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Beyond the Basics: Trends and Changes in Pediatric Care
CEU Review Form Trends and Changes in Pediatric Care (PDF)Valid until June 8, 2007
Changes in the standard of care for pediatric patients are not something the medical community takes lightly. In the world of medicine, clinical care guidelines are typically developed around sound clinical research; however, there is an exception to this rule when developing clinical care guidelines for use with the pediatric patient. Although this is counterintuitive, it does make sense; there are fewer research projects involving children and, as a result, less science to support changes in clinical care guidelines.
Interestingly enough, the lack of evidence-based medicine in pediatrics draws a direct comparison between pediatric medicine and EMS. In the early days of EMS, clinical care guidelines were based simply on the current practices of the day and a physician or surgeon deciding that an intervention had merit in the out-of-hospital environment.
This article reviews some of the scientifically published articles that affect children and relate to EMS. The reviews in this article are not intended to be recommendations for change in your clinical practice. If you are interested in implementing any changes to your protocols based on information contained in this article, we suggest you review the literature and any peripheral studies related to the guideline you hope to change and involve your medical director early in the process.
Evidence-Based Medicine
Evidence-based medicine (EBM) is defined as judicious use of the best current evidence in making decisions about the care of an individual patient. The intent of EBM is to integrate clinical expertise with the best available research evidence while observing the psychosocial needs of the child.
Evidence-based medicine follows four steps:
- Formulate a clear clinical question from a patient's problem>
- Conduct a literature search of peer-reviewed journals for relevant clinical articles
- Evaluate the literature for its value to EMS practice and collaborate with your medical director
- Implement changes to the patient care protocols.
Family-Centered Care
The concept of family-centered care was initially introduced by Foote Hospital in Michigan and prompted former U.S. Surgeon General C. Everett Koop's initiative for family-centered, community-based, coordinated care for children with special healthcare needs and their families in 1987. Family-centered care suggests that healthcare providers acknowledge and utilize the family's knowledge of their family member's condition and make use of the family's abilities to communicate with their family member.
Although the concept of family-centered care is not new, it is new to EMS. This initiative is championed by EMS for Children (EMSC). EMS providers must garner an appreciation and understanding of family-centered care, of which a major principle is the need to understand normal growth and psychosocial development. With a comprehensive understanding of the principles of growth and development, EMS providers will be able to anticipate the physiologic needs of children based on the effects of illness or injury. Furthermore, family-centered care advocates open communications with family members throughout the assessment and management of the child.
Pediatric Trauma Care
One of the most important considerations in management of the pediatric trauma victim is transport destination. It is critically important for EMS providers to understand that there are significant differences between adult and pediatric trauma centers. Although we recognize that certain parts of the country do not have readily available access to a pediatric trauma center, many do have access to rapid air medical capabilities that can provide transport to a pediatric trauma center.
A significant number of traumatically injured children across the country are being treated in non-trauma facilities. For years, there have been numerous debates on the real impact of pediatric trauma centers over adult trauma centers in the management of critically injured children. The debate is over: Pediatric trauma centers do make a difference. As with any clinical practice, the findings of a single study cannot and should not change practice, but we have identified four studies that concluded that injured children treated at pediatric trauma centers have better outcomes and are more likely to survive than those treated at adult trauma centers. It is important to note that one of these studies also concluded that children treated at a pediatric trauma center or an adult trauma center with a pediatric commitment had significantly better outcomes compared with those treated at adult trauma centers. The single greatest variation between pediatric trauma centers and level I adult trauma centers with a pediatric commitment was nonsurgical treatment of injured children compared with treatment in a pediatric trauma center.
While it is important to recognize the value of pediatric trauma centers, it is equally important to recognize the need for rapid care of a trauma patient. If the child requires trauma care and a pediatric center is reasonably close, he should be taken to the pediatric center. If transport to a pediatric trauma center can be rapidly accomplished through air medical resources, it should be attempted, with the understanding that waiting on scene for a helicopter is not appropriate. An option would be to have the helicopter meet the ambulance at the local hospital or adult trauma center for transfer as necessary.
