Pediatric emergency medicine trisk 1160

The American College of Emergency Physicians and the American Academy
of Pediatrics released a policy statement advocating the use of an Emergency
Information Form (EIF) for children with special healthcare needs. The EIF is a
medical summary that describes the patient’s medical conditions, medications,
and special healthcare needs. This can help improve the accuracy of the history
and improve the quality of care administered. Currently there is not a central
standardized electronic repository of EIFs; however, individual groups have
demonstrated feasibility on a smaller scale, suggesting that a central repository
may be possible with the appropriate advocacy and oversight.
When caring for the technology-assisted child, several important principles
emerge that should be used in the acute care setting ( Table 135.1 ).
First, common things are common; common pediatric illnesses may afflict
children with medical devices. This point is always important to remember when
evaluating a seemingly complicated child who presents with the routine signs and
symptoms characteristic of typical childhood diseases. For example, a child with
a CSF shunt may have vomiting caused by gastroenteritis.
Second, the presence of indwelling devices predisposes the patient to infection.
When a child presents with symptoms associated with a specific piece of
equipment, the clinician must be suspicious of infection of that equipment. For
example, if a child with a tracheostomy presents with fever, cough, and increasing
secretions, it is crucial to evaluate for the possibility of tracheitis. At the same
time, the equipment has a tendency to become colonized with commensal
organisms. Therefore, all bacterial growth does not indicate acute infection and
other sources of infection should be considered.
Above all, families should be relied on for important information because they
often have become knowledgeable of specific illnesses and equipment. Parents
are sensitive to subtle changes in their children. Families are experts and should
play an integral role in the evaluation, management, and ultimate disposition of
their child in the ED setting.
Children with chronic illnesses have a higher likelihood of being admitted to
the hospital, resulting in longer lengths of stay in the ED. The practitioner should

realize that the families of technology-assisted children often have sufficient
equipment and trained personnel available in the home setting to care for an
exacerbation of a chronic problem or an unrelated acute problem. For example,
family members whose child has a chronic respiratory illness often have
supplemental oxygen in the home and are facile with its use. Knowing that
families of technology-assisted children are compliant and likely to return to the
ED if their child’s degree of illness exceeds the capabilities of the home care is


reassuring. Thus, the practitioner should consider altering the usual criteria for
admission in this specific population. On the other hand, technology-dependent
children may show more subtle signs of illness and can deteriorate rapidly.
Having a technology-assisted child in the home creates a stressful situation for
family members and other caregivers. A visit to the ED for an acute problem
exacerbates this level of stress. These families may be more likely to question the
diagnostic tests and therapies offered during the evaluation of their child because
of their level of medical knowledge, as well as the constant illness-related anxiety
that intrudes upon their lives. The ED visit is more effective if the practitioner
recognizes the psychosocial issues associated with this population of patients.
TABLE 135.1
APPROACH TO THE TECHNOLOGY-DEPENDENT CHILD IN THE
EMERGENCY DEPARTMENT
Common pediatric illnesses can afflict chronically ill children
Presence of foreign bodies or hardware predisposes the patient to infection
Families are the experts in their children’s problems—rely on them for
important information
Consider altering the usual criteria for admission
Latex allergy is common among technology-dependent children

TRACHEOSTOMY CARE

Background
Advances in neonatology and pediatric critical care medicine have enabled
children to survive the complications of premature birth, congenital anomalies,
and severe life-threatening illnesses. As home care has become more widely
recognized as an alternative to prolonged and costly hospitalization, the number
of children managed at home with tracheostomies and mechanical ventilation has
increased dramatically. Consequently, the number of such children seeking care in
the ED has also increased. To approach these situations calmly and
systematically, the emergency physician should (1) appreciate the physiologic
differences in a patient with chronic respiratory insufficiency (CRI), (2) be
familiar with the equipment used in the care, and (3) understand the commonly
encountered complications and their management.

Pathophysiology


In healthy people, respiration is maintained via a complex mechanism involving
the alveolocapillary network, the diaphragm and intercostal musculature, and the
central respiratory centers in the brainstem. Respiratory compromise results when
one or more components of this mechanism are affected by disease. Chronic
respiratory support may be a part of the management plan for children with
diverse disease processes, including neurologic and neuromuscular disorders,
central hypoventilation syndromes, obstructive apnea, congenital facial and
airway anomalies, and others. Processes such as bronchopulmonary dysplasia
once accounted for the majority of CRI; however, recent epidemiologic studies
have demonstrated a shift in the proportion of CRI from chronic lung disease to
neurologic and neuromuscular disorders.

Equipment
The complexity of the many tubes and attachments extending from the patient’s

airway can be overwhelming, especially in the emergent situation. Familiarity
with the equipment used in caring for a patient with a tracheostomy ensures the
emergency physician’s adept management of these situations. Starting from the
patient’s neck, each piece of equipment can be easily identified ( Fig. 135.1 ).

FIGURE 135.1 Tracheostomy parts.


Tracheostomy Tubes
Modern tracheostomy tubes are made of polyvinylchloride, a soft substance that
conforms to the shape of the trachea, but is rigid enough to avoid collapse. Unlike
their metal predecessors, they have little tissue reactivity, causing less tracheal
wall irritation. Several manufacturers package sterile tracheostomy tubes for onetime use. Intensivists directing the long-term airway management of their patients
may prefer one manufacturer to another, but the emergency physician does not
need to know the minor differences among the products. However, the emergency
physician should know what types of tracheostomy tubes are stocked by the ED’s
facility and how to convert from the patient’s brand and size to an available tube
with suitable dimensions.
Three dimensions determine the size of a tracheostomy tube: the inner
diameter, the outer diameter, and the length. The inner diameter refers to the same
measurement used in describing the size of an endotracheal tube, ranging from
2.5 to 10 mm. This measurement is generally imprinted on the flanges of the
tracheostomy tube and is standardized among manufacturers. The outer diameter
and length are often not identified on the tube and can vary considerably among
manufacturers. When a tracheostomy tube change is indicated and an identical
replacement is not available, the clinician should choose a tube that has
dimensions as close as possible to the patient’s original. Select a replacement tube
that has all three dimensions either equal to or slightly smaller than the patient’s
usual tube. Down sizing to a smaller tube may be indicated as a temporizing
measure until a more suitable replacement tube can be located.

A tracheostomy tube may be cuffed or uncuffed. An infant or young child may
have a cuffed tracheostomy tube, especially if he or she has an airway anomaly or
has developed tracheomegaly. Checking for the presence of a cuff is important
because the cuff must be deflated before removing the tube.
Some tracheostomy tubes are fenestrated. The hole in the posterior aspect of
the tube facilitates retrograde movement of air through the larynx, allowing
vocalization. In addition, some tracheostomy tubes have an inner cannula that is
positioned within the lumen of the tracheostomy tube (i.e., the outer cannula) so
that it can be removed for cleaning while the airway is maintained by the outer
cannula. Importantly, the proximal portion of the inner cannula is required to
connect the tracheostomy to the manual resuscitator bag; therefore, the inner
cannula must be in place when bag–valve ventilation is performed ( Fig. 135.2 ).