Pediatric emergency medicine trisk 4622 4622
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hospital, such as a cardiac catheterization team on-call or a pediatric trauma center, and the distance and time to a
receiving facility. Many EMS systems are now specifying certain hospitals as approved POE for conditions such
as stroke, acute coronary syndrome, or pediatric trauma. This assures that the patient is going to a facility that can
best manage their condition.
Regionalization is “a process of organizing resources within a geographic region to ensure access to medical
care of a level appropriate to a patient’s needs, while maintaining efficient use of available resources.” The
purpose is to ensure that services and resources are optimally allocated and used to improve the health of patients
across an entire region. Regionalization incorporates categorization to delineate available regional resources,
accreditation to verify institutional commitment to provide the needed services, and designation to preclude the
inefficient duplication of resources. In the 1980s, evidence supporting the regionalization of trauma care was
published, and the ACS-COT formed the trauma center verification review program in 1987. The past decade has
seen the development of regionalized systems of care for ST-elevation myocardial infarction and stroke.
Pediatric emergency care regionalization in the United States is still undergoing development and refinement.
It has been recognized as a priority by the IOM, and the EMSC program has published a Pediatric
Regionalization of Care Primer, available at ter/programs/sproc/sproc-grantresources-and-products/ .
The primer is an excellent resource for those who are interested in organizing shared resources to optimize
access to pediatric specialty care.
PEDIATRIC PREHOSPITAL AIRWAY MANAGEMENT
Respiratory arrest is the most common cause of pediatric cardiac arrest and is associated with three conditions
seen frequently in the prehospital setting: trauma, respiratory distress, and seizures. Emergency airway
management can be lifesaving for critically ill children; however, it requires a significant amount of training and
experience and a broad range of skills in evaluation and interventions. The high-risk and low-frequency nature of
pediatric airway management allows for controversies in current recommendations.
ETI is taught in the majority of paramedic schools and has been accepted in the scope of practice for
paramedics for decades. The current literature on pediatric prehospital ETI highlights several shortcomings, and
few studies have shown improved patient outcomes. Errors and adverse events are frequent, with successful
intubation rates documented between 60% and 85%, while complications such as esophageal intubation or
unrecognized tube dislodgement are noted in 2% to 25% of successful intubations. In addition, skill deterioration
is almost inevitable, as only 1% to 5% of pediatric patients treated in the prehospital setting receive airway
management. In some systems, paramedics may attempt pediatric intubation no more than once a year.
The largest randomized controlled trial of ETI versus noninvasive bag-valve-mask (BVM) ventilation was
published in 2000. The study included 830 patients under the age of 13 in two large metropolitan counties served
by 56 EMS agencies. Results demonstrated no difference in mortality or neurologic outcomes across the study
population; however, the results also noted that scene time and total prehospital time was significantly longer in
the ETI group. Retrospective review of the National Pediatric Trauma Registry revealed significantly higher
observed versus expected mortality for children intubated in the prehospital setting across all injury severities.
Both of these studies were performed before the common use of rapid sequence intubation (RSI) medications.
Newer technologies can aid in placement of endotracheal tubes or provide enhanced ventilation without an
endotracheal device. Video laryngoscopy has been employed in the hospital setting to improve airway
visualization and supervision of trainees. Studies in a simulated prehospital setting have shown promise for its
widespread use; however, none of these studies have addressed pediatric patients. Alternatives to ETI include
supraglottic airway devices, such as the laryngeal mask airway device and laryngeal tube device. The laryngeal
mask airway is available for use in smaller patients, including neonates, while commercially available laryngeal
tubes, like the King airway (Kingsystems, Noblesville, IN), are not suitable for use in patients under 10 kg.
Available research on supraglottic devices in pediatric patients is limited to studies performed in the operating
room or simulation setting, and further studies on the use of these devices in the prehospital setting is needed.
Chemically assisted intubation with medications, drug-facilitated intubation or RSI, is commonly used in the
ED setting and has wide use in U.S. aeromedical and European EMS systems. An international meta-analysis
including pediatric patients has documented increased ETI success rates with the use of RSI. Perspectives from
an expert panel on RSI for head-injured patients concluded that literature examining RSI by EMS systems is
inconclusive with differences in outcomes, possibly related to EMS and trauma system characteristics. This group
