South Suburban EMS Education Corporation 12901 S Marquette Avenue Chicago, IL 60633 www.ssemse.net Continuing Education Self-Study Packet Shakes, Rattles, & Rolls: Pediatric Medical & Traumatic Emergencies This packet contains materials needed to complete 2 hours of continuing education. Please review the required materials, case studies, and attachments. After reviewing the materials, complete the attached quiz. You must score 80% or higher to obtain credit for this module. Materials: Introduction Pediatric Patient ABCs: 7 Tips for EMTs and Paramedics Pediatric Physical Abuse: 4 Tips to Recognize it During the Physical Exam The Young Airway: Prehospital Assessment & Management of Pediatric Respiratory Distress Overview of Pediatric Emergency Department Visits, 2015 Quiz
Transcript
South Suburban EMS Education Corporation12901 S Marquette Avenue
Chicago, IL 60633www.ssemse.net
Continuing Education Self-Study Packet
Shakes, Rattles, & Rolls: Pediatric Medical & Traumatic Emergencies
This packet contains materials needed to complete 2 hours of continuing education. Please review therequired materials, case studies, and attachments. After reviewing the materials, complete the attached quiz.You must score 80% or higher to obtain credit for this module.
Materials:
Introduction
Pediatric Patient ABCs: 7 Tips for EMTs and Paramedics
Pediatric Physical Abuse: 4 Tips to Recognize it During the Physical Exam
The Young Airway: Prehospital Assessment & Management of Pediatric Respiratory Distress
Overview of Pediatric Emergency Department Visits, 2015
Quiz
South Suburban EMS Education Corporation12901 S Marquette Avenue
Chicago, IL 60633www.ssemse.net
Introduction
Pediatric EMS calls are a low-frequency, high-acuity event for most care providers. As such, it is pertinent forEMTs and Paramedics to continuously review and practice assessment techniques and treatments forcommon medical and traumatic emergencies. The following articles highlight several important topics for EMSproviders.
In this pre-course module, the EMS provider will review pediatric assessment, signs of child abuse, pediatricairway management, and the most common causes of pediatric emergency room visits.
At the end of this packet is a quiz. Please fill out and turn in the quiz to your proctor in order to receivecontinuing education credit.
Lights & Sirens
with Kevin Grange
Pediatric patient ABCs: 7 tips for EMTs andparamedicsFollow these steps to facilitate a successful outcome for dealing with emergencies involving kids
Mar 7, 2016
Updated Dec. 28, 2017
Sick or injured pediatric patients are notorious for showing vague changes in their mental statusand vital signs, only to suddenly deteriorate and become critical.
"With kids, you need to start at death and work backwards," my paramedic school teacher taught."If you’re not two steps ahead, you’re eight steps behind."
Always have a card, guide, or app with pediatric vital signs and drug dosages.
Suspect physical abuse of a child when there is a mismatch between the reported mechanism ofinjury, patient history and the physical exam findings
When you’re called to help a pediatric patient whose life hangs in a critical balance betweencompensated and decompensated, here are seven ways to help save a pediatric patient.
1. Acknowledge anatomical differences
You should avoid thinking of pediatric patients as little adults and instead understand theiranatomical differences. For example, a child’s head is larger in proportion to their body than anadult, which makes them more susceptible to trauma, especially after a fall. Children also haveless blood and are, therefore, in greater danger of developing shock or bleeding to death from awound.
Children have larger tongues and smaller airways with more soft tissue, making them moresusceptible to foreign body and airway obstructions. The temperature control mechanism onpediatric patients is also unstable and they dehydrate easier. The first sign of shock is often arapid heart rate and irritability, a drop in blood pressure is a late, ominous sign, and cardiac arrestis usually secondary to respiratory failure causing respiratory arrest.
2. Use the pediatric assessment triangle
You should be able to form your general impression of the child from the door and determine ifthe child is sick or not sick. Before you approach the patient, take a moment to look at theirABCs — appearance, breathing and circulation — from across the room.
Is the child alert, agitated, sleepy or unresponsive in regards to their appearance? Is their airway open? How is their work of breathing? Do you hear any sounds from them breathing? What is their respiratory rate? Do you see an accessory muscle use? What is the skin color and condition?
This set of visual vital signs should give immediate clues about the need for rapid treatment andtransport to the hospital.
3. Attack the chief complaint
Since pediatric patients often can’t vocalize their chief complaint — or give a detailed history oftheir present illness or injury — don’t fall into the trap of walking into the room and delayingyour primary assessment to get the full story from mom or dad. If you obtain OPQRST andSAMPLE histories first, precious time can pass before you even begin to assess the patient.
Instead, walk into the room, quickly determine the chief complaint and attack it by immediatelyperforming an assessment of the child’s airway, breathing, circulation and treating any lifethreats. Once the child is stable, move on to the secondary assessment to find out what happened,the child’s medical history and vital signs.
4. Pay attention to the parents
Many parents seem to have an intuitive sense about their child’s health. When a mom or dad saysa vague phrase like, "My baby just isn’t acting right," or "Something’s very wrong with mychild," your index of suspicion should raise and it’s time to immediately find out exactly whatthe parent is noticing.
Conversely, I’ve also run numerous calls for a pediatric patient who "overdosed" or who is"altered," only to find the child is perfectly fine and the mother or father is drunk or on drugs. Inthese sad cases, the parents were so altered they thought their babies had stopped breathing orswallowed the pills, so we immediately called the police and child protective services to look outfor the kids.
When you run a pediatric call, always keep your eyes open for neglect or abuse, such as bruisesin multiple stages of healing or burns that present in the pattern of a splash or cigarette. It is up toyou to be the child’s advocate. We don’t assume it is child abuse, but we assume it could be.
5. Make your job easier
Like many emergency departments — or pilots preparing for a departure or dealing with an in-flight emergency — I am a big fan of using checklists and reference charts to deal with anemergency.
The vital signs for pediatric patients change from 0-6 months, 6-12 months, 1-3 years, 3-5 years,6-10 years and from 11-14 years. Trying to remember all the correct numbers for an age-appropriate heart rate, respiratory rate and blood pressure on a stressful call is simply too much.
Instead, keep a pediatric vital sign reference card in your pocket, clipboard or smartphone, anduse the Broselow Pediatric Emergency Tape which lists correct vital signs, drug dosages andequipment sizes.
When you use these resources on-scene, you are less likely to make critical errors and youpresent to the parents as an EMT or paramedic that is diligent, professional and methodical.
6. Know childhood development by age
On a pediatric emergency, we can’t always get a good history from the patient or parent but, byknowing the characteristics and behaviors of childhood development by age, you can figure outwhat constitutes an altered patient, what the chief complaint might be and how to best handle it.
Infants (0-12 months) generally respond to the voice or face of their parents, like to beheld by caregivers and crying can indicate pain, discomfort or hunger.
Toddlers (1-3 years) are curious and, therefore, more apt to have an ingestion emergencyor foreign body airway obstruction. Toddlers fear separation from their parents, so givingthem a stuffed animal and allowing them to sit on their parents lap might help build trust.
Preschoolers (3-5 years) can talk with simple words, but often can’t understand what’shappening and are scared by the sight of blood, so it’s important to bandage even thesimplest cuts and give constant reassurance.
School-aged kids (6-12 years) can generally answer questions and follow the guidance ofEMS providers but have very vivid imaginations, especially about death, and might needconstant reminders that they’ll be okay.
Adolescents (13-18 years) can provide accurate information but fear permanent scaringwith trauma, feel modesty is very important to them, and can get caught up in the hysteriaof a 911 call, so it’s important to be well versed in a variety of calming measures.
7. Competence breeds confidence
Most EMS providers don’t run many pediatric emergency calls so it’s imperative to keep yourskills and knowledge base up by running scenarios with your agency, reading articles and takingclasses such as Pediatric Advanced Life Support and Emergency Pediatric Care.
Then, when you respond to a pediatric emergency, you’ll find yourself better prepared to dealwith an emergency. Competence breeds confidence and confidence breeds competence.
Pediatric physical abuse: 4 tips to recognize itduring the physical examSuspect physical abuse of a child when there is a mismatch between the reported mechanism ofinjury, patient history and the physical exam findings
Oct 15, 2015
By Ben Neal
Pediatric patients can be the most mentally stressful and complex patients we encounter on adaily basis. Emotions during these cases are at times hard to control, especially in the case of adeath or traumatic injury. However, what about apparently benign calls for what seems to be aminor complaint? While the patient may not be able to articulate where they hurt or exactly whathappened, our index of suspicion should always be high and a thorough physical assessmentshould follow — you never know what it may reveal.
The hard truth
Bruising consistent with abuse. (Photo courtesy ofUniversity of Louisville, Kosair Charities Division of Pediatric Forensic Medicine)
In 2013 there were 678,932 reported victims of child abuse and neglect reported in the UnitedStates. This is 9.1 victims for every 1,000 children in the population and accounted for 1,484child fatalities [1]. Emergency medical professionals are often the first medical contact for thesepatients and our findings can be the best opportunity to identify abuse or neglect and protect thechild, as in most cases, child abuse does not stop on its own — it only escalates.
