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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.]

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.

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.

Point-of-care ultrasonography is increasingly being used to facilitate accurate and timely diagnoses and to guide procedures. It is important for pediatric emergency physicians caring for patients in the emergency department to receive adequate and continued point-of-care ultrasonography training for those indications used in their practice setting. Emergency departments should have credentialing and quality assurance programs. Pediatric emergency medicine fellowships should provide appropriate training to physician trainees. Hospitals should provide privileges to physicians who demonstrate competency in point-of-care ultrasonography. Ongoing research will provide the necessary measures to define the optimal training and competency assessment standards. Requirements for credentialing and hospital privileges will vary and will be specific to individual departments and hospitals. As more physicians are trained and more research is completed, there should be one national standard for credentialing and privileging in point-of-care ultrasonography for pediatric emergency physicians.

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.

The death of a child in the emergency department (ED) is one of the most challenging problems facing ED clinicians. This revised technical report and accompanying policy statement reaffirm principles of patient- and family-centered care. Recent literature is examined regarding family presence, termination of resuscitation, bereavement responsibilities of ED clinicians, support of child fatality review efforts, and other issues inherent in caring for the patient, family, and staff when a child dies in the ED. Appendices are provided that offer an approach to bereavement activities in the ED, carrying out forensic responsibilities while providing compassionate care, communicating the news of the death of a child in the acute setting, providing a closing ritual at the time of terminating resuscitation efforts, and managing the child with a terminal condition who presents near death in the ED.

This multiorganizational literature review was undertaken to provide an evidence base for determining whether recommendations for out-of-hospital termination of resuscitation could be made for children who are victims of traumatic cardiopulmonary arrest. Although there is increasing acceptance of out-of-hospital termination of resuscitation for adult traumatic cardiopulmonary arrest when there is no expectation of a good outcome, children are routinely excluded from state termination-of-resuscitation protocols. The decision to withhold resuscitative efforts in a child under specific circumstances (decapitation or dependent lividity, rigor mortis, etc) is reasonable. If there is any doubt as to the circumstances or timing of the traumatic cardiopulmonary arrest, under the current status of limiting termination of resuscitation in the field to persons older than 18 years in most states, resuscitation should be initiated and continued until arrival to the appropriate facility. If the patient has arrested, resuscitation has already exceeded 30 minutes, and the nearest facility is more than 30 minutes away, involvement of parents and family of these children in the decision-making process with assistance and guidance from medical professionals should be considered as part of an emphasis on family-centered care because the evidence suggests that either death or a poor outcome is inevitable.

Regionalization of pediatric emergency care is a necessary and enormous task assigned to Emergency Medical Services for Children. One of the founders of medical regionalization, perinatology, has experienced difficulties over the past decade maintaining the structure and systems that had so dramatically improved patient care. Pediatric trauma regionalization, as a component of pediatric emergency care as well as adult trauma care, is foreseeing similar degradation of their system if key issues are not addressed soon. Pediatric emergency care, under the leadership of Emergency Medical Services for Children, is seeking to build strong and sustainable systems of regionalization as the next step toward improving access to high-quality emergency and definitive care for children of all ages throughout the United States.

Pediatricians regularly see emergencies in the office, or children that require transfer to an emergency department, or hospitalization. An office self-assessment is the first step in determining how to prepare for an emergency. The use of mock codes and skill drills make office personnel feel less anxious about medical emergencies. Emergency information forms provide valuable, quick information about complex patients for emergency medical services and other physicians caring for patients. Furthermore, disaster planning should be part of an office preparedness plan.

Copyright © 2016 by the American Academy of Pediatrics. Transitions of care (ToCs), also referred to as handoffs or sign-outs, occur when the responsibility for a patient's care transfers from 1 health care provider to another. Transitions are common in the acute care setting and have been noted to be vulnerable events with opportunities for error. Health care is taking ideas from other high-risk industries, such as aerospace and nuclear power, to create models of structured transition processes. Although little literature currently exists to establish 1 model as superior, multiorganizational consensus groups agree that standardization is warranted and that additional work is needed to establish characteristics of ToCs that are associated with clinical or practice outcomes. The rationale for structuring ToCs, specifically those related to the care of children in the emergency setting, and a description of identified strategies are presented, along with resources for educating health care providers on ToCs. Recommendations for development, education, and implementation of transition models are included.

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.

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.

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.

There are approximately 30 to 35 million children participating in organized sports in the United States. With this increasing participation, we have seen an overall increase in sports-related injuries in young athletes over the past 20 years. Young athletes suffer both acute and chronic, or overuse, injuries. They are susceptible to many of the same injuries as their adult counterparts; but because of the effects of growth on the musculoskeletal system, they are at risk for injuries to the growth plate, apophysis, and joint surface as well. Overuse injuries can be hard to diagnose because of the lack of radiographic findings and overt abnormalities on physical examination in many patients. In addition, they can be a challenge to treat, especially in athletes who wish to continue participating in their sport. Common overuse injuries seen in young athletes will be discussed.

