, and broadening the rapid availability and use of health data for all children and youth is proposed. A broader approach to data accessibility and use could extend the benefits of rapid access to critical information for all children receiving emergency care as well as further facilitating emergency preparedness during disaster management.

Current variability of clinical practice management of pediatric diabetic ketoacidosis in Illinois pediatric emergency departments.

OBJECTIVE: This study aimed to investigate the management of pediatric patients with diabetic ketoacidosis (DKA) presenting to emergency departments (EDs) participating in the Illinois Emergency Medical Services for Children (EMSC) Facility Recognition program. METHODS: In 2010, Illinois EMSC conducted a survey (including case scenarios) and medical record review regarding management of pediatric patients with DKA. Data were submitted by 116 EDs. RESULTS: Survey response rate was 94%. Only 34% of EDs had a documented DKA guideline/policy; 37% reported that they did not have hospital adult or pediatric endocrinology services. Case scenarios identified a high percentage of respondents given an intravenous (IV) isotonic sodium chloride solution of 10 to 20 mL/kg during the first hour. However 17% to 21% would use an alternative choice such as administering initial IV solution of 0.45 sodium chloride, initiating an insulin drip before fluids, or waiting for more laboratory results before giving fluids or insulin. A total of 532 medical record reviews were submitted. In 87% of records, patients received an initial IV isotonic sodium chloride solution within the first hour. In 74%, patients received IV insulin infusion/drip (0.1 U/kg/h) after the initial fluid bolus. Of the patients, 51% were transferred to another facility; 22% were admitted to an intensive care unit. CONCLUSIONS: Best ED practice management of pediatric DKA includes establishing a specific guideline/protocol and ensuring access to a pediatric endocrinologist. Both were identified as improvement areas in this project. Illinois EMSC has developed an educational module and provided direct feedback to all participating EDs, to improve their management of pediatric patients with DKA.

Guidance for Cardiopulmonary Resuscitation of Children With Suspected or Confirmed COVID-19.

This article aims to provide guidance to health care workers for the provision of basic and advanced life support to children and neonates with suspected or confirmed coronavirus disease 2019 (COVID-19). It aligns with the 2020 American Heart Association Guidelines for Cardiopulmonary Resuscitation (CPR) and Emergency Cardiovascular care while providing strategies for reducing risk of transmission of severe acute respiratory syndrome coronavirus 2 to health care providers. Patients with suspected or confirmed COVID-19 and cardiac arrest should receive chest compressions and defibrillation, when indicated, as soon as possible. Because of the importance of ventilation during pediatric and neonatal resuscitation, oxygenation and ventilation should be prioritized. All CPR events should therefore be considered aerosol-generating procedures. Thus, personal protective equipment (PPE) appropriate for aerosol-generating procedures (including N95 respirators or an equivalent) should be donned before resuscitation, and high-efficiency particulate air filters should be used. Any personnel without appropriate PPE should be immediately excused by providers wearing appropriate PPE. Neonatal resuscitation guidance is unchanged from standard algorithms, except for specific attention to infection prevention and control. In summary, health care personnel should continue to reduce the risk of severe acute respiratory syndrome coronavirus 2 transmission through vaccination and use of appropriate PPE during pediatric resuscitations. Health care organizations should ensure the availability and appropriate use of PPE. Because delays or withheld CPR increases the risk to patients for poor clinical outcomes, children and neonates with suspected or confirmed COVID-19 should receive prompt, high-quality CPR in accordance with evidence-based guidelines.

The Origins and Evolution of Emergency Medical Services for Children.

The emergency medical services for children (EMSC) program was established in 1984 to improve the quality of emergency care for children. Since that time, all 50 states and Washington, DC, 5 US territories, and 3 freely associated states have received federal funding to achieve this goal. There have been many unique training and education programs developed, along with quality improvement and pediatric research initiatives. This article provides a history of the EMSC program and its accomplishments. [Pediatr Ann. 2021;50(4):e150-e154.].