1. TEN-4, good buddy!
The TEN-4 rule of pediatric bruising, introduced by Pierce, Kaczor et al. has proved to behelpful in the identification of potential child abuse [2]. The TEN-4 rule, or TEN-4 BCDR (bodyregion and age based bruising clinical decision rule).
TEN stands for torso, ears and neck — the body regions that, if bruised, were found to bepredictive of abuse in patients less than 4 years old. These areas of the anatomy are not easilybruised in the everyday activities of a top-heavy toddler. Children this age are more apt tobruising on their heads, knees and arms from falls or playful injuries. Furthermore, any childwho is not "cruising" (normally less than 4-months-old, dependent on developmental status)should never have bruising in any anatomic region [2]. Bruising on the torso, ears or neck in achild less than 4 years old or any bruising in an infant 4 months old or less, can be predictive ofabuse.
2. Recognizing pattern injuries
Pattern injuries may be one of the easiest to spot while performing an assessment and are oftenaccompanied by an inconsistent history from the caregiver or parent. However, detecting theseinjuries requires a complete physical assessment, as many times, the child's clothing may hideclues. The simple act of removing a garment to fully inspect the skin may reveal previouslyconcealed findings. Some examples of these injuries may be a handprint from a slap, a circularburn from a lit cigarette or cigar or even a small hole from a belt lash. Sadly, the mechanisms inwhich abuse occurs are quite endless, thus we must always be aware during our encounters andmaintain a high index of suspicion.
3. Abusive head trauma
Abusive head trauma (AHT), or previously called "shaken baby syndrome" occurs when a childis forcefully shaken or experiences an impact to the head in a manner that is so violent that itruptures blood vessels within the skull, causing intracranial hemorrhage. Patients who experienceAHT often develop severe brain damage with accompanying neurological disorders, andapproximately 25 percent do not survive [3].
Discoveries indicative of AHT may be subtle initially, such as mild lethargy, vomiting withoutdiarrhea and subconjunctival hemorrhages. More ominous signs and symptoms can range fromseizures, unconsciousness or cardiac arrest and can frequently have physical findings such as ribfractures from the violent circumferential grasp of the child, unequal pupils and Battle’s sign.
4. Burn patterns
While children, specifically toddlers that are beginning their "cruising" phase of development,are prone to accidents such as falls and scrapes, burns are a type of injury that shouldimmediately raise suspicions for potential abuse. Obtain a thorough history of how the injuryoccurred and mentally put together the "could that mechanism cause this injury" puzzle. Forexample, could a 1-month-old roll over on to a hot curling iron that was lying near the baby on abed? What is the likelihood that a 4-year-old would have multiple accidents that caused quarterinch diameter burns on their arms and legs?
As patient history and mechanism of injury information is obtained, dig into the injury itself andthink, "Does this injury physically match this mechanism?" For example hot water immersionburns are often easy to spot, as they are not only severe, but look just as you would expect with achild being held by the shoulders and being placed into hot water. You will ordinarily observeburns on the buttocks, genitals, feet and posterior legs, as well as potentially the hands and arms,as the child attempts to fight away from the water.
Mandatory reporter
Encountering an abused child can be quite overwhelming and daunting in some cases, whichcalls for great composure and restraint in how to handle the situation. As medical professionals,we must always be aware for the potential of intentional physical injury when assessing ouryoung patient population. In doing so, utilizing these tips in conjunction with a thorough physicalexam — a complete skin inspection — and a comprehensive history of the injury andmeticulously documenting those findings in our care reports, be the difference between life anddeath. Catching the subtle signs early can potentially prohibit the abuse from escalating to whatcould cause the tragic loss of young and innocent life.
Finally, remember your obligation as a mandatory reporter. Follow your local protocols andpolicy to document and report known or suspected abuse.
The Young Airway: Prehospital assessment &management of pediatric respiratory distressSat, May 31, 2008By Michael F. Murphy, MD, FRCPCMichael F. Murphy, MDMichael Keller, REMT-PRobert Luten, MDColby J. Rowe, EMT-P, FP-C, CICMary Beth Skarote, REMT-P
Case presentation
A 12-year-old male is accidentally shot in the face by a friend with a 410 shotgun at a distance ofabout 5 yards. His friend assists him in walking about a half mile out of the woods and summons9-1-1. The location is rural, with a 20-minute response time and a 30-minute travel time to ahospital. Air transport is not possible due to fog and rain.
When you arrive on scene, the patient is alert, talking and anxious (see photo). He's experiencingincreasing difficulty swallowing. His initial vital signs include a pulse of 120, a blood pressure of160/90, a respiratory rate of 24, and an oxygen saturation of 97% on room air. There's no stridor,and his voice is normal. A non-rebreather mask is applied, and his oxygen saturation increases to100%.
His face is peppered with buckshot entry wounds on the left side, and there's a moderate degreeof edema. The eyes are spared. There’s no neurological deficit. He can open his mouth, andthere's no swelling apparent inside the mouth or deviation of any anatomical structures.
Your neck exam reveals full and painless range of C-spine motion. There's mild to moderateswelling of the left side of the neck. Examination of the chest reveals no obvious subcutaneousair, and the remainder of the physical examination is normal.
You start an 18-gauge IV with lactated Ringers in an antecubal area, and your crew packages thepatient for transport to the hospital.
But what about his airway, which is likely to become obstructed? Should it be managed in thefield? If his vitals deteriorate, how will you proceed?
Assessment of the pediatric respiratory system
Experience often lends providers a "sixth sense" about adult patient assessment. However,because pediatric care makes up just 10-20% of our prehospital patient population, manyotherwise competent and experienced EMTs and paramedics often fear the assessment and careof critically ill or injured pediatric patients. (1) For this reason, we should rely on well-established and easily reproduced assessment tools for our pediatric cases.
The Pediatric Assessment Triangle (PAT) is a widely published and recognized tool to facilitateassessment of pediatric patients. The PAT relies on three key components -- appearance, work ofbreathing and circulation -- to quickly assess and triage patients into treatment categories of"sick" and "not sick." (2)
Appearance: How does the patient look? Is there acknowledgement of your presence? This firstassessment is the most important aspect of the PAT.„
A general impression of appearance quickly reflects adequacy of ventilation, oxygenation, brainperfusion and central nervous system (CNS) function. (1) This initial assessment enables you toquickly prioritize your airway-management plan.
Loud, boisterous crying is the best sound any prehospital provider can ever hear going into anunknown pediatric emergency. Conversely, a flaccid, unresponsive child with a fixed gazeshould be considered seriously ill, requiring immediate action to ensure adequate ventilation andoxygenation.„
TICLS -- which stands for tone, interactiveness, consolability, look/gaze, and speech/cry -- is auseful mnemonic for assessing the pediatric patient for oxygenation failure and CNSdysfunction. This tool expands the first leg of the PAT and reminds you to examine all aspects ofthe patient's appearance.
Utilizing the PAT appearance and TICLS assessment tools allows you to better detect subtleabnormalities than the more conventional AVPU (alert, voice, pain, unresponsive) scale. (1)
Work of breathing: Unlike the adult patient, a child's work of breathing is often a betterassessment of oxygenation and ventilation status than breath sounds and respiratory rate. Workof breathing reflects the patient’s attempt to overcome abnormalities in respiratory function andthe patient's ability to exchange gas. (2)
This doesn't mean breath sounds should not be auscultated in the pediatric patient; however, anevaluation of the work of breathing in pediatric patients will alert providers of imminentrespiratory arrest before auscultation will.
During this leg of your assessment, the first step can often be accomplished without using astethoscope. Abnormal, audible airway sounds can quickly alert providers to upper airway status.Snoring, difficulty swallowing secretions and a muffled voice (aka, "hot-potato" voice, as thoughthe patient is rolling hot potato with their tongue) or hoarse voice are subtle indicators of upperairway obstruction.
Stridor (a high-pitched, audible sound on inspiration) is a particularly sinister finding in pediatricpatients with acute airway disorders and heralds total obstruction that's often insurmountable bybag-mask ventilation. Croup, bacterial infections, foreign bodies, edema or bleeding can allresult in upper-airway obstructions, which are clearly audible on work of breathing assessment.(2)„
Grunting, like the pursed-lip expiration in adults with chronic obstructive pulmonary disease,provides a degree of positive pressure to be maintained throughout the expiratory phase and maybe thought of as "auto-PEEP" (positive end-expiratory pressure). This maneuver enables you tostent open small airways and alveoli facilitating gas exchange. (2)
Pediatric patients who have an acute respiratory disorder and exhibit grunting are usually alreadymoderately or severely hypoxic, reflecting poor gas exchange. Conditions most often associatedwith grunting in children include pneumonia and pulmonary edema. (1) Additional signs ofincreased work of breathing include displaying the sniffing position while breathing; the tripodposition; retraction of the sternal notch, supraclavicular areas and intercostals spaces (a sign seenmore in children than adults due to the pliability of their tissues); head bobbing; and nasalflaring.