Infants, children, adolescents, and young adults have unique physical, mental, behavioral, developmental, communication, therapeutic, and social needs that must be addressed and met in all aspects of disaster preparedness, response, and recovery. Pediatricians, including primary care pediatricians, pediatric medical subspecialists, and pediatric surgical specialists, have key roles to play in preparing and treating families in cases of disasters. Pediatricians should attend to the continuity of practice operations to provide services in time of need and stay abreast of disaster and public health developments to be active participants in community planning efforts. Federal, state, tribal, local, and regional institutions and agencies that serve children should collaborate with pediatricians to ensure the health and well-being of children in disasters.

This publication presents the 2005 American Heart Association (AHA) guidelines for cardiopulmonary resuscitation (CPR) and emergency cardiovascular care (ECC) of the pediatric patient and the 2005 American Academy of Pediatrics/AHA guidelines for CPR and ECC of the neonate. The guidelines are based on the evidence evaluation from the 2005 International Consensus Conference on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations, hosted by the American Heart Association in Dallas, Texas, January 23–30, 2005.The “2005 AHA Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care” contain recommendations designed to improve survival from sudden cardiac arrest and acute life-threatening cardiopulmonary problems. The evidence evaluation process that was the basis for these guidelines was accomplished in collaboration with the International Liaison Committee on Resuscitation (ILCOR). The ILCOR process is described in more detail in the “International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations.”The recommendations in the “2005 AHA Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care” confirm the safety and effectiveness of many approaches, acknowledge that other approaches may not be optimal, and recommend new treatments that have undergone evidence evaluation. These new recommendations do not imply that care involving the use of earlier guidelines is unsafe. In addition, it is important to note that these guidelines will not apply to all rescuers and all victims in all situations. The leader of a resuscitation attempt may need to adapt application of the guidelines to unique circumstances.The following are the major pediatric advanced life support changes in the 2005 guidelines: There is further caution about the use of endotracheal tubes. Laryngeal mask airways are acceptable when used by experienced providers.Cuffed endotracheal tubes may be used in infants (except newborns) and children in in-hospital settings provided that cuff inflation pressure is kept 20 kg who have a perfusing rhythm. Correct placement must be verified when the tube is inserted, during transport, and whenever the patient is moved.During CPR with an advanced airway in place, rescuers will no longer perform “cycles” of CPR. Instead, the rescuer performing chest compressions will perform them continuously at a rate of 100/minute without pauses for ventilation. The rescuer providing ventilation will deliver 8 to 10 breaths per minute (1 breath approximately every 6–8 seconds).Timing of 1 shock, CPR, and drug administration during pulseless arrest has changed and now is identical to that for advanced cardiac life support.Routine use of high-dose epinephrine is not recommended.Lidocaine is de-emphasized, but it can be used for treatment of ventricular fibrillation/pulseless ventricular tachycardia if amiodarone is not available.Induced hypothermia (32–34°C for 12–24 hours) may be considered if the child remains comatose after resuscitation.Indications for the use of inodilators are mentioned in the postresuscitation section.Termination of resuscitative efforts is discussed. It is noted that intact survival has been reported following prolonged resuscitation and absence of spontaneous circulation despite 2 doses of epinephrine.The following are the major neonatal resuscitation changes in the 2005 guidelines: Supplementary oxygen is recommended whenever positive-pressure ventilation is indicated for resuscitation; free-flow oxygen should be administered to infants who are breathing but have central cyanosis. Although the standard approach to resuscitation is to use 100% oxygen, it is reasonable to begin resuscitation with an oxygen concentration of less than 100% or to start with no supplementary oxygen (ie, start with room air). If the clinician begins resuscitation with room air, it is recommended that supplementary oxygen be available to use if there is no appreciable improvement within 90 seconds after birth. In situations where supplementary oxygen is not readily available, positive-pressure ventilation should be administered with room air.Current recommendations no longer advise routine intrapartum oropharyngeal and nasopharyngeal suctioning for infants born to mothers with meconium staining of amniotic fluid. Endotracheal suctioning for infants who are not vigorous should be performed immediately after birth.A self-inflating bag, a flow-inflating bag, or a T-piece (a valved mechanical device designed to regulate pressure and limit flow) can be used to ventilate a newborn.An increase in heart rate is the primary sign of improved ventilation during resuscitation. Exhaled CO2 detection is the recommended primary technique to confirm correct endotracheal tube placement when a prompt increase in heart rate does not occur after intubation.The recommended intravenous (IV) epinephrine dose is 0.01 to 0.03 mg/kg per dose. Higher IV doses are not recommended, and IV administration is the preferred route. Although access is being obtained, administration of a higher dose (up to 0.1 mg/kg) through the endotracheal tube may be considered.It is possible to identify conditions associated with high mortality and poor outcome in which withholding resuscitative efforts may be considered reasonable, particularly when there has been the opportunity for parental agreement. The following guidelines must be interpreted according to current regional outcomes: When gestation, birth weight, or congenital anomalies are associated with almost certain early death and when unacceptably high morbidity is likely among the rare survivors, resuscitation is not indicated. Examples are provided in the guidelines.In conditions associated with a high rate of survival and acceptable morbidity, resuscitation is nearly always indicated.In conditions associated with uncertain prognosis in which survival is borderline, the morbidity rate is relatively high, and the anticipated burden to the child is high, parental desires concerning initiation of resuscitation should be supported.Infants without signs of life (no heartbeat and no respiratory effort) after 10 minutes of resuscitation show either a high mortality rate or severe neurodevelopmental disability. After 10 minutes of continuous and adequate resuscitative efforts, discontinuation of resuscitation may be justified if there are no signs of life.