A statewide model program to improve emergency department readiness for pediatric care.

Pediatric emergency patients have unique needs, requiring specialized personnel, training, equipment, supplies, and medications. Deficiencies in these areas have resulted in historically poorer outcomes for pediatric patients versus adults. Since 1985, federally funded Emergency Medical Services for Children (EMSC) programs in each state have been working to improve the quality of pediatric emergency care. The Health Resources and Services Administration now requires that all EMSC grantees report on specific performance measures. This includes implementation of a standardized system recognizing hospitals that are able to stabilize or manage pediatric medical emergencies and trauma cases. We describe the steps involved in implementing Illinois' 3-level facility recognition process to illustrate a model that other states might use to provide appropriate pediatric care and comply with new Health Resources and Services Administration performance measures.

Cardiopulmonary resuscitation and pediatric advanced life support update for the emergency physician.

Although pediatric cardiopulmonary arrest is uncommon, out-of-hospital survival is dismal. Through international consensus conferences, the American Heart Association develops new treatment recommendations for cardiopulmonary resuscitation every few years. The recent changes in cardiopulmonary resuscitation and pediatric advanced life support, with some background information about these changes, will be reviewed.

Advocating for Life Support Training of Children, Parents, Caregivers, School Personnel, and the Public.

Pediatric cardiac arrest in the out-of-hospital setting is a traumatic event for family, friends, caregivers, classmates, and school personnel. Immediate bystander cardiopulmonary resuscitation and the use of automatic external defibrillators have been shown to improve survival in adults. There is some evidence to show improved survival in children who receive immediate bystander cardiopulmonary resuscitation. Pediatricians, in their role as advocates to improve the health of all children, are uniquely positioned to strongly encourage the training of children, parents, caregivers, school personnel, and the lay public in the provision of basic life support, including pediatric basic life support, as well as the appropriate use of automated external defibrillators.

Advocating for Life Support Training of Children, Parents, Caregivers, School Personnel, and the Public.

Out-of-hospital cardiac arrest occurs frequently among people of all ages, including more than 6000 children annually. Pediatric cardiac arrest in the out-of-hospital setting is a stressful event for family, friends, caregivers, classmates, school personnel, and witnesses. Immediate bystander cardiopulmonary resuscitation and the use of automated external defibrillators are associated with improved survival in adults. There is some evidence in which improved survival in children who receive immediate bystander cardiopulmonary resuscitation is shown. Pediatricians, in their role as advocates to improve the health of all children, are uniquely positioned to strongly encourage the training of children, parents, caregivers, school personnel, and the lay public in the provision of basic life support, including pediatric basic life support, as well as the appropriate use of automated external defibrillators.

Definitions and Assessment Approaches for Emergency Medical Services for Children.

Pediatric Life Support (PLS) courses and instructional programs are educational tools developed to teach resuscitation and stabilization of children who are critically ill or injured. A number of PLS courses have been developed by national professional organizations for different health care providers (eg, pediatricians, emergency physicians, other physicians, prehospital professionals, pediatric and emergency advanced practice nurses, physician assistants). PLS courses and programs have attempted to clarify and standardize assessment and treatment approaches for clinical practice in emergency, trauma, and critical care. Although the effectiveness of PLS education has not yet been scientifically validated, the courses and programs have significantly expanded pediatric resuscitation training throughout the United States and internationally. Variability in terminology and in assessment components used in education and training among PLS courses has the potential to create confusion among target groups and in how experts train educators and learners to teach and practice pediatric emergency, trauma, and critical care. It is critical that all educators use standard terminology and patient assessment to address potential or actual conflicts regarding patient evaluation and treatment. This article provides a consensus of several organizations as to the proper order and terminology for pediatric patient assessment. The Supplemental Information provides definitions for terms and nomenclature used in pediatric resuscitation and life support courses.