The sniffing position is when the patient spontaneously flexes their neck slightly forward andextends their head up and back in order to open a partially obstructed upper airway. The tripodposition is when the patient has an erect torso and their arms planted firmly on a horizontalsurface to maximize the mechanical advantage of the accessory muscles of respiration in theneck and chest. Head bobbing is typically in response to the child's use of accessory muscles andthe attempt to produce maximal negative intrathoracic pressure for inspiration.
The Silverman-Anderson Index is an assessment scoring system that evaluates five parameters ofwork of breathing and assigns a numerical score for each parameter (see Table 1, p. 60). Eachcategory is scored as "0" for normal, "1" for moderate impairment or "2" for severe impairment.Parameters assessed are retractions of the upper chest, lower chest and xiphoid; nasal flaring; andexpiratory grunt. (3) Normally functioning children should have a cumulative score of 0,whereas critically ill and severely depressed children will have scores closer to 10.
The last physical assessment tool used to evaluate work of breathing should be auscultation ofthe lower airways with a stethoscope. Because a child's chest is so small, stethoscope placementdiffers slightly from auscultation of an adult's chest. The transmission of sounds from areasdistant from the stethoscope can be a problem when assessing breath sounds in small children.For this reason, place the stethoscope bell near the armpit to maximize transmitted breath sounds.(4)
Wheezing, the movement of air through partially blocked smaller airways, is the most commonlower airway sound heard in children with respiratory compromise. Initially, wheezing is heardonly on exhalation and upon auscultation with a stethoscope. But as the degree of obstructionincreases, it may be heard in both inspiration and expiration, and may even be audible to thenaked ear.
Once a patient becomes extremely fatigued, airflow velocity begins to fatigue and wheezing mayattenuate and disappear, a pre-arrest finding. Therefore, it's necessary to treat wheezingaggressively in the early stages before the increased work of breathing leads to fatigue andrespiratory arrest. (1)
Circulation: The goal is to determine the adequacy of cardiac output. (1) Key findings in thedistressed child are related to signs of poor oxygenation, such as peripheral or central cyanosis.Bluish tinting to the skin and/or mucous membranes reflects significant hypoxemia. Correctiveaction regarding airway management and optimal oxygenation must be made a priority.
Beyond the PAT
EMS providers must also consider respiratory effort and rate when assessing the pediatric airway(see Table 2). Tachypnea is often the first manifestation of respiratory distress in children. (4)Irrespective of cause, rapidly breathing children will eventually tire and respiratory arrest willensue.
Slow respiratory rates in acutely ill children, often associated with a disorder of mentation ordecreased level of consciousness, is a particularly ominous sign. (4) Be alarmed if an acutely illchild has a slowing respiratory rate. Do not assume slowing rates equal improvement.
Lastly, diagnostic equipment can be very helpful in assessing the child's respiratory system(including the upper airway). In children, pulse oximetry readings above 94% saturation aregenerally considered acceptable. A reading below 90% during administration of 100% oxygen isan indication for immediate intervention with assisted ventilations.
However, crews must be cautious not to discount or disregard symptoms or signs of respiratorydistress in a child simply because the pulse oximetry reading is above 94%. This is becausechildren in respiratory distress or failure can maintain acceptable oxygen saturation levels byincreasing work of breathing and respiratory rate until the point of respiratory arrest, particularlyif supplementary oxygen is being administered. Thus, pulse oximetry should always be used inconjunction with work of breathing assessment.
Anatomical„&„physiological factors
The fundamental priorities of prehospital pediatric airway management are: optimizingoxygenation, ventilation and airway protection. Decisions regarding airway management must bemade rapidly, and the course of action selected should be designed to minimize error.
The anatomical development of the child in general, and the lungs in particular, along withassociated changes in the maturing physiology, must be taken into consideration in pediatricairway management. Another factor frequently underemphasized is that, excluding congenitalanomalies, children are remarkably consistent from one to another.
In pediatric patients from one to two years of age, the principal difference between the adult andpediatric airway is size. (5) For patients younger than one, the relative proportions of somestructures vary from the adult proportions. In fact, most descriptions of the "pediatric" airway inthe purest sense focus on this latter age group.
The age group from two to eight years represents a transition to the adult airway and, in fact,more closely resembles the adult airway than the infant's. Besides size, the most obvious
difference between the adult and pediatric airway is its position in the neck. The pediatric airwayis described as "anterior," when in reality it's more superior, the glottic opening lying higher, atapproximately the level of C-2 or C-3, as opposed to C-6 in the adult. This position places theglottic opening at the base of the proportionally larger and predominantly intra-oral tongue.Because the airway may become "hidden" up high behind the tongue on laryngoscopy, thisposition is often referred to as "anterior."
All airways are anterior in the sense that they're palpable externally, but the pediatric airway isalso more superior. The relatively larger intra-oral tongue exacerbates this position.
The epiglottis is also proportionally larger in the child than the adult. The ligamentousconnection between the base of the tongue and the epiglottis isn't as strong as it is in the adult,making elevation of the proportionally larger epiglottis by manipulation of the vallecular spacewith a curved blade more difficult. For this reason, and because the large tongue is more difficultto remove from the field of vision with the curved blade, a straight blade is preferred for the firstyear or two of life when these changes are most pronounced. A straight blade can be insertedpast the epiglottis to lift it up out of the field of vision.
The narrowest portion of the child's airway is at the level of the cricoid ring, as compared withthe adult, in which the narrowest portion is at the level of the vocal cords. The significance ofthis anatomical variation is that, in the adult patient, endotracheal tube size is less critical,because a low-pressure cuff can be inflated to ensure adequate fit.„
In the child, the size is more critical because an uncuffed tube is used and therefore the largestpossible tube is inserted to ensure the largest internal diameter possible. A smaller tube reducesventilatory ability, and a tube that is too large can cause pressure ischemia and necrosis of thetracheal mucosa with resultant subglottic stenosis. At approximately eight years of age, thisvariation normalizes and cuffed tubes are appropriate.
Two anatomic variations preclude blind naso-tracheal intubation in the child younger than eightto 10 years of age. The first is the presence of adenoidal tissue, which is frequentlyhypertrophied. This tissue can easily be injured, resulting in copious bleeding. Second, the angleof approach that a nasally introduced endotracheal tube must take to find its way into the glottisis much more acute in a child than an adult, so the success rate of the procedure is unsatisfactory.
The optimal position for alignment of the tracheal, pharyngeal and oral axis for bag-valve maskventilation (BVM) or intubation is the sniffing position. In the adult, optimal axis alignment isaccomplished by flexion of the neck on the chest (usually accomplished by placing a towel orother support beneath the occiput) and hyperextension of the head at the atlanto-occipital joint.
In most children, it's unnecessary to provide support to flex the neck because of theirproportionally large occiput. Slight extension of the head at the atlanto-occipital joint (nothyperextension, which can actually cause obstruction) is all that's necessary.
To achieve the sniffing position in small infants, it's sometimes necessary to balance thedisproportionate occipital size by placing a support under the shoulders. The older child andadolescent are positioned similar to the adult.
In all ages, once positioned, if an imaginary horizontal line can be drawn traversing the externalauditory canal and passing anterior to the shoulders, correct positioning has been obtained (seeFigure 1).
Proper BVM technique is particularly important in pediatric patients, whose crisis is often drivenby a primary respiratory problem. They are more frequently hypoxemic than their adultcounterparts and are subject to more rapid oxyhemoglobin desaturation, so BVM (Sellick's ismaintained during BVM to prevent one from inflating the stomach and enhancing the risk ofregurgitation and aspiration) is frequently required during the pre-oxygenation and paralysisphases of rapid sequence intubation (RSI) to achieve and maintain adequate O2 saturation.
As in adults, oral and nasopharyngeal airways are important adjuncts to BVM.
Because of the miniscule size of the cricothyroid membrane in the child, surgical cricothyrotomyis contraindicated. Needle cricothyrotomy is the procedure of choice for small children.„
A combination of physiological factors decrease the ability to pre-oxygenate the pediatric patientas efficiently as the adult patient. The first and most important is„that the pediatric patientmetabolizes oxygen twice as quickly as the adult (6 mL/kg versus 3 mL/kg).
Because of the lack of elastic lung recoil of the pediatric patient_s chest, the child also possessesa proportionally smaller FRC -- the lung volume measured when all forces in the chest are inequilibrium. This latter effect is especially exacerbated in the supine position.
Under similar pre-oxygenating conditions, the child sustains a significantly shorter period ofoxygen saturation above 90% than the adult. The clinical implication is that a child maydesaturate during the RSI procedure, and the provider must anticipate this and be prepared toinitiate BVM ventilation with cricoid pressure.
Pediatric ventilation requires smaller tidal volumes, higher rates and size-specific equipment.The pediatric airway is particularly amenable to positive pressure ventilation, even in thepresence of upper airway obstruction.