This article summarizes discussions held during a conference on outcomes research in emergency medical services for children. It provides detailed information on existing outcome measures for pediatric minor head injury. Benefits and/or limitations in their applicability for use in pediatric emergency medicine and pediatric minor head injury research are highlighted.

Workup of simple febrile seizures (SFS) has changed as the American Academy of Pediatrics made revisions to practice guidelines. In 2011, revisions were made regarding need for lumbar puncture (LP) as part of the SFS workup. This study surveyed more than 100 emergency departments regarding workup of children with SFS and performed a medical record review of workup that was performed. The survey shows that laboratory workup is done routinely and LP is done infrequently. The majority documents a complete exam. The medical record review demonstrates documentation of the examination, frequent laboratory and infrequent LP evaluation. Consistent with the American Academy of Pediatrics’ revisions, survey and record reviews demonstrate that LP testing is infrequent. Contrary to the guideline, laboratory studies are routinely performed. This study suggests there is an opportunity to improve management of SFS by directing efforts toward finding the source of the fever and away from laboratory workup.

The death of a child in the emergency department (ED) is one of the most challenging problems facing ED clinicians. This revised technical report and accompanying policy statement reaffirm principles of patient- and family-centered care. Recent literature is examined regarding family presence, termination of resuscitation, bereavement responsibilities of ED clinicians, support of child fatality review efforts, and other issues inherent in caring for the patient, family, and staff when a child dies in the ED. Appendices are provided that offer an approach to bereavement activities in the ED, carrying out forensic responsibilities while providing compassionate care, communicating the news of the death of a child in the acute setting, providing a closing ritual at the time of terminating resuscitation efforts, and managing the child with a terminal condition who presents near death in the ED.

Freestanding urgent care centers are in- creasing as a source of after-hours pediatric care. These facilities may be used as an alternative to hospital emer- gency departments for the care and stabilization of seri- ous and critically ill and injured children. The purpose of this policy statement is to provide recommendations for assuring appropriate stabilization in pediatric emergency situations and timely transfer to a hospital for definitive care when necessary. F reestanding urgent care facilities remain a fix- ture in provision of health services in a man- aged care environment. Although the Academy does not approve of the routine use of urgent care facilities because it detracts from the medical home concept, 1,2 the use of these facilities as part of urgent and emergent care systems is increasing in the man- aged care environment. The term urgent care may imply to the public that a facility is capable of man- aging critical or life-threatening emergencies. There- fore, these facilities must have the capability to iden- tify patients with emergency conditions, stabilize them, and provide timely access to definitive care should critically ill or injured children need care. Urgent care facilities must have appropriate pediat- ric equipment and staff trained and experienced to provide critical support for ill and injured children until transferred for definitive care. It is necessary for urgent care facilities to have prearranged access to comprehensive emergency services through transfer and transport agreements to which both facilities adhere. Available and appropriate modes of trans- port should be identified in advance. When after-hours urgent care clinics are used as a resource for pediatric urgent care, they should solicit help from the pediatric professional community, and pediatricians should be accessible who are prepared to assist in the stabilization and management of crit- ically ill and injured children. Pediatricians respon- sible for managing the health care of children may occasionally need to use the resources of urgent care facilities after hours. When such clinics are recom- mended to patients, pediatricians should be certain that the urgent care center is prepared to stabilize and manage critically ill and injured children. RECOMMENDATIONS

The purpose of this survey and record review was to characterize emergency department management of unprovoked seizures and status epilepticus in children in Illinois. The survey was sent to 119 participating emergency departments in the Emergency Medical Services for Children program; responses were received from 103 (88% response rate). Only 44% of the emergency departments had a documented protocol for seizure management. Only 12% of emergency departments had child neurology consultation available at all times. Record review showed that 58% of patients were discharged home, 26% were transferred to another institution, and 10% were admitted to a non-intensive care unit setting. Ninety percent of patients were treated with anticonvulsants. Seizure education was provided by the primary emergency department nurse (97%) and the treating physician (79%). This project demonstrated strengths and weaknesses in the current management of pediatric seizure patients in Illinois emergency departments.