Changes in AHA Standards
The first major change in the CPR guideline for children is a change in compression-to-ventilation ratio. The previous 3:1 and 5:1 ratios, which no longer exist, have been replaced with the 30:2 ratio. These changes occurred because there was no evidence-based medicine to support the variations in compression-to-ventilation ratios between various age groups.
An additional change to the CPR guidelines is the recommendation to limit the time of ventilation delivery to one second, rather than up to two seconds. This recommendation occurred as a result of EBM's finding that too much ventilation actually promotes limited blood return to the heart because of higher pressures inside the chest.
The previous ECC guidelines recommended three stacked shocks in the event of cardiac arrest. The new guidelines recommend that only one shock be delivered by an AED because of the time required (30-60 seconds) to reanalyze the cardiac rhythm. If three stacked shocks were still implemented, the patient would be without oxygen or circulation for one to two minutes while the AED analyzed. This is not an option, since the majority of cardiac arrests in children occur as a result of hypoxia. In addition, research has demonstrated that in most cases of ventricular fibrillation (a rare rhythm in children) cardiac arrest, the first shock will terminate the VF and therefore the two latter shocks will not be warranted. The guidelines also suggest that CPR be conducted for two minutes before attaching the AED to the patient because of the child's sensitivity to hypoxia. The most important consideration in the AHA standards remains BLS maneuvers and assurance that hypoxia does not develop. Hypoxia kills kids!
The Pediatric Airway
Airway management is the single most important skill of an EMS provider. This is especially true with regard to managing a pediatric patient. Children are highly sensitive to changes in oxygen saturation; without an adequate airway, they will rapidly deteriorate and die.
BVM
Bag-mask ventilation is the preferred means for ventilating and oxygenating pediatric patients. It is often difficult to distinguish between respiratory distress and failure without providing bagged ventilation. A child with respiratory compromise who responds well to bag-valve mask ventilation and quickly returns to the prior state of distress should be considered to be in respiratory failure. If the child remains in respiratory failure despite appropriate resuscitative interventions, intubation or another form of invasive ventilation should be considered.
Intubation
If intubation is necessary, it is still recommended in the prehospital setting to use an uncuffed ET tube. In recent changes to the PALS guidelines, there has been some discussion about whether a cuffed or uncuffed ET tube is preferred. While there are valid concerns on both sides of the argument, the reason that an uncuffed ET tube currently remains preferred in the prehospital setting is because of the concern for overinflation of the cuff and, ultimately, damage to the airway. During the in-hospital phase of care, cuffed tubes may be appropriate because cuff pressures can be better controlled and are advocated because they protect the airway from aspiration and are more appropriate for high airway pressures, as in the case of asthma. One study at Children's Hospital Los Angeles involving 210 children intubated with cuffed endotracheal tubes demonstrated no significant difference in the airway, regardless of whether the tube was cuffed or not.
For many years, EMS providers have utilized the three-times tube size to determine the appropriate depth for ET tube placement. A recent study showed that using this formula has contributed to 15%-25% tube malposition. The study further suggested that the reliability of this formula could be improved through utilizing the recommended ETT size as suggested by pediatric resuscitation guides (Broselow tape, crash cards, etc.). Remember, however, that BLS rules. Above all else, when you ensure solid BLS airway care, you are doing well for your pediatric patient.
LMA
The laryngeal mask airway (LMA) was introduced in 1983, but was not used in clinical practice in the United States until 1992. The LMA is a tube with an inflatable mask designed to occlude the esophagus, while allowing for adequate, but low-pressure, ventilation. In EMS, the LMA is used by BLS providers not trained in tracheal intubation and by ALS providers as a rescue device.
The role of the LMA is variable from region to region due to the lack of adequate science and clear prehospital practice guidelines. In one study involving paramedic and medical students, 94% of trainees were able to successfully insert an LMA in a manikin on the first attempt, compared with 69% with an ET tube. Furthermore, five students were unable to place an ET tube after three attempts, compared to none using the LMA. The overall time to adequately ventilate the manikin with an LMA was 39 seconds versus 88 seconds with the ET tube.
When compared to a bag-valve mask, the LMA is thought to be easier to insert and has been shown to produce more effective ventilation with less gastric insufflation, since excess pressure is vented upward around the LMA rather than forced down the esophagus, as in the case of BVM ventilation. Unfortunately, there are few studies in the prehospital use of LMAs and none in prehospital pediatrics.