In pediatric airway management, identification and use of size-appropriate equipment is crucial.For this reason, standardized age and size-appropriate systems, such as the Broselow-LutenColor Coded systems (shown on the cover photo), are recommended.
Advanced airway management
Because inadequate oxygenation and ventilation have been identified as primary contributors topreventable mortality, it would seem intuitive that successful endotracheal intubation (ETI)
would mitigate these deaths. Thus, ETI has become the gold standard in prehospital airwaymanagement.
However, considerable controversy exists as to whether pediatric patients requiring ETI shouldhave it performed in the field or deferred until hospital arrival. Studies have shown higher ratesof complication and failure in children than in adults, and one prospective, pseudo-randomizedtrial showed no demonstrable advantage in survival outcome following ETI compared with agroup managed via BVM. (6-10)
Despite controversy, the indications for ETI of adults and children in an emergency remain:failure to maintain adequate oxygenation, failure to maintain adequate ventilation (CO2removal), failure to protect the airway, the need for neuromuscular blockade or the anticipatedclinical course. (5) So even though there may not be a compelling reason to intubate the tracheaat a given point in your care of a patient, prehospital providers must continually evaluate the riskof an insidiously progressive condition advancing to the point when intubation would becomemore hazardous or physically impossible.„
The best example in prehospital care relates to the transport environment, such as in the openingcase. Ground„EMS providers should consider whether future patient positioning in a helicopterwill severely limit access to the head and neck, and thus the airway.
Once the decision to intubate is made, you must decide how to proceed. First responders andbasic rescuers are typically limited to basic upper-airway adjuncts and BVM ventilation.Intermediate rescuers may employ supraglottic devices, such as the Laryngeal Mask Airway(LMA), the Combitube and the King LT Airway, to facilitate bag ventilation and provide someelement of airway protection. For these personnel, the decision is typically a simple one: Will thevictim tolerate insertion of the device?
ALS providers capable of endotracheal intubation who do not use neuromuscular blockingagents have limited options available to them beyond BVM ventilation and direct laryngoscopyintubation.
Once the child is intubated, the endotracheal tube (ETT) must be secured at the mouth, and sincehead and neck movement translates into ETT movement, a cervical collar or other device shouldbe employed.
In infants, small movements are capable of dislocating the ETT into the esophagus, emphasizingthe importance of head and neck immobilization. Securing the ETT at the mouth is traditionallydone by taping the tube to the cheek or by using commercial devices.
Drug dosage& selection
A significant problem in the management of pediatric emergencies is the timely and accuratedelivery of medications. The use of color-coded resuscitation aids for drug dosing and estimatingETT size in children precludes many of these problems, including having to estimate weight andremember and calculate drug doses.„
One particular drug worthy of special mention when used with children is succinylcholine.Because the drug is rapidly distributed into extracellular water, and children have a relativelylarger volume of extracellular fluid than adults, the recommended dose of succinylcholine ishigher in children. (5)
In 1993, the FDA, in conjunction with pharmaceutical companies, revised the package labelingof succinylcholine after reports arose of hyperkalemic cardiac arrests due to the drug'sadministration to patients with previously undiagnosed neuromuscular disease. However, theinitial advisory warnings continue to recommend succinylcholine for emergency or full-stomachintubation in children.
Case wrap-up
Because the 12-year-old patient's respiratory status was kept stable, the patient's airway did notrequire further field management.
On arrival at the emergency department (ED), the patient was unable to swallow secretions, hada muffled voice, was complaining of occasional air hunger and refused to lie flat. The attendingemergency physician (a family practitioner) was unwilling to intubate the patient withoutanesthesia or surgery back-up available at the hospital. The weather had cleared, so airevacuation was requested.
When the air medical transport team arrived 20 minutes later, the patient's condition wasunchanged. The flight crew elected to progressively sedate the young patient and proceeded witha sedation-assisted direct-vision intubation prior to transport. He was sedated and paralyzed forthe duration of the transport and arrived at the Level 1 trauma center in stable condition. He wasweaned and extubated on the sixth hospital day, and the remainder of his recovery wasuneventful.
Summary
Respiratory assessment and airway management in the pediatric patient present many challenges,including differences in equipment sizes and drug dosing, anatomical variation that continuouslyevolves as development proceeds from infancy to adolescence, and the stress of resuscitating acritically ill child.
During the emotional mix of a pediatric resuscitation, it's easy to get sidetracked by co-existingconfounding issues. Therefore, the importance of methodically working your way throughairway evaluation and management cannot be overstressed. Assessment is the key to gatheringcritical evidence of a pediatric patient's respiratory status or warning of impending respiratoryarrest.
1
August 2018 Overview of Pediatric Emergency Department Visits, 2015 Kimberly W. McDermott, Ph.D., Carol Stocks, Ph.D., R.N., and William J. Freeman, M.P.H. Introduction Pediatric emergency department (ED) visits constitute roughly 20 percent of all ED visits.1 In 2015 alone, 17 percent of all children in the United States sought emergency care at least once.2 Although reasons for pediatric ED visits vary by age, conditions such as wounds, sprains and strains, and viral and respiratory infections are common, as well as symptoms such as fever, cough, nausea, vomiting, and abdominal pain.3 Of note, some of the most common pediatric diseases and symptoms, including asthma and abdominal pain, have been shown to exhibit seasonal variation.4,5 Although some ill and injured children are treated at children’s hospitals or large pediatric units of medical centers, the vast majority are brought to community hospital EDs.6 In recent years, national experts have raised concerns about pediatric emergency preparedness in community hospitals and have released guidelines to promote greater equity in pediatric emergency care.7,8 Updated
1 Moore BJ, Stocks C, Owens PL. Trends in Emergency Department Visits, 2006–2014. HCUP Statistical Brief #227. September 2017. Agency for Healthcare Research and Quality, Rockville, MD. www.hcup-us.ahrq.gov/reports/statbriefs/sb227-Emergency- Department-Visit-Trends.pdf 2 National Center for Health Statistics. Health, United States, 2016: With Chartbook on Long-Term Trends in Health. Table 73. Emergency Department Visits Within the Past 12 Months Among Children Under Age 18, by Selected Characteristics: United States, Selected Years 1997–2015. Centers for Disease Control and Prevention, National Center for Health Statistics. www.cdc.gov/nchs/data/hus/hus16.pdf#073. Accessed April 4, 2018. 3 Wier LM, Yu H, Owens PL, Washington R. Overview of Children in the Emergency Department, 2010. HCUP Statistical Brief #157. June 2013. Agency for Healthcare Research and Quality, Rockville, MD. www.hcup-us.ahrq.gov/reports/statbriefs/sb157.pdf 4 Cohen HA, Blau H, Hoshen M, Batat E, Balicer RD. Seasonality of asthma: a retrospective population study. Pediatrics. 2014;133(4):e923–32. 5 Saps M, Blank C, Khan S, Seshadri R, Marshall BM, Bass LM, et al. Seasonal variation in the presentation of abdominal pain. Journal of Pediatric Gastroentrology and Nutrition. 2008;46(3):279–84. 6 American Academy of Pediatrics, Committee on Pediatric Emergency Medicine; American College of Emergency Physicians, Pediatric Committee; Emergency Nurses Association, Pediatric Committee. Joint policy statement: guidelines for care of children in the emergency department. Journal of Emergency Nursing. 2013;39(2):116–31. 7 American Academy of Pediatrics, Committee on Pediatric Emergency Medicine; American College of Emergency Physicians, Pediatric Committee; Emergency Nurses Association, Pediatric Committee. Joint policy statement: guidelines for care of children in the emergency department. Journal of Emergency Nursing. 2013;39(2):116–31. 8 Institute of Medicine, Committee of the Future of Emergency Care in the US Health System. Emergency Care for Children: Growing Pains. Washington, DC: National Academy Press; 2006.
HEALTHCARE COST AND UTILIZATION PROJECT
Agency for Healthcare Research and Quality
Highlights
■ In 2015, there were 30 million ED visits for children aged 18 years or younger, with a rate of 382.9 per 1,000 population. The vast majority of these visits (96.7 percent) were treat and release.
■ Infants and children aged <5 years, representing 25.5 percent of all children in the U.S. population, accounted for more than 40 percent of pediatric ED visits in 2015.
■ Medicaid was the expected primary payer for more than 60 percent of pediatric ED visits in 2015.
■ The number of pediatric ED visits covered by Medicaid increased by more than 50 percent from 2007 to 2015.
■ During 2011 through 2015, pediatric ED visits for respiratory conditions peaked from October through March, whereas injury-related ED visits were more frequent from April through September.
■ Respiratory disorders, and injury and poisoning were the most common reasons for pediatric ED visits in 2015.
■ In 2015, upper respiratory diseases and infections were the most common respiratory-related ED diagnoses across all pediatric age groups, with the highest rate among infants aged <1 year.