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.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.After two rounds of the modified Delphi, consensus for expected triage level was85% for 28 of 30 victims, with the remaining two achieving85% 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.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.

The death of a child in the emergency department (ED) is one of the most challenging problems facing ED clinicians. This revised technical report and accompanying policy statement reaffirm principles of patient- and family-centered care. Recent literature is examined regarding family presence, termination of resuscitation, bereavement responsibilities of ED clinicians, support of child fatality review efforts, and other issues inherent in caring for the patient, family, and staff when a child dies in the ED. Appendices are provided that offer an approach to bereavement activities in the ED, carrying out forensic responsibilities while providing compassionate care, communicating the news of the death of a child in the acute setting, providing a closing ritual at the time of terminating resuscitation efforts, and managing the child with a terminal condition who presents near death in the ED.

Emergency department (ED) management of skull fractures in children remains controversial. Because infants incurring head trauma have a high incidence of skull fracture, we chose to describe fractures in this subset of patients and to determine if there are clinical predictors of associated intracranial injury (ICI) that may have utility in developing more efficient management schemes in these patients.A retrospective medical record review was conducted on all awake patients13 months of age with an acute skull fracture from non-birth trauma, presenting to the ED of a university-affiliated children's hospital during a three-year period. Clinical and radiographic data extracted were used to describe skull fractures in these patients. The ability of various characteristics to determine the presence of ICI was assessed by calculating sensitivity, specificity, positive predictive value, and negative predictive value for each.The predominant mechanism of injury for the 102 infants was falls (91%). Suspicion of abuse was found in only one case. The parietal bone was fractured in 87 infants, and 34 had nonparietal fractures. The most prevalent fracture type was linear (92 infants), and 31 had1 cranial bone fractured. CT scans obtained on 32 infants (CT group) revealed 21 ICIs in 15 patients. Two with temporoparietal fractures required emergent evacuation of epidural blood. In the CT group, seven of the 15 (47%) with ICI (ICI group) were lethargic compared to two of the 17 (12%) without ICI (No ICI group) (P = 0.035). Five (33%) in the ICI group had temporal bone fractures compared to 0 in the No ICI group (P = 0.015). The presence of any sign or symptom had a sensitivity and negative predictive value of 100%, but only a specificity of 35%. The presence of lethargy had a positive predictive value of 78%. The presence of temporal and frontal bone fractures had positive predictive values of 100 and 75%, respectively.This study reports a high prevalence of fracture characteristics often associated with inflicted injury in other studies when virtually all injuries in our sample were accidental. Several clinical characteristics were demonstrated to be potentially useful in predicting ICI associated with skull fracture; however, prospective study is recommended to validate these findings prior to clinical application.

The objective of this guideline is to recommend evidence-based practices for timely prehospital pediatric seizure cessation while avoiding respiratory depression and seizure recurrence.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.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 if60 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.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.

Objective: To compare the efficacy and safety of continuous nebulized (CN) albuterol therapy with those of intermittent nebulized (IN) albuterol therapy in the ED treatment of children with moderate to severe asthma exacerbations. Methods: A prospective, randomized, single-blind study was conducted at a children's hospital ED. Patients aged 2 to 18 years with a moderate to severe asthma exacerbation (asthma score ≥8) were enrolled. Patients were randomized to receive either IN albuterol (0.15 mg/kg/dose every 30 min) or CN albuterol (0.3 mg/kg/ hr) for a maximum of 2 hours. All patients received prednisone at entry. All released patients were evaluated by telephone, 48 hours after the ED visit. Estimates of respiratory therapist (RT) time commitments for the 2 delivery systems were calculated. Results: There were 35 patients assigned to IN therapy and 35 to CN therapy. Nine of the 35 patients (26%) in the IN group and 8 of the 35 patients (22%) in the CN group were hospitalized (p = NS). Although the durations of ED therapy were comparable in the 2 groups, the time spent by the RTs in delivering asthma therapy was significantly less for the CN group than it was for the IN group (30.3 min vs 51.9 min per patient; p < 0.001). There was no major adverse effect in either study group. Conclusion: There was no difference in efficacy or safety between CN therapy and IN therapy in the ED management of moderate to severe asthma exacerbations in children. Moreover, CN therapy provided a significant time savings in the delivery of asthma therapy to patients in a busy ED.

