Simulation in the pediatric emergency department

Simulation provides a means to educate, monitor, evaluate, and potentially document the competency of emergency physicians. The evolution of high-fidelity simulators has led to a surge of enhanced medical applications that fit nicely into the core of emergency medicine training. Simulation can facilitate training in resuscitation, procedures, CRM, and mass casualty management. Although improved outcomes from simulation are not well established, there is a general consensus regarding the added value over current training. And finally, simulation provides the ability to construct training to match the current educational efforts related to individual physicians or system-level improvements in communication and patient safety.     

规范儿科急诊预检与分诊

分析儿科急诊预检分诊的国内外现状,阐述急诊预检分诊的目的及正确实施预检分诊在急诊医疗服务中的重要性,提出对儿科急诊预检分诊的建议和设想.     

Managing headache in the pediatric emergency department

Headache is a common complaint in children and adolescents. While the majority of headaches are self-limited and benign, headaches occasionally herald a life-threatening illness such as a brain tumor, intracranial hemorrhage, or meningitis. The emergency department physician has to distinguish between “benign” and “serious” headaches and therefore must have a rational, organized approach to the evaluation of these patients. This article will focus on a clinical classification system for childhood and adolescent headaches and discuss their emergency department evaluation and current recommended therapy.     

End-of-life issues in the pediatric emergency department

The death of a child is one of the most tragic and stressful times in the life of a parent or caretaker. The natural order seems contradicted. Countless and unforeseen problems and challenges exist for the family of the child who died. Physicians, however, are also greatly affected by the death of a patient. In Western society, death has become institutionalized and secularized, and there are fewer societal support systems to facilitate bereavement. Physicians may find themselves in the unexpected role of providing these services at the time of death. Despite or perhaps because of these challenges, there are many appropriate and well-received interventions for bereaved families. The emergency department (ED) is a place where many lives are saved and a few lost. Most ED deaths are unexpected and are usually caused by trauma or acute infections. But many children with terminal diseases, chronic illnesses, and technological dependence are now living at home, and may present to the ED with complications leading to death. This article will address many of the procedural and ethical issues surrounding end-of-life care for children in the ED.     

Acute asthma in the pediatric emergency department

The management of children with acute asthma remains a difficult and challenging process. Although newer asthma medications are being developed, they are unlikely to have a large impact on the management of children with acute asthma. The leukotriene inhibitors are new anti-inflammatory agents for asthma and are beneficial for the treatment of patients with chronic asthma but have no therapeutic effect during the acute phase of an exacerbation. Older treatments, including the use of magnesium and heliox, have been revisited. Although some children with severe asthma may respond, these do not provide relief for most children with acute exacerbation. The new challenge for asthma care is finding ways to link children with their primary care providers so that regular asthma care can be established. The NHLBI recommends that children with asthma have regular visits with their primary care providers (e.g., four times a year). Regular care results in better adherence to medical and preventive management plans and improves the relationship between patients and physicians. Instituting an asthma action plan, which instructs families on when and how to begin therapy for an acute exacerbation, may prevent progression to a more severe condition.     

Managing pain in the pediatric emergency department

In summary, it is common to encounter children in pain in the pediatric ED. It is often impossible to avoid inflicting pain on some children in the ED. The proper management of this pain is thus essential. This management should be accomplished with a variety of narcotic and nonnarcotic analgesics, as well as local and topical anesthetics. Other agents such as nitrous oxide, and techniques such as hypnosis and transcutaneous nerve stimulation, have a more limited role in pain management. Gentle restraint and reassurance are of paramount importance.     

Analgesia in the pediatric emergency department]

Pain concerns more than 50% of the children cared in the emergency unit. After evaluation, it has to be cured with drugs adapted to its level and its origin. Residual pain needs therapeutic adjustment. The goal is to allow the child to restart his activities. A preventive sedation analgesia is necessary when a painful exam is to be performed, either for diagnosis or therapeutic purpose. For this goal ideal analgesics, either for monotherapy or associated, are easily and painlessly administered. They have rapid onset of action, brief half-life, predictable, effective analgesic properties without side effects and they are quickly reversible. These drugs do not exist and every sedation procedure has a risk of hypoxemia. With the human and equipment's investment an emergency department should be able to ensure that procedures are performed in children under sedation with a standard of safety that is similar to general anaesthesia. The main drawback in a well-organised system should be a significant children's rate for which general anaesthesia is preferred.     

