A 14-month-old boy in respiratory distress is carried into your ED by his parents after choking on a piece of meat. Upon presentation, he is noted by the nurse to have audible stridor and severe retractions. His initial vital signs are: heart rate, 190 beats/min; respiratory rate, 10 breaths/min; oxygen saturation, 78% on room air; temperature, 37.4ºC; and blood pressure, 90/54 mm Hg. The patient is rapidly triaged using the Emergency Severity Index, and on arrival at the patient’s bedside, you are immediately notified by the staff of abnormal vital signs. You initiate bag-mask ventilation for hypoventilation and hypoxia. There is poor chest rise, and you feel resistance to ventilation. You recognize that this child is in respiratory failure with an upper airway obstruction, and you begin the process of relieving the obstruction. The scenario calls to mind a meeting you had earlier that morning regarding treatment of pediatric patients in your ED and equipment you might need. You think about some of the questions that were brought up and how they might apply to care for this child, such as:
Because parents are most likely to take sick children to the closest emergency department (ED), 90% of children are seen in general EDs.1,2 On the emergency clinician's side, however, opportunity to care for critically ill or injured children is relatively uncommon, and anxiety can be high when such children present. Discovering that the necessary equipment and personnel are not available to respond efficiently should never occur at the moment they are needed. Just as hospitals anticipate and prepare for the care of trauma, stroke, and cardiac patients, preparation for the care of children should also be in place. Guidelines for pediatric readiness are well defined and readily available from many sources. Developing the expertise within hospitals to ensure pediatric readiness of EDs can be a challenge, but it can be accomplished with dedicated staff assigned to the role of ensuring readiness.
Evidence-based medicine requires a critical appraisal of the literature based upon study methodology and number of subjects. Not all references are equally robust. The findings of a large, prospective, randomized, and blinded trial should carry more weight than a case report.
To help the reader judge the strength of each reference, pertinent information about the study, such as the type of study and the number of patients in the study will be included in bold type following the references, where available. The most informative references cited in this paper, as determined by the author, will be noted by an asterisk (*) next to the number of the reference.
Katherine Remick, MD, FAAP; Sally Snow, BSN, RN, CPEN, FAEN; Marianne Gausche-Hill, MD, FACEP, FAAP
December 1, 2013