The Pediatric patient in the ED: Peculiar and Paramount

The Pediatric patient in the ED

Children are not young adults!

This was the opening speech of the first Pediatrics lecture in my medical school.
As Emergency Physicians, we deal with everything and everyone at the same time; in some instances, the segmentation between types of patients blurs. The pediatric patient in the middle might be a challenge if you are not working in an independent Pediatrics Emergency Department.

In some situations, you will have to make decisions by conscious contemplation rather than pattern matching, which we mostly depend on in our approach.

Having had the privilege of working in an independent Pediatrics ED, I realized how much easier decision making becomes when you have a set of mind prepared to deal with a child.

Health problems for children differ from those of adults. A child’s response to disease and stress varies with age and development; therefore, it’s fundamental to approach children in a way that identifies and tackles the differences.

child response to disease

Judge by appearance

We use heuristics frequently in our practice, perhaps the most popular among which is the (sick/not sick) paradigm. When it comes to children, appearance is of particular importance.

The look might be deceptive in adults, but it’s not the case in children; as they say, the eyes don’t lie, but it can be lied to.

For its virtual implication, appearance represents the first component of the Pediatrics assessment triangle, our quick and orderly assessment tool for children.

Power and authority

Children can’t consent or advocate for themselves, a parent or legal guardian approval is required to deliver health care. The most notable exception to this is the emergency situation, in which consent is not required, and care can be delivered if parents are not present and even against their wishes. The emergency situation gives the emergency physician the highest authority in decision making in children, which is a titanic responsibility.

pediatric patient in the ed

The Math geek

Dosing for most medications in children is weight dependent. It might be good practice for your brain but can also represent a dilemma if you are giving verbal orders and your phone is not with you. My colleague once said I was terrible at Math; that’s why I went to medical school; I think she made a good point.

Baby shark

ED is a noisy environment, but the Pediatrics ED is on another level of noise. Other than natural sounds found in the ED and crying fussy children, you will also encounter countless children’s music and disturbing games. It might sound nihilistic and resentful, but I have to be forthright, the current children’s entertaining materials lack educational value and taste, and it needs resuscitation.

pediatric ed noise

Priceless outcome

In the end, the smile on a child’s face is one of the most satisfying experiences ever and a blessing. Establishing a rapport with a child is the key to a proper exam. Children won’t trust anything that’s not genuine, and care should be delivered with love and passion. You might also need to learn some tricks and give some treats to accomplish that, in the hope that you reach the fruitful outcome of drawing a smile on God’s angelic creatures.

Cite this article as: Israa M Salih, UAE, "The Pediatric patient in the ED: Peculiar and Paramount," in International Emergency Medicine Education Project, January 13, 2020, https://iem-student.org/2020/01/13/the-pediatric-patient-in-the-ed-peculiar-and-paramount/, date accessed: December 2, 2022

A 20-months-old head trauma: CT or Not CT?

by Stacey Chamberlain

A 20-month-old female was going up some wooden stairs, slipped, fell down four stairs, and hit the back of her head on the wooden landing at the bottom of the stairs. She did not lose consciousness and cried immediately. She was consolable after a couple of minutes and is acting normal per her parents. She has not vomited. On exam, she is well-appearing, alert, and has a normal neurologic exam. She is noted to have a left parietal hematoma measuring approximately 4×4 cm.

Should you get CT imaging of this child to rule out clinically significant head injury?

PECARN Pediatric Head Trauma Algorithm

Age < 2

Age ≥ 2

  • GCS < 15, palpable skull fracture, or signs of altered mental status
  • Occipital, parietal or temporal scalp hematoma; History of LOC≥5 sec; Not acting normally per parent or Severe Mechanism of Injury?
  • GCS < 15, palpable skull fracture, or signs of altered mental status
  • History of LOC or history of vomiting or Severe headache or Severe Mechanism of Injury?

The PECARN (Pediatric Emergency Care Applied Research Network) Pediatric Head Trauma Algorithm was developed as a CDR to minimize unnecessary radiation exposure to young children. The estimated risk of lethal malignancy from a single head CT in a 1-year-old is 1 in 1000-1500 and decreases to 1 in 5000 in a 10-year-old. Due to these risks, in addition to costs, length of stay and potential risks of procedural sedation, this CDR is widely employed given the frequency of pediatric head trauma ED visits. This CDR has the practitioner use a prediction tree to determine risk, but unlike some other risk stratification tools, the PECARN group does make recommendations based on what they consider acceptable levels of risk. In the less than 2-year-old group, the rule was found to be 100% sensitive with sensitivities ranging from 96.8%-100% sensitive in the greater than two-year-old group.

This algorithm does have some complexity and ambiguity. It requires the practitioner to know what were considered signs of altered mental status and what were considered severe mechanisms of injury. In addition, certain paths of the decision tree lead to intermediate risk zones. In these cases, the recommendation is “observation versus CT,” allowing for the ED physician to base his/her decision to image or not based on numerous contributory factors including physician experience, multiple versus isolated findings, and parental preference, among others.

Other pediatric head trauma CDRs rules have been derived and validated; however, in comparison trials, PECARN performed better than the other CDRs. Of note, in this study, physician practice (without the use of a specific CDR) performed as well as PECARN with only slightly lower specificity.

Case Discussion

For purposes of the case study, the patient falls into an intermediate risk zone of clinically important brain injury. However, a sub-analysis of patients less than two years old with isolated scalp hematomas suggests that patients were higher risk if they were < 3 months of age, had non-frontal scalp hematomas, large scalp hematomas (> 3cm), and severe mechanism of injury. Given the large hematoma in the case study patient and a severe mechanism of injury (a fall of > 3 feet in the under two age group), one might more strongly consider imaging due to these two additional higher risk factors.

Cite this article as: iEM Education Project Team, "A 20-months-old head trauma: CT or Not CT?," in International Emergency Medicine Education Project, May 15, 2019, https://iem-student.org/2019/05/15/a-20-months-old-head-trauma-ct-or-not-ct/, date accessed: December 2, 2022