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(a “no load”). When in doubt, it is usually safest to transport the patient. Language barriers can be an important
factor in accurately assessing a patient and situation, and it is important to address how to approach language
incompatibilities ahead of time. There are numerous resources for telephone-based interpreters available (at a
cost), but these are difficult to access unless the EMS service already has an existing account with a translation
service (such as Language Line). Using telephone interpreters is cumbersome in the EMS setting due to the need
for privacy and mobility, but at times it is the only option. It may also be useful to have printed medical
translation cards specific to the demographics of the EMS service area.
All healthcare providers must understand their duties to provide care. Questions often arise concerning issues
of consent, especially when children are involved. The doctrine of implied consent permits the treatment of
minors without parental consent when a medical emergency exists. In general, any minor with a condition that
threatens “life and limb” is considered an emergency and should be treated and transported. This is typically true
even in the difficult situation when a parent refuses EMS for a patient who appears to be emergent. Minor
patients cannot refuse treatment and transport in an emergency situation. The same is true when parents are
incapable of understanding the risks of refusing care because of cognitive impairment from intoxication or injury.
The use of online medical command can help evaluate and resolve a situation where there may be disagreement
at the scene regarding the need for transport.
Patient refusals for EMS transport are a large source of patient care liability for EMS providers. If
parents/guardians refuse care for their ill or injured child, and the EMS provider deems the child’s condition to be
serious or feels that the parent is not acting in the child’s best interest, the EMS provider is warranted in
escalating to medical control as well as calling the police when indicated. The parents must be informed of the
risk of not transporting a sick or injured pediatric patient, which typically may include death or permanent
disability. Regardless of religious beliefs or parental desires, a child must be treated and transported if there is a
life-threatening emergency or if providers suspect child abuse, even if parents refuse. Medical control should be
involved early, and law enforcement may be necessary to ensure that the patient receives the necessary
emergency stabilization and transport.
All EMTs, regardless of certification level, have a duty to report suspected child abuse at all times and in all
patients. Even if the ED says that they will report a suspected case later on, it is important to immediately report
to the authorities to protect the EMS provider. In some states, failure to report suspected child abuse is treated as
a felony, and providers and medical directors should know the law in the state where they practice. The EMSC
program in Colorado and pediatric specialists at the University of Colorado offer an online training module to
assist EMS providers recognize signs of child abuse, which can be found at .

Many states have an EMS do not resuscitate (DNR) protocol to limit resuscitative efforts for those who have
made that decision with their physician. These are under the authority of the parent/guardian, not the physician,
and they can be revoked at any time if the parent changes his or her mind, something common in pediatric
medical emergencies. Providers and medical oversight physicians must be familiar with the specific documents
required for an EMS DNR to be in effect, commonly a patient wristband as well as accompanying paperwork.
When in doubt, EMS providers must resuscitate a patient and transport them to the ED.
A challenging situation for EMS providers is when a clinician unknown to the EMS service stops at an
emergency scene and wishes to participate in and/or direct the medical care. This is a precarious situation for both
the provider and clinician, since it is difficult to verify the qualifications of the bystander. Wherever possible, this
situation should be guided by a protocol, and at no time should the clinician be allowed to endanger the patient or
providers. ACEP has produced a policy statement that outlines the issues involved in having a bystander clinician
involved in the care of the EMS patient. Because of the liabilities involved in having an unknown bystander take
a role in an established system of providing prehospital care, this is a circumstance where online medical control
should be contacted to determine the ways in which the bystander may assist. Options may range from providing
an extra set of hands to having the clinician assume control for the patient and accompanying them to the ED. It
is strongly encouraged that EMS systems draft an information card or document to give to on-scene providers to
explain how this will work for a specific service. This should be written in conjunction with the EMS service’s
medical director.

REGIONALIZATION
Based on protocol and/or the online medical control, a decision is made regarding the receiving hospital, or point
of entry (POE). The POE selection is based on various factors: patient condition, the capabilities of the receiving


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


offered guidance to EMS systems considering the addition of RSI protocols that include emphasis on initial and
ongoing training.
Key messaging for EMS systems is that basic airway management, including positioning and effective BVM
ventilation, is an imperative skill for EMTs of all levels to learn and maintain. Due to the lack of evidence
supporting the use of ETI in pediatric patients and the recognition that educational efforts to maintain proficiency
have severe limitations, some systems have discontinued the practice. In general, however, protocols for pediatric
prehospital airway management have been determined by conventional wisdom over published evidence and
impacted by local/regional transport scenarios. EMS systems should perform rigorous self-evaluation and
continuous quality assurance when creating airway support protocols. Methods supported in protocols should be
based on the skill level of the providers, equipment and medications available, ongoing training and experience of
providers, average transport times, and most importantly, medical oversight.