Objective: To examine the concordance of pediatric radiograph interpretation between emergency medicine residents (EMRs) and radiologists. Methods: A prospective, observational study was performed in a university pediatric ED with an annual census of 60,000 visits. Radiographs ordered by EMRs from December 1993 through October 1994 were initially interpreted solely by the EMR, with subsequent unmasked final review by attending radiology staff. Misinterpreted radiographs were placed into 3 categories. The groupings included overreads, underreads with no change in treatment, and underreads that required a change in treatment. Results: A total of 415 radiographs were interpreted by PGY1–3 residents. Overall concordance was found for 371 radiographs (89.4%). There were 44 misinterpretations (10.6%), with 24 (5.78%) overreads, 13 (3.13%) underreads, and 7 (1.69%) underreads that required follow-up interventions. Misinterpretations were similar for the different levels of training: The 5 most frequently ordered radiographs were chest (28%), ankle (7%), foot (6%), wrist (5%), and hand (5%). The most frequently misinterpreted radiographs were sinus, foot, shoulder, facial, and hand. Conclusion: 89.4% of all the radiographs interpreted by PGY1–3 residents were read correctly. Only 1.69% of the misinterpreted radiographs led to a change in management. Level of training did not significantly correlate with radiograph misinterpretation rates.

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.

Disasters affect all ages of patients from the newborn to the elderly. Disaster emergency management includes all phases of comprehensive emergency management from preparedness to response and recovery. Disaster planning and management has frequently overlooked the unique issues involved in dealing with the pediatric victims of a disaster. The following will be addressed: disaster planning and management as related to pediatric patients and the integration of pediatric disaster management as part of an all-hazard, comprehensive emergency management approach. Key recommendations for dealing with children, infants, and special needs patients in a disaster are delineated.

Pediatric observation units (OUs) are hospital areas used to provide medical evaluation and/or management for health-related conditions in children, typically for a well-defined, brief period. Pediatric OUs represent an emerging alternative site of care for selected groups of children who historically may have received their treatment in an ambulatory setting, emergency department, or hospital-based inpatient unit. This clinical report provides an overview of pediatric OUs, including the definitions and operating characteristics of different types of OUs, quality considerations and coding for observation services, and the effect of OUs on inpatient hospital utilization.

Although most health care services can and should be provided by their medical home, children will be referred or require visits to the emergency department (ED) for emergent clinical conditions or injuries. Continuation of medical care after discharge from an ED is dependent on parents or caregivers’ understanding of and compliance with follow-up instructions and on adherence to medication recommendations. ED visits often occur at times when the majority of pharmacies are not open and caregivers are concerned with getting their ill or injured child directly home. Approximately one-third of patients fail to obtain priority medications from a pharmacy after discharge from an ED. The option of judiciously dispensing ED discharge medications from the ED’s outpatient pharmacy within the facility is a major convenience that overcomes this obstacle, improving the likelihood of medication adherence. Emergency care encounters should be routinely followed up with primary care provider medical homes to ensure complete and comprehensive care.

Study objective: To determine the efficacy of rectal midazolam as sedation for laceration repair in preschool children in the pediatric emergency department. Design: Randomized, double-blind, placebo-controlled trial. Participants: Thirty-four anxious children aged 14 to 51 months with face or scalp lacerations 3 cm or less in length requiring two or more sutures and behavior scores of 3 or more. Interventions: Subjects received 0.45 mg/kg rectal midazolam or saline placebo rectally followed by a topical anesthetic 15 minutes before repair. Results: Sixteen patients received rectal midazolam, and 18received placebo. The groups were similar in age, race, gender, laceration length and location, entry behavior score, and entry anxiety score. Ten patients in the rectal midazolam group and 1 in the placebo group achieved adequate sedation ( P P P =.003 and P =.08, respectively). Two patients in the rectal midazolam group experienced inconsolable agitation after the repair. None of the patients suffered cardiopulmonary complications. Conclusion: Rectal midazolam is an effective method of sedationfor facilitating uncomplicated laceration repair in preschool children. However, physicians must be aware of the possibility of paradoxical reactions when using midazolam in children.

Parental consent generally is required for the medical evaluation and treatment of minor children. However, children and adolescents might require evaluation of and treatment for emergency medical conditions in situations in which a parent or legal guardian is not available to provide consent or conditions under which an adolescent patient might possess the legal authority to provide consent. In general, a medical screening examination and any medical care necessary and likely to prevent imminent and significant harm to the pediatric patient with an emergency medical condition should not be withheld or delayed because of problems obtaining consent. The purpose of this policy statement is to provide guidance in those situations in which parental consent is not readily available, in which parental consent is not necessary, or in which parental refusal of consent places a child at risk of significant harm.