Nitrous oxide in the pediatric emergency department

Nitrous oxide is a gas that has anxiolytic, amnestic, and mild-to-moderate analgesic properties. Patients describe a detached or “floating” sensation but typically remain awake during the procedure and are able to follow commands while breathing the gas. Nitrous oxide is particularly useful in the emergency department because it does not require intravenous access and has a rapid onset of action (< minutes) and recovery (< 5 minutes). There are no reports of adverse cardiopulmonary events, but minor side effects, including vomiting, dizziness and headache, occur in 6% to 30% of patients. The authors use a relatively inexpensive, in-house-constructed, continuous-flow system, with an alarmed nitrous oxide-oxygen oxygen blender and in-wall suction/gas scavenging, to provide sedation for children undergoing suturing, intravenous cannulation, lumbar puncture, foreign body removal, burn debridement, and minor fracture reductions. Cardiorespiratory monitors, including pulse oximetry, bag-valve-mask device, oxygen, and auxiliary wall suction, should be prepared before administration, and all patients must be monitored in accordance with American Academy of Pediatrics guidelines.     

Detection of cancer in the pediatric emergency department

We reviewed the Tumor Registry for 1981 at the Children's Hospital of Philadelphia to identify all the children with newly diagnosed cancer who were seen initially in the emergency department (ED). Of the 220 new patients listed, 16 (7.3%) sought initial care in the ED (1 per 4,500 ED visits). Seven had leukemia, five had non-CNS solid tumors (2 lymphoreticular, 1 Wilms', 1 neuroblastoma, and 1 ovarian), and four had CNS tumors. Among the children with leukemia, pallor (6) and decreased activity (4) were the most common complaints. Duration of symptoms ranged from 4 days to 3 weeks. Physical examination showed pallor (5), splenomegaly (4), fever (3), hepatomegaly (3), lymphadenopathy (3), and ecchymoses or petechiae (2). The complete blood count and peripheral smears were all abnormal. The five patients with non-CNS solid tumors had symptoms related to the location of their neoplasms. The patients with Wilms' tumor, neuroblastoma, and ovarian dysgerminoma had abdominal masses; the patient with lymphoma had a large, painful inguinal node; and the patient with histiocytosis X had an infiltrative rash, gingivitis, and pneumonitis. Of the four children with CNS tumors, three had headache, and one had an incidentally detected scotoma following head trauma. All four eventually had abnormal neurologic exams and computer tomographic scans, but two were discharged initially with psychiatric diagnoses. We conclude that cancer, although rare in children, occurs with greater relative frequency in the referral hospital ED than that predicted by published cancer rates from the referring hospital's ED.(ABSTRACT TRUNCATED AT 250 WORDS)     

Recognizing serotonin toxicity in the pediatric emergency department

ABSTRACT: The use of selective serotonin reuptake inhibitors and serotonin-norepinephrine reuptake inhibitors in treating depression, mood disorders, and behavioral disorders has escalated dramatically in the last 20 years, resulting in increased risk and clinical presentation of serotonin toxicity. Health care providers must also be aware of other medications and substances with proserotonergic activity that can cause serotonin toxicity when used in combination with these medications. There are many adverse effects of selective serotonin reuptake inhibitors and serotonin-norepinephrine reuptake inhibitors, although their toxicity profile compared to older antidepressants seems to be safer. Serotonin syndrome is described as a clinical triad of mental status changes, autonomic hyperactivity, and neuromuscular abnormalities. It encompasses a spectrum of clinical findings ranging from a few nonspecific symptoms to significant clinical toxicity that can result in death. The objectives of this article are to review specific serotonergic medications including their adverse effects and toxicity in overdose, to describe other medications/substances that have proserotonergic effects, which could result in serotonin excess in combination with traditional serotonergic agents, and to define the criteria for serotonin syndrome/toxicity and its treatment.     

Family member presence in the pediatric emergency department

Traditionally, family members were excluded from viewing invasive procedures and cardiopulmonary resuscitation in the pediatric emergency department. The concept of family-centered care in the emergency department has now become more widespread. Consequently, family member presence during routine invasive procedures such as venipuncture, intravenous cannulation, urethral catheterization, and lumbar puncture has become more accepted. Survey evidence indicates parents' overwhelming desire to be present for invasive procedures and cardiopulmonary resuscitation. Healthcare provider opinions about family witnessed resuscitation lack similar uniformity. Variations in approval of witnessed resuscitation are influenced by occupation, level of training and experience, and prior exposure to family member presence practices. Although several organizations formally support family presence policies, citing benefits for grieving relatives, critics point to a lack of rigor in a large body of the research cited to underpin these endorsements. We review the literature from the perspective of pediatric emergency physicians, offer suggestions for family member presence, and provide directions for future study.