CHILDREN WITH SPECIAL HEALTHCARE NEEDS
Special healthcare needs in children are defined as long term (lasting longer than 6 months) and are more
significant than that of the general population. The prevalence of this group in the United States is 15.1% and has
been described as the most rapidly growing group of the pediatric population who require emergency medical
care. Special considerations for EMS systems include the identification of these patients in the community,
additional education for providers on unique care and transport needs, and the importance of preparedness for
disasters. Educational programs available to the prehospital provider are listed in Table 134.5 . Spaite et al. also
note the importance of adherence to existing EMS protocols to optimize treatment for this population of patients.
It is important to recognize that these patients may be transported on a more frequent basis than their
counterparts, therefore specific needs, learning, and feedback from each interaction can be used to anticipate and
prepare for the next encounter. EM and PEM providers are an important part of that feedback loop.
The AAP and ACEP have recommended that families with CWSHCN use an emergency information form
(EIF) to assist in providing accurate and complete information that will aid the prehospital provider in assessment
and transport decisions. Medical jewelry has also been noted as a useful adjunct to help provide immediate access
to critical information. Use of healthcare directives is important, but can be especially challenging for the EMS
provider in an acute situation. Clear protocols should address this issue for each service, and medical control
providers should be literate with this issue. Identification of the medical home can help families and providers
plan and partner for optimal interactions. Contact information for providers who can help with care and process
can be invaluable.


TABLE 134.5
CWSHCN EDUCATIONAL PROGRAMS AVAILABLE TO THE PREHOSPITAL PROVIDER
Educational programs available to the prehospital provider
Program

Online resource

Special children’s outreach
and prehospital education

/>
A full-day course for prehospital providers that covers the care and management of CSHCN. Developed by the
EMS and Children with Special Health Care Needs Project at Children’s National Medical Center in
Washington, DC. Instructor’s manual is available via the link.
Teaching resource for
/>instructors in prehospital
pediatrics
Developed at New York University, Langone Medical Center, with input from subject matter experts from
across the country and incorporating American Heart Association guidelines.
Utah telehealth
/>Developed by pediatric emergency medicine physicians at the University of Utah. Consists of eight online
learning videos covering topics from general pediatric prehospital care, to CSHCN.
Pediatric education for
/>prehospital professionals
Sponsored by the AAP, this course comes in 9.25-hr BLS and 16.75-hr advanced life support versions for a
wide array of prehospital providers and covers a range of general pediatric topics.
Reprinted from Kaziny BD. The prehospital care of children with special health care needs. Clin Pediatr Emerg Med 2014;15:89–95. Copyright ©
2014 Elsevier. With permission.

EMERGENCY PREPAREDNESS
EMS systems are an essential component to a coordinated emergency preparedness program. EMS is ready every
day for an emergency, and should be integrated into local and national preparedness initiatives. EMS providers
and students should be educated in mass casualty incident triage systems, such as that outlined in the Model
Uniform Core Criteria (MUCC), which was developed to help ensure interoperability among multiple existing
triage tools. Current mass casualty incident triage systems include Simple Triage and Rapid Treatment (START)
and its pediatric equivalent, Jump START, as well as Sort-Assess-Lifesaving Interventions-Treatment/Triage
(SALT) and Sacco Triage Method. These triage systems generally begin by differentiating ambulatory from
nonambulatory victims, then identifying signs of death or immediately life-threatening conditions, such as airway
obstruction or hemorrhage. Victims are then further triaged based on physiologic and severity of injury criteria

and transport from the scene is delayed for stable victims.
Triaging children during a mass casualty incident or disaster presents unique challenges. Firstly, children may
not follow commands well. Children may hide from rescuers rather than presenting themselves for care. Children
separated from adult family members may be scared and difficult to console, as well as quite challenging for
families and providers. Some injured children will be extricated from disaster scenes by adults present on the
scene, and the triage personnel may not know the circumstances in which the child was found, making judgment
of the severity of injury difficult. In the case of a well child accompanying an injured adult, triage personnel may
need a dedicated supervisor to monitor mobile children who may wander off. Additional pediatric emergency
preparedness resources are available at .

EMS FOR CHILDREN PROGRAM
The EMSC program was established when Congress approved the Preventive Health Amendments of 1984. The
intent was to enhance the pediatric capability of EMS systems originally designed primarily for adults, with a
goal of reducing child and youth mortality and morbidity sustained as a result of severe illness or trauma. The
program is administered through the Maternal and Child Health Bureau of the Health Resources and Services
Administration (HRSA). Project efforts have included systems development, injury prevention, research,