Background. Recent studies have shown that the use of parenteral corticosteroids in the emergency department decreases the hospitalization rate for patients with acute asthma. We studied the efficacy of oral corticosteroids in the emergency department treatment of moderately ill children with acute asthma. Methods. Emergency department patients aged 1 through 17 years whose chief complaint was acute asthma were assigned a pulmonary index, based on clinical evaluation. Those with a moderate exacerbation (pulmonary index = 9 through 13) received either 2 mg/kg of oral prednisone or placebo in a randomized, double-blind fashion. Patients in each group were then treated with an identical regimen of frequent aerosolized albuterol, for up to a maximum of 4 hours. Results. Seventy-five patients were assessed. Overall, 11 (31%) of 36 in the prednisone group required hospitalization compared with 19 (49%) of 39 in the placebo group (P = .10). Among the sickest patients (initial pulmonary index > 10), 7 (32%) of 22 prednisone-treated patients required hospitalization compared with 13 (72%) of 18 placebo-treated patients (P < .05). Among patients who had a suboptimal response to initial β2-agonist therapy and who therefore would have been hospitalized had treatment been restricted to 2 hours, 9 (45%) of 20 in the prednisone group ultimately required hospitalization when duration of care was extended 2 additional hours compared with 15 (83%) of 18 in the placebo group (P < .05). In addition, prednisone-treated patients had a significantly greater improvement in median pulmonary index (5.0 vs 3.0, P < .001). Conclusions. These data demonstrate that oral prednisone, within 4 hours of its administration, reduced the need for hospitalization among a subset of children treated in the emergency department for acute asthma.

Only recently has attention turned to the needs of children in the EMS system, and it has been shown that there is work to be done if these needs are to be met. The founders of EMS systems were trained in adult specialties and worked without input from the pediatric community. It is not surprising that the special needs of children within an adult-oriented EMS system were underemphasized. Children make up less than 10% of prehospital runs and less than 5% of the critically ill patients. Numerous EMS systems nationwide are undertaking this work and federal support is evident through the Maternal and Child Health EMSC program. Vital issues include the need for experts in emergency medical services to work together with experts in pediatric emergency care and for sound program evaluations to be performed to demonstrate the efficacy of these new programs.

In rural America pediatricians can play a key role in the development, implementation, and ongoing supervision of emergency medical services for children (EMSC). Often the only pediatric resource for a large region, rural access pediatricians are more likely to treat pediatric emergencies in their own offices, and are a vital resource for rural physicians, or other rural health care professionals (physician assistants, nurse practitioners), and emergency medical technicians (EMTs) to improve system-wide EMSC by providing education about issues from prevention to rehabilitation, technical assistance in protocol writing, hospital care, and data accumulation, and as advocates for community and state legislation to support the goals of EMSC.

