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Paediatric procedural sedation within the emergency department

Essentials 1 Procedural sedation has mirrored the development of paediatric emergency medicine as a subspecialty. 2 Local (departmental, hospital, state and national) governance and educational programmes must be developed to facilitate safe sedation practice. Ask ‘Can we do this procedure?’ before considering sedation. 3 Develop a sedation plan that includes patients, families/carers and staff. 4 Organise staff, equipment and the environment to allow the procedure to…

Analgesia

Essentials 1 Acute pain is one of the most common emergency department presenting problems. 2 Pain-rating scales appropriate to the age and development of the child are useful in establishing a child’s level of pain and assessing the adequacy of analgesia. 3 Adopt a multimodal (nonpharmacological, pharmacological) and multidisciplinary (medical staff, play therapists, parents) approach to pain management. 4 Tailor interventions to the individual child. 5…

Sepsis recognition and initial management

Essentials 1 Paediatric sepsis is the final common pathway for many decompensated infections. 2 Clinical judgement is the best-performing tool for early recognition; senior clinician review should be sought if there is diagnostic uncertainty. 3 Initial resuscitation includes intravenous access, sampling for blood culture and venous blood gas and early administration of empiric intravenous antibiotics. 4 Haemodynamic support using fluid resuscitation should be titrated carefully to…

Shock

Essentials 1 Shock is a syndrome that arises because of acute failure of the circulation that results in inadequate tissue perfusion. It may result from hypovolaemic, distributive, cardiogenic, obstructive or dissociative causes. 2 The normotensive child may have profound compensated shock. 3 As tachycardia may be a nonspecific sign and hypotension occurs late, it is crucial to recognise the early features of shock in a child…

Paediatric resuscitation in specific circumstances

Teamwork in critical care management Paediatric resuscitation involves a series of critical decisions and procedures which should be performed rapidly and safely with the aim of stabilising and/or reversing clinical deterioration in a child. As these critical procedures (e.g. endotracheal intubation) are performed in the seriously unwell child, management should also be focused upon avoiding further clinical deterioration and cardiac arrest. The individuals, the team and…

Paediatric advanced life support

Essentials 1 In the absence of signs of life, pulse check should be limited to 10 seconds and cardiopulmonary resuscitation (CPR) commenced immediately if no detectable pulse or heart rate <60 beats per minute (bpm). It has been established that diagnosis of cardiac arrest using palpation alone results in delays to initiation of resuscitation even amongst healthcare personnel. 2 The major causes of cardiopulmonary arrest in…

Paediatric basic life support

Essentials 1 Paediatric life support differs from adult life support in several aspects, but the basic principles remain the same: Ensure both the patient and rescuer are safe Call for help Initiate basic life support (BLS) measures at the earliest possible moment 2 DRSABC is a mnemonic used to remind the rescuer of the appropriate sequence of events that should be followed when encountering any collapsed…

Paediatric cardiopulmonary arrest

Essentials 1 Cardiopulmonary arrest (CPA) can occur either as in-hospital cardiac arrest (IHCA) or as an out-of-hospital cardiac arrest (OHCA), but prevention of both is the key to decreasing paediatric deaths. 2 CPA in children usually results from the development of progressive hypoxia and/or shock, which may be due to a myriad of causes. 3 Paediatric patients who sustain OHCA have survival to hospital discharge rates…

Common chronic paediatric conditions

Essentials 1 Children with chronic medical conditions make up 10–20% of paediatric emergency department (ED) presentations. 2 These patients have a longer ED stay and have increased rates of hospital and intensive care unit admission. 3 Liaise with the medical teams who know these patients well. 4 Trust the parents/caregivers: if they are worried, you should be worried. 5 Minimise pain and anxiety associated with procedures.…

Approach to the paediatric patient

Essentials 1 Gaining rapport with the child and the confidence of the parents is the key to assessing children. Never underestimate the power of distraction and entertainment. 2 A child needs to be approached according to chronological and developmental age. 3 Observation is a vital diagnostic tool, which is vastly more important in children than in adult patients. 4 The need for investigations is a balance…