■ The younger the pediatric age group, the higher the rate of ED visits for influenza in 2015.
information on patient characteristics and common conditions associated with pediatric ED visits may provide additional insight into the unique needs of the pediatric population and assist community EDs in improving their pediatric care resources. This Healthcare Cost and Utilization Project (HCUP) Statistical Brief presents data on pediatric ED visits (excluding births), with children defined as patients aged 18 years or younger.9 The time frame of focus is fiscal year (FY) 2015 (from quarter 4 [Q4] of 2014 through Q3 2015), with comparison data provided for FY 2007 through FY 2014.10 In this Statistical Brief, FY 2015 will hereinafter be referred to as 2015, FY 2014 will be referred to as 2014, and so forth. The number and rate of pediatric ED visits are compared with adult ED visits in 2015 for three visit types: all ED visits, treat-and-release ED visits, and ED visits resulting in admission to the same hospital. Patient characteristics are presented for pediatric ED visits across these same categories. Trends in pediatric ED visits from 2007 through 2015 are provided by expected primary payer. The most common reasons for pediatric ED visits by body system in 2015 are presented, along with the most common respiratory conditions by age group. Finally, seasonal variation in pediatric ED visits involving respiratory conditions and injuries for 2011 through 2015 are provided. Differences greater than 10 percent between estimates are noted in the text.
9 This definition aligns with the definition of child used by the Children’s Health Insurance Program (CHIP) to determine eligibility. 10 FYs were used in this Statistical Brief because beginning FY 2016, on October 1, 2015, the United States transitioned from the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) clinical coding system to the International Classification of Diseases, Tenth Revision, Clinical Modification/Procedure Coding System (ICD-10-CM/PCS) clinical coding system. Although the impact of the change in coding systems on pediatric ED diagnoses has not been studied directly, the change has been observed to result in substantial shifts in the overall number of ED visits for some of the most frequent diagnoses (ref. Moore BJ, McDermott KW, Elixhauser A. ICD-10-CM Diagnosis Coding in HCUP Data: Comparisons With ICD-9-CM and Precautions for Trend Analyses. November 28, 2017. Rockville, MD: U.S. Agency for Healthcare Research and Quality. www.hcup-us.ahrq.gov/datainnovations/ICD-10_DXCCS_Trends112817.pdf). Although the coding change did not affect calendar years prior to 2015, FYs for all data reported in this Statistical Brief (2007–2015) were used to allow for comparability across years.
Findings Emergency department visits among children compared with adults, 2015 Table 1 compares pediatric ED visits with adult ED visits in 2015. Visit totals and population rates are presented for all ED visits, treat-and-release ED visits, and ED visits resulting in hospital admission, among patients aged 18 years or younger, patients aged 19–64 years, and patients aged 65 years and older. Corresponding U.S. population totals are presented for comparison. Table 1. Pediatric ED visits compared with adult ED visits, FY 2015 Variable 0–18 years 19–64 years 65+ years U.S. populationa 78,473,200 171,311,200 46,447,200 All ED visits
Number of visits 30,047,000 86,102,900 26,775,600 Rate per 1,000 population 382.9 502.6 576.5
Treat-and-release ED visitsb Number of visits 29,066,900 76,635,500 17,653,500 Rate per 1,000 population 370.4 447.3 380.1 ED visits, % 96.7 89.0 65.9
ED visits resulting in hospital admission Number of visits 980,100 9,467,500 9,122,200 Rate per 1,000 population 12.5 55.3 196.4 ED visits, % 3.3 11.0 34.1
Abbreviation: ED, emergency department; FY, fiscal year Notes: Pediatric ED visits exclude births. Totals are rounded to the nearest hundred. a To adjust for use of fiscal year data, U.S. population estimates were calculated as the sum of one-quarter of the 2014 population and three-quarters of the 2015 population. b Among treat-and-release pediatric ED visits, the majority resulted in routine discharge (88.3%). Others resulted in transfer to a short-term hospital (1.4%), transfer to another type of facility (0.7%), discharge against medical advice (0.7%), or discharge to an unknown destination (8.8%). Death in the ED and discharge to home health care each accounted for less than 0.1% of discharges. Source: Agency for Healthcare Research and Quality (AHRQ), Center for Delivery, Organization, and Markets, Healthcare Cost and Utilization Project (HCUP), Nationwide Emergency Department Sample (NEDS), Q4 2014–Q3 2015 ■ Children had a lower rate of ED visits than adults in 2015.
In 2015, there were approximately 30 million pediatric ED visits, with a rate of 382.9 per 1,000 population. This rate was lower than the rate of ED visits among adult patients aged 19–64 years (502.6 per 1,000) and patients aged 65 years and older (576.5 per 1,000).
■ Fewer than 5 percent of pediatric ED visits resulted in admission to the same hospital.
In 2015, 96.7 percent of pediatric ED visits were treat and release, compared with 89.0 percent of visits among patients aged 19–64 years and 65.9 percent of visits among patients aged 65 years and older.
4
Patient characteristics related to pediatric ED visits, 2015 Table 2 presents patient characteristics for all pediatric ED visits, treat-and-release pediatric ED visits, and pediatric ED visits resulting in hospital admission in 2015. Corresponding U.S. population totals are presented as a means of comparison. Table 2. Patient characteristics for ED visits in the pediatric population, FY 2015
Variable All pediatric ED visits
Treat-and-release
pediatric ED visits
Pediatric ED visits
resulting in admission
U.S. population, 0–18 yearsa
Number of visits or population 30,047,000 29,066,900 980,100 78,473,200 Visits or population, % 100.0 96.7 3.3 100.0 Age group, years, %
Patient residence, % Large central metropolitan 30.1 29.9 34.6 31.0 Large fringe metropolitan 21.1 21.0 23.4 24.8 Medium and small metropolitan 31.9 31.9 30.8 30.2 Micropolitan and noncore 16.7 16.9 10.9 14.0
Abbreviation: ED, emergency department; FY, fiscal year Notes: Pediatric ED visits exclude births. Totals are rounded to the nearest hundred. The “other” payer category does not include missing values. a To adjust for use of fiscal year data, U.S. population estimates were calculated as the sum of one-quarter of the 2014 population and three-quarters of the 2015 population. b Population data are not available for primary expected payer categories. Source: Agency for Healthcare Research and Quality (AHRQ), Center for Delivery, Organization, and Markets, Healthcare Cost and Utilization Project (HCUP), Nationwide Emergency Department Sample (NEDS), Q4 2014–Q3 2015
5
■ Children younger than 5 years of age accounted for more than 40 percent of pediatric ED visits in 2015.
The two youngest pediatric age groups—infants younger than 1 year old and children aged 1–4 years—constituted a disproportionately high share of pediatric ED visits. Whereas these age groups accounted for 5.1 and 20.4 percent of the U.S. population, respectively, their treat-and-release ED visits comprised 11.0 and 29.5 percent of all pediatric treat-and-release visits. Infant ED visits accounted for an event greater share (21.3 percent) of admitted pediatric ED visits. Children aged 5–9 years and 10–14 years accounted for a disproportionately low share of pediatric ED visits. This was particularly the case for ED visits resulting in hospital admission. These two age groups each constituted approximately 26 percent of the U.S. population but accounted for only 15.8 and 16.1 percent of admitted pediatric ED visits, respectively. Children aged 15–18 years accounted for 22.1 percent of the U.S. population and a similar share of pediatric treat-and-release and admitted ED visits (19.7 and 23.7 percent, respectively).
■ Overall, the proportion of pediatric ED visits was inversely related to community-level income,
with children in the lowest income quartile constituting more than a third of pediatric ED visits.
In 2015, children in the lowest income quartile constituted a disproportionately high share of pediatric ED visits. This group accounted for 26.6 percent of the U.S. population aged 18 years and younger and 36.4 percent of pediatric ED visits. Conversely, the highest income quartile constituted a disproportionately low share of pediatric ED visits, accounting for 24.9 percent of the U.S. population and only 15.3 percent of pediatric ED visits.
■ More than 60 percent of pediatric ED visits in 2015 were covered by Medicaid.
Medicaid was the most common primary expected payer among pediatric treat-and-release and admitted ED visits, accounting for 61.6 percent and 59.0 percent of visits, respectively. This was followed by private insurance, which was the expected payer for 28.0 percent of treat-and-release visits and 34.8 percent of ED visits resulting in hospital admission. Pediatric ED visits for patients with no insurance were less common, constituting 6.4 percent and 2.7 percent of treat-and-release and admitted pediatric ED visits, respectively.