This publication contains the pediatric and neonatal sections of the 2005 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations (COSTR). The consensus process that produced this document was sponsored by the International Liaison Committee on Resuscitation (ILCOR). ILCOR was formed in 1993 and consists of representatives of resuscitation councils from all over the world. Its mission is to identify and review international science and knowledge relevant to cardiopulmonary resuscitation (CPR) and emergency cardiovascular care (ECC) and to generate consensus on treatment recommendations. ECC includes all responses necessary to treat life-threatening cardiovascular and respiratory events.The COSTR document presents international consensus statements on the science of resuscitation. ILCOR member organizations are each publishing resuscitation guidelines that are consistent with the science in this consensus document, but they also take into consideration geographic, economic, and system differences in practice and the regional availability of medical devices and drugs. The American Heart Association (AHA) pediatric and the American Academy of Pediatrics/AHA neonatal sections of the resuscitation guidelines are reprinted in this issue of Pediatrics (see pages e978–e988).The 2005 evidence evaluation process began shortly after publication of the 2000 International Guidelines for CPR and ECC. The process included topic identification, expert topic review, discussion and debate at 6 international meetings, further review, and debate within ILCOR member organizations and ultimate approval by the member organizations, an Editorial Board, and peer reviewers. The complete COSTR document was published simultaneously in Circulation (International Liaison Committee on Resuscitation. 2005 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations. Circulation. 2005;112(suppl):73–90) and Resuscitation (International Liaison Committee on Resuscitation. 2005 International Consensus Conference on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations. Resuscitation. 2005;67:271–291).Readers are encouraged to review the 2005 COSTR document in its entirety. It can be accessed through the CPR and ECC link at the AHA Web site: www.americanheart.org. The complete publication represents the largest evaluation of resuscitation literature ever published and contains electronic links to more detailed information about the international collaborative process.To organize the evidence evaluation, ILCOR representatives established 6 task forces: basic life support, advanced life support, acute coronary syndromes, pediatric life support, neonatal life support, and an interdisciplinary task force to consider overlapping topics such as educational issues. The AHA established additional task forces on stroke and, in collaboration with the American Red Cross, a task force on first aid. Each task force identified topics requiring evaluation and appointed international experts to review them. A detailed worksheet template was created to help the experts document their literature review, evaluate studies, determine levels of evidence, develop treatment recommendations, and disclose conflicts of interest. Two evidence evaluation experts reviewed all worksheets and assisted the worksheet reviewers to ensure that the worksheets met a consistently high standard.A total of 281 experts completed 403 worksheets on 275 topics, reviewing more than 22000 published studies. In December 2004 the evidence review and summary portions of the evidence evaluation worksheets, with worksheet author conflict of interest statements, were posted on the Internet at www.C2005.org, where readers can continue to access them. Journal advertisements and e-mails invited public comment.Two hundred forty-nine worksheet authors (141 from the United States and 108 from 17 other countries) and additional invited experts and reviewers attended the 2005 International Consensus Conference for presentation, discussion, and debate of the evidence. All 380 participants at the conference received electronic copies of the worksheets. Internet access was available to all conference participants during the conference to facilitate real-time verification of the literature. Expert reviewers presented topics in plenary, concurrent, and poster conference sessions with strict adherence to a novel and rigorous conflict of interest process. Presenters and participants then debated the evidence, conclusions, and draft summary statements. Wording of science statements and treatment recommendations was refined after further review by ILCOR member organizations and the international editorial board. This format ensured that the final document represented a truly international consensus process.The COSTR manuscript was ultimately approved by all ILCOR member organizations and by an international editorial board. The AHA Science Advisory and Coordinating Committee and the editor of Circulation obtained peer reviews of this document before it was accepted for publication.The most important changes in recommendations for pediatric resuscitation since the last ILCOR review in 2000 include: Increased emphasis on performing high quality CPR: “Push hard, push fast, minimize interruptions of chest compression; allow full chest recoil, and don't provide excessive ventilation” Recommended chest compression-ventilation ratio: For lone rescuers with victims of all ages: 30:2For health care providers performing 2-rescuer CPR for infants and children: 15:2 (except 3:1 for neonates)Either a 2- or 1-hand technique is acceptable for chest compressions in childrenUse of 1 shock followed by immediate CPR is recommended for each defibrillation attempt, instead of 3 stacked shocksBiphasic shocks with an automated external defibrillator (AED) are acceptable for children 1 year of age. Attenuated shocks using child cables or activation of a key or switch are recommended in children Some of the most important changes in recommendations for neonatal resuscitation since the last ILCOR review in 2000 include less emphasis on using 100% oxygen when initiating resuscitation, de-emphasis of the need for routine intrapartum oropharyngeal and nasopharyngeal suctioning for infants born to mothers with meconium staining of amniotic fluid, proven value of occlusive wrapping of very low birth weight infants The scientific evidence supporting these recommendations is summarized in the neonatal document (see pages e978–e988).

Objective To determine if high-dose epinephrine (HDE) used during out-of-hospital cardiopulmonary arrest refractory to prehospital interventions improves return of spontaneous circulation, 24-hour survival, discharge survival, and neurological outcomes. Methods A multicenter randomized controlled trial was conducted between May 1991 and October 1996 to compare the effectiveness of HDE versus standard-dose epinephrine (SDE) in patients having out-of-hospital cardiopulmonary arrest refractory to prehospital resuscitation efforts. Cardiopulmonary arrest was classified as "medical" or "traumatic." Two hundred thirty patients were enrolled in 7 pediatric emergency departments. Ages ranged from newborn to 22 years. Seventeen patients met exclusion criteria. Patients were assigned to receive HDE (0.1 mg/kg for the initial dose and 0.2 mg/kg for subsequent doses) or SDE (0.01 mg/kg). The main end points evaluated were return of spontaneous circulation, 24-hour survival, discharge survival, and neurological outcome. Results One hundred twenty-seven patients received HDE (32 trauma patients), and 86 patients received SDE (27 trauma patients). Among medical patients, 24 (25%) of 95 experienced return of spontaneous circulation in the HDE group as compared with 9 (15%) of 59 in the SDE group (P = 0.14, chi2 = 2.17, relative risk = 1.66 [0.83-3.31]). Sixteen (17%) of 95 HDE patients and 5 (8%) of 59 SDE patients survived at least 24 hours (P = 0.14, chi2 = 2.16, relative risk = 1.99 [0.77-5.14]). Nine survivors to discharge received HDE, and 2 received SDE (P = 0.21, Fisher exact test, relative risk = 2.75 [0.61-12.28]). There were no long-term survivors among the trauma patients. Eight of 11 long-term survivors had severe neurological outcomes defined by the Glasgow Outcome Scale (2/2 SDE, 6/9 HDE; P = 0.51, Fisher exact test). Conclusion HDE does not improve or diminish return of spontaneous circulation, 24-hour survival, long-term survival, or neurological outcome compared with SDE in out-of-hospital cardiopulmonary arrest.