Should Parents Be Present During Resuscitation?
Some EMS providers are afraid of having parents present when managing a pediatric patient. This may be the result of perceived intimidation or distraction, resulting in procedural performance anxiety and a resultant deleterious outcome. Other fears may be of litigation in the event of a complication or bad outcome, or that the presence of parents may adversely affect the child's behavior.
There are several studies, however, that suggest the opposite is true. In one study, parents actually appeared to be more accepting of the death of their child when they were present during the resuscitation. This may be because they were able to see that everything possible was done for their child and they could achieve closure.
In another study involving emergency medicine physicians, researchers also did not find that the presence of parents had a deleterious effect on performance. This result suggests that procedures can be performed without much change in success rate despite the fact that parents are present. Interestingly, children were also found to be more cooperative and less fearful when their parents were present. This suggests that procedural success rates may actually be higher if parents are with the child.
Yet another study demonstrated that, when given the option, most parents preferred to remain with their child during a resuscitation or procedure and, as a result, viewed the experience as favorable. Even in the case of pediatric death, the majority of parents were thankful for their involvement in the process. Your rationale for excluding parents (whether to protect them or you) may do more harm than good.
Pediatric Traumatic Brain Injury
Prehospital providers have the distinct advantage of being first on scene in the event of a pediatric brain injury. As discussed earlier in this article, evidence-based medicine needs to be the basis for everything we do, but, in children, it is often hard to come by. Initial studies involving clinical therapy intended for children are often conducted on animal models. Many studies have demonstrated that much of the damage to a brain occurs within the first few hours after the initial head injury and is known as primary injury. Therefore, prehospital providers should concentrate their efforts on preventing secondary brain injury that occurs hours to days after the primary injury.
Future research in TBI will likely include prevention of hyperthermia in the prehospital setting with the use of rectal antipyretic agents (drugs that reduce fever) and other cooling modalities. Therapeutic hypothermia has shown some promise in animal and adult models. Antioxidants have also shown promise in preventing secondary brain injury. Hypertonic saline (7.5% NaCl) is another therapy that has been shown to potentially improve survivability in the early management of severe TBI. Hypertonic saline has greater value than mannitol in TBI management, because it decreases cerebral edema while conserving the circulating volume to prevent hypotension. Regardless of what the future holds, effective oxygenation and ventilation will either decrease the potential for or completely protect the child from secondary brain injury.
Pediatric Seizure Management
Prolonged seizure activity in a child can provide significant challenges for the prehospital care provider. It is well documented that the duration of seizure activity has a direct impact on death and disability. Management of seizures in the prehospital setting is accomplished through administration of benzodiazepines like Valium, Ativan and Versed.
Unfortunately, traditional medication delivery routes are routinely difficult for prehospital providers to access due to their lack of experience and competence in intravenous access. These difficulties can be exponentially increased if the child is actively seizing. In the majority of cases, IV access may be attempted without success and is often followed by administration of rectal Valium. Although an appropriate therapy, Valium administered rectally has been shown to be less effective in managing seizures compared with intravenous medication administration. Recent studies have suggested that intranasal Versed is safe and easy to administer to the actively seizing child and works better than rectal and intravenous drug delivery. Intranasal medication administration ensures that the drug is delivered directly to the blood and cerebrospinal fluid via the nasal mucosa. The key to pediatric seizure management is rapid cessation of seizure activity.
CEU Review Form Trends and Changes in Pediatric Care (PDF)Valid until June 8, 2007
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William S. Krost, BSAS, NREMT-P, is an operations manager and flight paramedic with the St. Vincent/Medical University of Ohio/St. Rita's Critical Care Transport Network (Life Flight) in Toledo, OH, and a nationally recognized lecturer.
Joseph J. Mistovich, MEd, NREMT-P, is a professor and chair of the Department of Health Professions at Youngstown (OH) State University, author of several EMS textbooks and a nationally recognized lecturer.
Daniel D. Limmer, AS, EMT-P, is a paramedic with Kennebunk Fire-Rescue in Kennebunk, ME, and EMS Program Coordinator at York County Community College in Wells, ME.