6
Figure 1 presents the number of pediatric ED visits (treat and release or admitted) by expected primary payer from 2007 through 2015. Figure 1. Trends in the number of pediatric ED visits by expected primary payer, FY 2007–FY 2015
Abbreviation: ED, emergency department; FY, fiscal year Notes: Pediatric ED visits exclude births. The “other” payer category does not include missing values. Percent change is reported based on nonrounded values. Source: Agency for Healthcare Research and Quality (AHRQ), Center for Delivery, Organization, and Markets, Healthcare Cost and Utilization Project (HCUP), Nationwide Emergency Department Sample (NEDS), Q4 2006–Q3 2015 ■ The number of pediatric ED visits covered by Medicaid generally increased from 2007 to 2015,
whereas the number of visits covered by other types of insurance generally decreased. Apart from a decline from 2013 to 2014, the number of pediatric ED visits with Medicaid as the primary expected payer increased steadily from 12.3 million in 2007 to 18.5 million in 2015—a 51.0 percent cumulative increase. During the same period, the number of pediatric ED visits with private insurance as the expected payer decreased from 11.8 million to 8.5 million (a 28.2 percent decrease) and the number of visits among uninsured pediatric patients decreased from 3.3 million to 1.9 million (a 42.7 percent decrease).
12.3
18.5
11.8
8.5
3.3
1.9 1.2 1.1
0
2
4
6
8
10
12
14
16
18
20
2007 2008 2009 2010 2011 2012 2013 2014 2015
Num
ber
of P
edia
tric
ED
Vis
its (
mill
ions
)
Year
Medicaid
Privateinsurance
Uninsured
Other(includingMedicare)
51.0% cumulative increase
28.2% cumulative decrease
42.7% cumulative decrease
7.9% cumulative decrease
7
Reasons for pediatric ED visits, 2015 Figure 2 shows the most common reasons for all pediatric ED visits by body system, based on all-listed diagnoses in 2015. Figure 2. Ten most common all-listed reasons for pediatric ED visits by body system, FY 2015
Abbreviation: ED, emergency department; FY, fiscal year Notes: Pediatric ED visits exclude births. Totals are rounded to the nearest hundred. Body systems are based on the Healthcare Cost and Utilization Project (HCUP) Clinical Classifications Software (CCS) and represent all-listed diagnoses. Only body systems with at least one million pediatric ED visits are shown. A single visit is counted only once per body system designation. Categories are not mutually exclusive. Source: Agency for Healthcare Research and Quality (AHRQ), Center for Delivery, Organization, and Markets, Healthcare Cost and Utilization Project (HCUP), Nationwide Emergency Department Sample (NEDS), Q4 2014–Q3 2015 ■ Respiratory disorders, and injury and poisoning (combined) were the most common reasons
for pediatric ED visits in 2015. In 2015, 9.6 million pediatric ED visits involved respiratory disorders and 8.2 million pediatric ED visits involved injury or poisoning. Other common reasons included nervous system disorders (4.8 million visits), digestive disorders (3.4 million), and infectious or parasitic diseases (2.6 million).
Figure 3 focuses on the most common reasons for pediatric ED visits—respiratory disorders—and presents population rates for six categories of first-listed ED respiratory diagnoses, by pediatric age group, in 2015. Figure 3. Six categories of first-listed respiratory conditions among pediatric ED visits by age group, FY 2015
Abbreviation: ED, emergency department; FY, fiscal year Notes: Pediatric ED visits exclude births. To adjust for use of fiscal year data, population denominators for rates were calculated as the sum of one-quarter of the 2014 population and three-quarters of the 2015 population. Rate is based on first-listed diagnoses, grouped using the Healthcare Cost and Utilization Project (HCUP) Clinical Classifications Software (CCS). Upper respiratory diseases and infections represent three CCS categories: Acute and chronic tonsillitis; Other upper respiratory infections (e.g., streptococcal sore throat and acute laryngitis); and Other upper respiratory disease (e.g., allergic rhinitis and deviated nasal septum). Other upper respiratory infections constituted the vast majority (88.6 percent) of pediatric ED visits in this category. Lower respiratory diseases represent five CCS categories: Other lower respiratory disease (e.g., wheezing and cough), Chronic obstructive pulmonary disease (COPD) and bronchiectasis; Pleurisy, pneumothorax, pulmonary collapse; Aspiration pneumonitis, food vomitus; and Lung disease due to external agents. Other lower respiratory disease accounted for the vast majority (75.7 percent) of pediatric ED visits in this category. As defined here, upper respiratory includes the nose, sinus, throat, larynx, and trachea. Lower respiratory includes the bronchial tubes and lungs. Source: Agency for Healthcare Research and Quality (AHRQ), Center for Delivery, Organization, and Markets, Healthcare Cost and Utilization Project (HCUP), Nationwide Emergency Department Sample (NEDS), Q4 2014–Q3 2015
1.3
1.7
4.2
11.7
15.3
2.0
1.4
2.7
12.3
59.5
2.5
3.2
6.1
8.6
11.4
5.0
6.8
12.3
14.6
5.2
7.5
5.4
8.0
15.9
35.4
23.9
23.7
45.4
91.7
164.2
0 20 40 60 80 100 120 140 160 180
15–18
10–14
5–9
1–4
<1
Rate per 1,000 Population
Age
Gro
up (y
ears
)
Upper respiratory diseases and infections
Lower respiratory diseases
Asthma
Influenza
Acute bronchitis
Pneumonia
9
■ Upper respiratory diseases and infections were the most common respiratory-related ED diagnoses across all pediatric age groups in 2015, with the highest rates among younger age groups. Among the youngest two pediatric age groups, the population rate of ED visits for upper respiratory diseases and infections, lower respiratory diseases, and pneumonia was triple (for infants) and double (for children aged 1–4 years) the corresponding rates for older children. For example, infants aged younger than 1 year and children aged 1–4 years had higher rates of ED visits with a first-listed diagnosis of upper respiratory disease or infection—164.2 and 91.7 per 1,000 population, respectively—compared with older pediatric age groups (which ranged from 23.7 to 45.4 per 1,000 population).
■ In 2015, the population rate of ED visits for acute bronchitis among infants was nearly 5 times higher than the rate among children aged 1–4 years and more than 22 times higher than the rates among older pediatric age groups. Among infants aged younger than 1 year, the rate of ED visits for acute bronchitis was 59.5 per 1,000 population. This was nearly 5 times higher than the rate for the next oldest pediatric age group (12.3 per 1,000 children aged 1–4 years) and more than 22 times higher than rates among the oldest three pediatric age groups (which ranged from 1.4 to 2.7 per 1,000 population).
■ In 2015, the rate of ED visits with a first-listed diagnosis of asthma was highest among children aged 1–4 years and 5–9 years.
First-listed ED diagnoses of asthma were most frequent among children aged 1–4 years (14.6 visits per 1,000 population) and children aged 5–9 years (12.3 visits per 1,000 population). At a rate of 5.2 per 1,000 population, ED visits for asthma were relatively uncommon among infants compared with ED visits for other respiratory conditions. In contrast, among older pediatric age groups, asthma was the second or third most common category of first-listed ED conditions.
■ The younger the age group, the higher the rate of ED visits for influenza in 2015.
Infants younger than 1 year had the highest rate of ED visits for influenza among pediatric age groups (11.4 per 1,000 population). Rates of ED visits with a first-listed diagnosis of influenza were inversely related to age, with the lowest rate of 2.5 per 1,000 population observed among children aged 15–18 years.
10
Figure 4 presents quarterly trends for two common reasons for pediatric ED visits—respiratory conditions and injuries—from 2011 through 2015. Although the condition category reported in Figure 2 includes both injuries and poisonings, this figure is limited to injury diagnoses to highlight the seasonal variation associated with these conditions. Totals are based on all-listed diagnoses. Figure 4. Comparison of seasonal variation for two common reasons for pediatric ED visits, FY 2011–FY 2015
Abbreviations: ED, emergency department; FY, fiscal year Note: Pediatric ED visits exclude births. Totals are based on all-listed diagnoses. Body systems are based on the Healthcare Cost and Utilization Project (HCUP) Clinical Classifications Software (CCS). Although this classification system combines injury and poisoning diagnosis categories, Figure 4 was limited to injury-related CCS diagnosis categories. Source: Agency for Healthcare Research and Quality (AHRQ), Center for Delivery, Organization, and Markets, Healthcare Cost and Utilization Project (HCUP), Nationwide Emergency Department Sample (NEDS), Q4 2010–Q3 2015 ■ From 2011 through 2015, the number of pediatric ED visits involving respiratory conditions
consistently peaked during the months of October through March. During 2011 through 2015, the number of pediatric ED visits associated with respiratory conditions demonstrated strong seasonal variation, with higher volumes from October through March compared with April through September. In FY 2015, for example, there were 2.8 and 3.0 million respiratory-related pediatric ED visits during the quarterly periods of October through December (Q4 2014) and January through March (Q1 2015), respectively, and only 2.1 and 1.7 million visits during April through June (Q2 2015) and July through September (Q3 2015), respectively. This equates to a 43.4 percent decrease from the highest volume quarter (October through December) to the lowest volume quarter (July through September) of that fiscal year.
