Pediatric emergency medicine trisk 1155

1. Respirator, volume-cycled, on/off operation, 100% oxygen, 40–50 psi pressure (child/infant capabilities)
2. Blood sample tubes, adult and pediatric
3. Automatic blood pressure device
4. Nasogastric tubes, pediatric feeding tube sizes 5F and 8F, sump tube sizes 8–16F
5. Size 1 curved laryngoscope blade
6. Gum elastic bougies
7. Needle cricothyrotomy capability and/or cricothyrotomy capability (surgical cricothyrotomy can be
performed in older children in whom the cricothyroid membrane is easily palpable, usually by puberty )
8. Rescue airway devices for children
9. Atomizers for administration of intranasal medications
Optional medications
A. Optional medications for BLS emergency ambulances
1. Albuterol
2. Epipen
3. Oral glucose
4. Nitroglycerin (sublingual tablet or paste)
5. Aspirin
B. Optional medications for ALS emergency ground ambulances
1. Intubation adjuncts, including neuromuscular blockers
Extrication equipment
In many cases, optimal patient care mandates appropriate and safe extrication or rescue from the patient’s
situation or environment. It is critical that EMS personnel possess or have immediate access to the expertise,
tools, and equipment necessary to safely remove patients from entrapment or hazardous environments. It is
beyond the scope of this document to describe the extent of these. Local circumstances and regulations may
affect both the expertise and tools that are maintained on an individual ground ambulance, and on any other
rescue vehicle that may be needed to accompany an ambulance to an EMS scene. The tools and equipment
carried on an individual ground ambulance need to be thoughtfully determined by local features of the EMS
system with explicit plans to deploy the needed resources when extrication or rescue is required.
From American Academy of Pediatrics, American College of Emergency Physicians, American College of Surgeons Committee on Trauma, et al.
Equipment for ground ambulances. Prehosp Emerg Care 2014;18(1):92–97. Reprinted by permission of Taylor & Francis Ltd, www.tandfonline.com .

TABLE 134.4
EXAMPLE OF STATE-APPROVED MEDICATIONS—REQUIRED AND OPTIONAL

Medical Records
An accurate medical assessment and record of any and all interventions in the field during an EMS encounter are
vital for the receiving ED staff. Any accompanying paperwork, such as a 12-lead ECG tracing, or paperwork
given to the EMTs should be provided with documentation that is left at the hospital. EMS run sheets become an
important part of the patient’s permanent medical record and may play an important role in determining the


patient’s hospital care. Especially important aspects of documentation are serial vital signs, medical allergies,
initial evaluation and responses to interventions, and any changes en route, as well as a record of the mechanism
of injury and details that help put the incident in perspective. It is essential to have times and dosages associated
with any medications that were given.
EMS providers use paper or electronic charts to document EMS runs. Paper “run sheets” have certain
disadvantages, such as legibility challenges due to poor handwriting or carbon copies and potential misplacement
in the transfer of the patient. With the recent advancement in computers and tablets that are smaller and more
durable, many EMS providers now use some type of electronic patient care record (ePCR). Some medical centers
are able to receive ePCRs ahead of the ambulance’s arrival. ED capability to electronically access or print ePCR
records from EMS is an important part of the information transfer process. ePCRs have the potential to improve
the quality of EMS records and the timeliness of patient handoff information. The use of standardized ePCRs also
allows EMS operators to gather and analyze clinical data and to participate in clinical research. NEMSIS has
established a uniform data set used by most ePCR vendors. Health Information Exchanges have been successfully
implemented in several communities and states, allowing patients’ clinical outcomes to be distributed back to the
EMS agencies.

Telemedicine in EMS
The use of HIPAA compliant telemedicine from the scene of an accident, mass casualty scene, or other disaster
could be of benefit in a variety of ways. Scene telemedicine would have clear theoretical advantages when there

are shortages of medical staff or in medical emergencies involving infectious, biologic, or chemical emergencies.
The utility of telemedicine during transport has not yet been defined. In a simulation study by Charash et al.,
the use of telemedicine in a moving ambulance improved the care of simulated trauma patients including the time
to identify abnormal physiologic variables and the recognition rates for key signs, processes, and critical
interventions. Further research will be needed to identify which technologies and for which types of patients
telemedicine will offer the most benefit.