Wellness, resilience and performance in emergency medicine

Essentials 1 Wellness is integral to performance and the ability to provide high-quality patient care. 2 Emergency physicians are at high risk of poor physical and mental health, including compassion fatigue and burnout. 3 Work-related distress is common. There is a need to move towards open discussion and encouragement of physicians to seek help when necessary. 4 Wellness interventions should include both individual and organizational strategies.…

Patient safety

Essentials 1 Approximately 1 in 10 hospital patients experiences an adverse event, of which half may be attributed to clinical error and one-third results in significant harm or death. 2 Emergency medicine faces particular challenges to safe patient care due to the undifferentiated and potentially unstable patient case mix, high staff turnover, staff inexperience and fatigue and distractions, noise and overcrowding in the clinical care environment.…

Complaints

Essentials 1 Complaints occur in every emergency department. They can be considered useful feedback. 2 Good complaints management involves being open to complaints and seeing them as an opportunity for improvement. 3 The majority of complaints are at least partly justified when properly investigated. 4 An acknowledgement, apology, commitment to investigate and truthful response are expected. 5 Resolution is by conveying the facts, any corrective actions…

Specialist training and recognition in emergency medicine in the United Kingdom

Essentials 1 Postgraduate medical training in the United Kingdom has become increasingly regulated and controlled by the General Medical Council (GMC). 2 Changes to immigration rules have occurred in response to insufficient training opportunities for UK and European graduates. This is one of the contributory factors in the deficit in the number of doctors in training in emergency medicine (EM). Nevertheless it is relatively easy for…

Accreditation, specialist training and recognition in Australia

Essentials 1 Specialist training in emergency medicine (EM) in Australia and New Zealand is the responsibility of the Australasian College for Emergency Medicine (ACEM). 2 Specialist international medical graduates require recognition from either the Australian Medical Council or the Medical Council of New Zealand. 3 Specialist training in EM under the ACEM is a 5-year program. Trainees must complete certain training requirements, including workplace-based assessment, the…

Business planning

Essentials 1 Organizational business planning describes the strategies an organization will take to achieve the goals of the strategic plan. 2 The emergency department (ED) business plan is an important multipurpose document and informs the organization about the agreed performance dimensions of revenue and expenditure, activity, efficiency and quality of services proposed for the next financial year. 3 Once the business plan is approved by the…

Quality assurance and quality improvement

Essentials 1 Quality improvement offers the tools to translate knowledge into improved patient care. 2 The six key aims for improvement are safety, effectiveness, patient-centeredness, timeliness, efficiency and equitable care. 3 The commonly used quality cycle known as ‘plan, do, study, act’ involves planning a test, carrying out a change, observing the consequences and putting in place modifications. 4 Standards provide a consistent and uniform set…

Emergency department layout

Essentials 1 The layout of the emergency department should functionally promote efficacy of care, safety and efficient patient flow by maximizing access to every space with the minimum of cross-traffic. 2 The triage location should enable staff directly to observe and gain access to both the ambulance entry and the patient waiting areas. 3 The acute treatment area should be open, with all spaces directly observable…

Emergency department staffing

Essentials 1 An emergency department staff structure that is appropriate in numbers and skill mix is required to provide high-quality and timely clinical care, while maintaining sustainable working conditions for staff. 2 Senior medical and nursing staff have clinical roles that include direct patient care, as well as supervision and teaching of junior staff, coordination of patient flow and liaison with other clinicians. 3 The senior…

Public health and emergency medicine

Essentials 1 Public health is a key component of a sustainable health system. 2 Emergency medicine has a mandate to advocate for public health initiatives. 3 Acute health care has limited opportunity to affect health care outcomes compared to public health. 4 Screening, brief intervention and referral for treatment are the cornerstone of emergency department (ED) prevention. 5 Disease and injury surveillance is an important function…