This survey was conducted to obtain information about career and practice issues facing pediatric emergency medicine (PEM) physicians and general emergency medicine (GEM) physicians. We hypothesized that PEM physicians work fewer clinical hours and perform more teaching and research in their positions than GEM physicians.Two surveys sponsored by the Future of Pediatric Education II Project were sent to 1545 emergency physicians identified by the American Board of Pediatrics, the American Academy of Pediatrics, and the American College of Emergency Physicians between October 1997 and February 1998. Data on demographics, job description, recent job changes, and career expectations were obtained and analyzed using Student t test or Welch analysis of variance for continuous variables and chi2 for categorical data. P values less than 0.05 were considered significant. Comparisons between PEM and GEM physicians were adjusted using analysis of covariance to control for the effect of medical school affiliation.Effective response rate was 934 (64%) of 1451. A total of 705 (75%) respondents identified themselves as a PEM physician, and 229 (25%) identified as a GEM physician. PEM physicians were younger (41.0 y vs 45.1 y) and more likely to be women (44% vs 15%, P0.0001 for both). Children younger than 18 years made up 80.9% and 28.6% of patients seen by PEM and GEM physicians, respectively (P0.001). Seventy-nine percent of PEM physicians and 42% of GEM physicians held an academic appointment (P0.0001). No differences were found for full-time equivalents per physician group (9.7 vs 9.1) or clinical hours spent in the emergency department (ED) (31.5 vs 32.7) when means were adjusted for academic appointment. During ED clinical activities, PEM physicians reported more time spent supervising trainees (34% vs 16%, P0.0001), and GEM physicians reported more time spent in direct patient care (77% vs 57%, P0.0001). Total clinical hours worked per week were greater for GEM physicians (37.9 vs 35.3, P0.05). PEM physicians spent more time than GEM physicians teaching (12% vs 8%, P0.005) and conducting clinical research (5% vs 2%, P0.0003). Of PEM and GEM physicians combined, 26% reported a job change in the past 3 years. Extended reduction of ED clinical duties occurred most commonly because of child care issues and was reported more commonly by women than men (53% vs 6%, P0.0001) irrespective of PEM or GEM practice. The likelihood of leaving emergency medicine practice within 5 years increased with age for both groups: 10% of PEM and GEM physicians under 40 years old anticipated leaving practice versus 30% of those older than 50 years (P0.0001). PEM physicians were more likely than GEM physicians to predict an increased need for additional pediatric subspecialists in general (60% vs 26%, P0.001) and for pediatric subspecialists in their discipline (54% vs 17%, P0.001). PEM subspecialists were twice as likely as GEM specialists to perceive competition in their subspecialty (60% vs 31%, P0.001).According to our sample, GEM and PEM physicians worked the same number of clinical hours in the ED but reported significant differences in how those hours are spent. Job changes and extended leaves were common in both groups. These results suggest that PEM and GEM physicians face similar vocational challenges, especially in the areas of balancing of family time, clinical hours, and academic productivity. These data also have important implications for workforce projection for the PEM physician supply, given the current estimated attrition rate, frequency of leave from clinical duties, and projection for increased need for PEM physicians in the future.

Objective: To determine the effect of an inhaled 50% nitrous oxide/50% oxygen mixture on measures of observed anxiety in children during laceration repair. Methods: A prospective, randomized, placebo-controlled, double-blind comparison of an inhaled 50% nitrous oxide/50% oxygen mixture (treatment group) with 100% oxygen (control group) during repair of lacerations was performed. The study population was a convenience sample of children aged 2–7 years in an urban pediatric ED. The primary outcome variable was the change in scores before and during laceration repair with a 10-point modified Children's Hospital of Eastern Ontario Pain Scale (CHEOPS) assessment. The secondary outcome variable was a 4-point anxiety scale measured before and during the procedure. Results: Thirty patients were entered into the study. Seventeen children inhaled the 50% nitrous oxide/oxygen mixture and 13 inhaled 100% oxygen during laceration repair. There was no statistically significant difference in initial CHEOPS and anxiety scores between the 2 groups (p = 0.687 and 0.809, respectively). The median CHEOPS scores in the treatment group decreased by 5 points, while those of the control patients increased by 3 (p < 0.001). The median anxiety scores in the treatment population decreased by 1 point, with an increase of 1 for the control patients (p < 0.001). Conclusion: Administration of a 50% nitrous oxide/50% oxygen mixture to children during their laceration repair resulted in a significant decrease in measures of anxiety when compared with inhalation of 100% oxygen.

In a quality and cost-conscious health care environment, the pediatrician and emergency physician must work as a team. This statement clarifies important issues of this relationship, including coordination of patient care, communication between clinicians, provision of continuity care, and responsibility for quality emergency care.