ISSUES IN EMS CARE
Culture of Safety
One of the most important aspects of the transit to the hospital is patient safety. EMS system safety practices also
affect EMS personnel and members of the community. EMS personnel often work long hours under unpredictable
circumstances and with limited supervision and resources. This combination can lead to preventable adverse
medical events for patients. Pediatric emergencies are low-frequency, but at times high-stakes, events that are at
high risk for adverse events and patient harm. EMS personnel are exposed to risks such as infectious diseases,
physical violence, occupational injury, and emotional stress, and the interaction of an ambulance and the general
motoring public puts both EMS providers and members of the community at risk.
Following the 1999 Institute of Medicine (IOM) report To Err Is Human , inpatient and outpatient healthcare
settings moved toward a culture of safety. Bringing these concepts to EMS, ACEP led a project, in cooperation
with NHTSA and the EMSC program, to develop a Strategy for a National EMS Culture of Safety , which was
made public in 2013. EMS leaders envision changing the status quo via a cultural shift to one in which “safety
considerations and risk awareness permeate the full spectrum of activities of EMS everywhere, every day—by
design, attitude, and habit.”
Medication errors gained immense attention after the 1999 IOM report, but little literature exists studying the
prevalence and outcomes of medication errors in the prehospital pediatric population. Both chart review and
patient simulation studies have documented medication error rates from 35% to 73% for pediatric doses of
epinephrine, atropine, diphenhydramine, and albuterol. One theme noted in these studies is the failure to use, or
incorrect usage of, length-based weight estimation tools.
A single data set does not exist to analyze the precise number of crashes involving emergency vehicles;
however, insurance companies report that approximately 10,000 ambulance crashes result in injury or death each
year. The relative risk of injury and death is high when collisions involve ambulances. An 11-year retrospective

review found that 339 fatal ambulance crashes from 1987 to 1997 resulted in a total of 405 deaths and 838
injuries to EMS patients, EMS personnel, and nonoccupant victims.


There are few times when a higher-speed drive with lights and siren (L&S) will be of benefit to a sick or
injured child. EMS personnel injury rates are nearly 15 times higher when ambulances are operating with L&S,
and time savings have not been shown to be meaningful. Sixty percent of these accidents are the fault of the
emergency vehicle driver. Intersections are the most common site for accidents involving EMS vehicles operating
L&S. The NAEMSP recommends that EMS services develop a policy on L&S use that should be reviewed by the
medical director, because accidents while running “hot” with L&S are a common cause of litigation. Emergency
vehicle accidents are an area of high, and frequently unnecessary, liability in EMS that is borne more out of a
tradition of L&S use than a medical necessity for the patient.
Every ambulance should have the capacity to secure a child or infant safely. Although specialized products do
exist to secure a child to an ambulance cot, the EMS provider must take great care to ensure that it is properly
attached to the cot, and that the child’s head, torso, and pelvis are appropriately secured to prevent injury in an
accident. Many of these products may not have established crashworthiness, and the degree of protection they
provide is unclear. Additional research, including crash testing of ambulance and child restraint devices, is on the
horizon.
In 2012, NHTSA published the Working Group Best-Practice Recommendations for the Safe Transportation of
Children in Emergency Ground Ambulances. The recommendations outline ideal transport mechanisms for five
situations, defined by the patient’s clinical status and the number of patients being treated
( ).
Ideally, children should be secured to ambulance cots either in a size-appropriate child restraint system or with
three horizontal restraints across the torso and one vertical restraint across each shoulder. The family’s own car
seat secured properly in the ambulance may often be the best alternative, providing it is medically safe and
appropriate for the patient’s condition. This also encourages a safe discharge home from the hospital by already
having the child’s safety seat available in the ED. The report also notes that “A child passenger … must never be
transported on an adult’s lap.” Additional means of making the ambulance interior safe for all occupants include:
seat belt use for all occupants;
securing movable equipment, such as monitors; and

monitoring of driver practices, including through the use of technology.

MEDICAL–LEGAL ISSUES
Prehospital care providers and their medical overseers are legally responsible for their actions or lack thereof.
Good Samaritan laws are variable by state and may not provide any coverage if a provider, from an EMT to a
physician, is being paid to be present at the scene of the emergency. It is vital to understand what type of
professional liability coverage exists for both EMS providers as well as medical control clinicians. Many medical
directors will obtain a separate medical license and Drug Enforcement Agency registration number to help
distinguish their activities performed as a medical director from that used for other clinical duties.
All prehospital providers and medical control personnel should provide care that mirrors the standards of
practice that apply to their profession. Standards of care and medical control are established to protect the EMS
provider professionally as well as serve the patient. Deviation from one’s level of training or from an established
and reviewed protocol with or without the involvement of medical control can expose the EMT to unfortunate
legal scrutiny in the event of a poor patient outcome. When a situation is unclear, prehospital care providers
should consult with the online medical control physician.
Proper documentation of EMS activities is the best defense against potential legal action. Special attention
should be given to accurately documenting the patient’s condition on arrival, including vital signs, position, and
restraint during transport, medication and fluid administration, airway status, and other interventions. Of special
importance is the documentation of a properly placed, secured, and patent airway if intubation is performed by
EMS. Some departments use a separate intubation checklist with multiple redundant confirmations for this
important but inherently risky procedure. All EMS documentation should be completed legibly, with errors noted
by a single line cross out, initial, and date. The provider’s signature must be legible and include a printed name
and credentials. The EMS chart is a medical–legal document as well as a simple record of what transpired in the
field. It should reflect the medical decision-making thought process as well as document any online medical
control orders that were acquired.
Many lawsuits that involve EMS result from the transport of patients to inappropriate facilities, deviation from
standardized protocols, perceived or actual slow response time, or the failure to transport patients when indicated