3.0
1.6
2.6
1.8
2.9
1.6
2.5
1.7
3.0
1.7 1.8
2.3
1.9
2.3
1.7
2.2
1.6
2.1
1.7
2.2
1.5
2.0
2.5
3.0
Oct
–D
ec
2010
Jan
–M
ar
2011
Apr
–Ju
n20
11Ju
l –S
ep20
11O
ct –
Dec
20
11Ja
n –
Mar
20
12Ap
r –
Jun
2012
Jul –
Sep
2012
Oct
–D
ec
2012
Jan
–M
ar
2013
Apr
–Ju
n20
13Ju
l –S
ep20
13O
ct –
Dec
20
13Ja
n –
Mar
20
14Ap
r –
Jun
2014
Jul –
Sep
2014
Oct
–D
ec
2014
Jan
–M
ar
2015
Apr
–Ju
n20
15Ju
l –S
ep20
15
FY 2011 FY 2012 FY 2013 FY 2014 FY 2015
Num
ber
of P
edia
tric
ED
Vis
its (
mill
ions
)
Quarter
Respiratory Conditions Injuries
11
■ Children visited the ED with injuries most frequently during the months of April through September in 2011–2015. Pediatric ED visits involving injury diagnoses showed a clear seasonality from 2011 through 2015. Injury-related visits were far more prevalent from April through September compared with October through March. This pattern was exemplified in FY 2015, when there were 2.2 million injury-related pediatric ED visits in both periods of April through June (Q2 2015) and July through September (Q3 2015), compared with 1.8 and 1.7 million visits during October through December (Q4 2014) and January through March (Q1 2015), respectively. The volume of pediatric ED visits associated with injuries increased by 29.9 percent between the lowest volume quarter (January through March) and the highest volume quarter (July through September) of FY 2015.
12
About Statistical Briefs Healthcare Cost and Utilization Project (HCUP) Statistical Briefs provide basic descriptive statistics on a variety of topics using HCUP administrative health care data. Topics include hospital inpatient, ambulatory surgery, and emergency department (ED) use and costs, quality of care, access to care, medical conditions, procedures, and patient populations, among other topics. The reports are intended to generate hypotheses that can be further explored in other research; the reports are not designed to answer in-depth research questions using multivariate methods. Data Source The estimates in this Statistical Brief are based upon data from the HCUP Q4 2014–Q3 2015 Nationwide Emergency Department Sample (NEDS). Historical data were drawn from the Q4 2006–Q3 2014 NEDS. Supplemental sources included population denominator data for use with HCUP databases, derived from information available from the U.S. Census Bureau11 and Claritas, a vendor that compiles and adds value to data from the U.S. Census Bureau.12 For this Statistical Brief, fiscal year (FY) was used. FY includes October through December of one year and January through September of the following year, thereby including all four seasons, as does calendar year. Beginning FY 2016, on October 1, 2015, the United States transitioned from the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) clinical coding system to the International Classification of Diseases, Tenth Revision, Clinical Modification/Procedure Coding System (ICD-10-CM/PCS) clinical coding system. Although the impact of the change in coding systems on pediatric ED diagnoses has not been studied directly, the change has been observed to result in substantial shifts in the overall number of ED visits for some of the most frequent diagnoses.13 Although the coding change did not affect calendar years prior to 2015, FYs for all data reported in this Statistical Brief (2007–2015) were used to allow for comparability across years. Definitions Diagnoses, ICD-9-CM, Clinical Classifications Software (CCS), and body systems The first-listed diagnosis is the condition, symptom, or problem identified in the medical record to be chiefly responsible for the emergency department (ED) services provided. For ED visits that result in an inpatient admission to the same hospital, the first-listed diagnosis is the principal diagnosis, the condition established after study to be chiefly responsible for the patient’s admission to the hospital. All-listed diagnoses include the first-listed diagnosis plus concomitant conditions that coexist at the time of the visit. ICD-9-CM is the International Classification of Diseases, Ninth Revision, Clinical Modification, which assigns numeric codes to diagnoses. There are approximately 14,000 ICD-9-CM diagnosis codes. CCS categorizes ICD-9-CM diagnosis codes into a manageable number of clinically meaningful categories.14 This clinical grouper makes it easier to quickly understand patterns of diagnoses. CCS categories identified as Other typically are not reported; these categories include miscellaneous, otherwise unclassifiable diagnoses that may be difficult to interpret as a group.
11 Barrett M, Coffey R, Levit K. Population Denominator Data for Use with the HCUP Databases (Updated with 2016 Population Data). HCUP Methods Series Report #2017-04. October 17, 2017. U.S. Agency for Healthcare Research and Quality. www.hcup-us.ahrq.gov/reports/methods/2017-04.pdf. Accessed January 18, 2018. 12 Claritas. Claritas Demographic Profile by ZIP Code. https://claritas360.claritas.com/mybestsegments/. Accessed June 6, 2018. 13 Moore BJ, McDermott KW, Elixhauser A. ICD-10-CM Diagnosis Coding in HCUP Data: Comparisons With ICD-9-CM and Precautions for Trend Analyses. November 28, 2017. U.S. Agency for Healthcare Research and Quality. https://www.hcup-us.ahrq.gov/datainnovations/ICD-10_DXCCS_Trends112817.pdf. Accessed, July 5, 2018. 14 Agency for Healthcare Research and Quality. HCUP Clinical Classifications Software (CCS) for ICD-9-CM. Healthcare Cost and Utilization Project (HCUP). Agency for Healthcare Research and Quality. Updated March 2017. www.hcup-us.ahrq.gov/toolssoftware/ccs/ccs.jsp. Accessed January 18, 2018.
The single-level CCS aggregates illnesses and conditions into 285 mutually exclusive diagnosis categories. The multilevel CCS expands the single-level CCS into a hierarchical system that groups single-level CCS categories into broader body systems or condition categories (e.g., Diseases of the Respiratory System and Injury and Poisoning). Case definition For this report, pediatric ED visits were defined as ED visits involving patients aged 18 years or younger. ED visits for births were excluded. Births were identified as having an ICD-9-CM diagnosis code of V3000 through V3901, with the last two digits being 00 or 01 in any diagnosis field. For FY 2015, rates per 1,000 population were calculated as follows:
• The numerator used HCUP data from October 2014 to September 2015 • The denominator used the sum of one-quarter of the 2014 U.S. population and three-quarters of
the 2015 U.S. population Types of hospitals included in the HCUP Nationwide Emergency Department Sample The Nationwide Emergency Department Sample (NEDS) is based on data from community hospitals, which are defined as short-term, non-Federal, general, and other hospitals, excluding hospital units of other institutions (e.g., prisons). The NEDS includes specialty, pediatric, public, and academic medical hospitals. Excluded are long-term care facilities such as rehabilitation, psychiatric, and alcoholism and chemical dependency hospitals. Hospitals included in the NEDS have hospital-owned EDs and no more than 90 percent of their ED visits resulting in admission. ED visits ED visits include information on all visits to hospital-owned EDs regardless of whether the patient was treated and released from that ED or admitted to the same hospital from the ED. Treat-and-release ED visits were defined as those ED visits in which patients were treated and then released from the ED; that is, patients were not admitted to the specific hospital associated with the ED. ED visits resulting in admission to the same hospital included those patients initially seen in the ED who were then admitted to the specific hospital associated with that ED. Unit of analysis The unit of analysis is the ED visit, not a person or patient. This means that a person who is seen in the ED multiple times in 1 year will be counted each time as a separate visit in the ED. Location of patients’ residence Place of residence is based on the urban-rural classification scheme for U.S. counties developed by the National Center for Health Statistics (NCHS) and based on the Office of Management and Budget (OMB) definition of a metropolitan service area as including a city and a population of at least 50,000 residents.
• Large Central Metropolitan: Counties in a metropolitan area with 1 million or more residents that satisfy at least one of the following criteria: (1) containing the entire population of the largest principal city of the metropolitan statistical area (MSA), (2) having their entire population contained within the largest principal city of the MSA, or (3) containing at least 250,000 residents of any principal city in the MSA
• Large Fringe Metropolitan: Counties in a metropolitan area with 1 million or more residents that do not qualify as large central metropolitan counties
• Medium and Small Metropolitan: Counties in a metropolitan area of 50,000–999,999 residents • Micropolitan and Noncore: Counties in a nonmetropolitan area (i.e., counties with no town greater
than 49,999 residents). Community-level income Community-level income is based on the median household income of the patient’s ZIP Code of residence. Quartiles are defined so that the total U.S. population is evenly distributed. Cut-offs for the
14
quartiles are determined annually using ZIP Code demographic data obtained from Claritas, a vendor that adds value to data from the U.S. Census Bureau.15 The value ranges for the income quartiles vary by year. The income quartile is missing for patients who are homeless or foreign. Payer Payer is the expected payer for the hospital stay. To make coding uniform across all HCUP data sources, payer combines detailed categories into general groups:
• Medicaid: includes patients covered by fee-for-service and managed care Medicaid • Private Insurance: includes Blue Cross, commercial carriers, and private health maintenance
organizations (HMOs) and preferred provider organizations (PPOs) • Uninsured: includes an insurance status of self-pay and no charge • Other: includes Medicare, Workers’ Compensation, TRICARE/CHAMPUS, CHAMPVA, Title V,
and other government programs. Note that for this Statistical Brief, Medicare is included in the Other category because of the small number of children covered by the Medicare Program.
Hospital stays billed to the State Children’s Health Insurance Program (SCHIP) may be classified as Medicaid, Private Insurance, or Other, depending on the structure of the State program. Because most State data do not identify patients in SCHIP specifically, it is not possible to present this information separately. For this Statistical Brief, when more than one payer is listed for a hospital discharge, the first-listed payer is used. Region Region is one of the four regions defined by the U.S. Census Bureau:
• Northeast: Maine, New Hampshire, Vermont, Massachusetts, Rhode Island, Connecticut, New York, New Jersey, and Pennsylvania
• Midwest: Ohio, Indiana, Illinois, Michigan, Wisconsin, Minnesota, Iowa, Missouri, North Dakota, South Dakota, Nebraska, and Kansas
• South: Delaware, Maryland, District of Columbia, Virginia, West Virginia, North Carolina, South Carolina, Georgia, Florida, Kentucky, Tennessee, Alabama, Mississippi, Arkansas, Louisiana, Oklahoma, and Texas
• West: Montana, Idaho, Wyoming, Colorado, New Mexico, Arizona, Utah, Nevada, Washington, Oregon, California, Alaska, and Hawaii
Discharge status Discharge status reflects the disposition of the patient at discharge from the ED and includes the following seven categories: routine (to home); transfer to a different short-term hospital; other transfers (including skilled nursing facility, intermediate care, and another type of facility such as a nursing home); home health care; against medical advice (AMA); died in the hospital; or destination unknown. About HCUP The Healthcare Cost and Utilization Project (HCUP, pronounced "H-Cup") is a family of health care databases and related software tools and products developed through a Federal-State-Industry partnership and sponsored by the Agency for Healthcare Research and Quality (AHRQ). HCUP databases bring together the data collection efforts of State data organizations, hospital associations, and private data organizations (HCUP Partners) and the Federal government to create a national information resource of encounter-level health care data. HCUP includes the largest collection of longitudinal hospital care data in the United States, with all-payer, encounter-level information beginning in 1988. These databases enable research on a broad range of health policy issues, including cost and quality of health services, medical practice patterns, access to health care programs, and outcomes of treatments at the national, State, and local market levels.
15 Claritas. Claritas Demographic Profile by ZIP Code. https://claritas360.claritas.com/mybestsegments/. Accessed June 6, 2018.
HCUP would not be possible without the contributions of the following data collection Partners from across the United States: Alaska Department of Health and Social Services Alaska State Hospital and Nursing Home Association Arizona Department of Health Services Arkansas Department of Health California Office of Statewide Health Planning and Development Colorado Hospital Association Connecticut Hospital Association District of Columbia Hospital Association Florida Agency for Health Care Administration Georgia Hospital Association Hawaii Health Information Corporation Illinois Department of Public Health Indiana Hospital Association Iowa Hospital Association Kansas Hospital Association Kentucky Cabinet for Health and Family Services Louisiana Department of Health Maine Health Data Organization Maryland Health Services Cost Review Commission Massachusetts Center for Health Information and Analysis Michigan Health & Hospital Association Minnesota Hospital Association Mississippi State Department of Health Missouri Hospital Industry Data Institute Montana Hospital Association Nebraska Hospital Association Nevada Department of Health and Human Services New Hampshire Department of Health & Human Services New Jersey Department of Health New Mexico Department of Health New York State Department of Health North Carolina Department of Health and Human Services North Dakota (data provided by the Minnesota Hospital Association) Ohio Hospital Association Oklahoma State Department of Health Oregon Association of Hospitals and Health Systems Oregon Office of Health Analytics Pennsylvania Health Care Cost Containment Council Rhode Island Department of Health South Carolina Revenue and Fiscal Affairs Office South Dakota Association of Healthcare Organizations Tennessee Hospital Association Texas Department of State Health Services Utah Department of Health Vermont Association of Hospitals and Health Systems Virginia Health Information Washington State Department of Health West Virginia Department of Health and Human Resources, West Virginia Health Care Authority Wisconsin Department of Health Services Wyoming Hospital Association
16
About the NEDS The HCUP Nationwide Emergency Department Database (NEDS) is a unique and powerful database that yields national estimates of emergency department (ED) visits. The NEDS was constructed using records from both the HCUP State Emergency Department Databases (SEDD) and the State Inpatient Databases (SID). The SEDD capture information on ED visits that do not result in an admission (i.e., patients who were treated in the ED and then released from the ED, or patients who were transferred to another hospital); the SID contain information on patients initially seen in the ED and then admitted to the same hospital. The NEDS was created to enable analyses of ED utilization patterns and support public health professionals, administrators, policymakers, and clinicians in their decisionmaking regarding this critical source of care. The NEDS is produced annually beginning in 2006. Over time, the sampling frame for the NEDS has changed; thus, the number of States contributing to the NEDS varies from year to year. The NEDS is intended for national estimates only; no State-level estimates can be produced. For More Information For other information on pediatric emergency department (ED) visits and hospital stays, refer to the HCUP Statistical Briefs located at www.hcup-us.ahrq.gov/reports/statbriefs/sb_pediatric.jsp. For additional HCUP statistics, visit:
• HCUP Fast Stats at www.hcup-us.ahrq.gov/faststats/landing.jsp for easy access to the latest HCUP-based statistics for health care information topics
• HCUPnet, HCUP’s interactive query system, at www.hcupnet.ahrq.gov/ For more information about HCUP, visit www.hcup-us.ahrq.gov/. For a detailed description of HCUP and more information on the design of the Nationwide Emergency Department Sample (NEDS), please refer to the following database documentation: Agency for Healthcare Research and Quality. Overview of the Nationwide Emergency Department Sample (NEDS). Healthcare Cost and Utilization Project (HCUP). Rockville, MD: Agency for Healthcare Research and Quality. Updated December 2017. www.hcup-us.ahrq.gov/nedsoverview.jsp. Accessed January 18, 2018. Suggested Citation McDermott KW (IBM Watson Health), Stocks C (AHRQ), Freeman WJ (AHRQ). Overview of Pediatric Emergency Department Visits, 2015. HCUP Statistical Brief #242. August 2018. Agency for Healthcare Research and Quality, Rockville, MD. www.hcup-us.ahrq.gov/reports/statbriefs/sb242-Pediatric-ED-Visits-2015.pdf. Acknowledgments The authors would like to acknowledge the contributions of Minya Sheng of IBM Watson Health.
∗ ∗ ∗
AHRQ welcomes questions and comments from readers of this publication who are interested in obtaining more information about access, cost, use, financing, and quality of health care in the United States. We also invite you to tell us how you are using this Statistical Brief and other HCUP data and tools, and to share suggestions on how HCUP products might be enhanced to further meet your needs. Please e-mail us at [email protected] or send a letter to the address below:
Virginia Mackay-Smith, Acting Director Center for Delivery, Organization, and Markets Agency for Healthcare Research and Quality 5600 Fishers Lane Rockville, MD 20857 This Statistical Brief was posted online on August 7, 2018.
1. A late, ominous sign of shock in pediatric patients is __________________.a. Respiratory arrestb. Irritability
c. Drop in blood pressured. Rapid heart beat
2. ____________ respond to the voice and face of their parents, and like to beheld by caregivers.
a. Adolescentsb. Toddlers
c. School-aged kidsd. Infants
3. Using the TEN-4 model as a guideline, children less than four years old_____.a. Will generally have bruising on their torso, ears, and neckb. Will generally NOT have bruising on their torso, ears, and neck
4. T / F EMS workers are mandatory reporters of suspected child abuse inIllinois.
5. The Pediatric Assessment Triangle uses all of the following EXCEPT:a. Appearanceb. Grimace
c. Work of breathingd. Circulation
6. Pediatric patients exhibiting grunting are usually ___________.a. Hypoxicb. Well-oxygenated
c. Tiredd. Faking it
7. Patients transition from a pediatric airway to an adult airway between theages of ___________________.
a. 1 and 5 b. 2 and 8
c. 3 and 7 d. 8 and 12
8. In 2015, ____________________ represented the largest reason for pediatricemergency department visits.
9. Most traumatic injuries to pediatric patients occur between _____________.a. January – Marchb. July – September
c. April – Juned. April – July
10. Which payer was the most frequent for pediatric patients seen inemergency departments in 2015?
a. Private insuranceb. Medicare
c. Cash or self-payd. Medicaid
11. Pediatric patients tend to compensate for long periods of time prior tocollapsing. What can the EMS provider do to prevent delay in obtaining thechief complaint of a pediatric patient?_____________________________________________________________________________________________________________________________________________________________________________________________
12. Explain burn patterns on pediatric patients that may indicate abuse._____________________________________________________________________________________________________________________________________________________________________________________________
13. Nearly 60% of emergency department visits by pediatric patients in2015 were paid for by Medicaid. Discuss potential reasons for the largenumber of Medicaid paid visits._____________________________________________________________________________________________________________________________________________________________________________________________
