Chapter 1: Approach to the Child in the Emergency Department

• The emergency physician must have a reasonable knowledge of the developmental stages to identify abnormal or delayed development.

• Observation of the young child during history taking provides much insight regarding the severity of his affliction.

• Often, the best examination occurs while the parent is holding the child in her lap or arms.

• Good history taking can minimize the need for blood work.

• Minimizing radiation exposure, the “as low as reasonably achievable” (ALARA) principle is particularly important in children.

The approach to children in the emergency department (ED) is completely different than for the adult. The physician gets one attempt to engage the patient, greet the parent, perform the examination, and formulate a treatment plan.

Children present to the ED for various reasons (Table 1-1).¹ This chapter focuses on deconstructing the visit and empowering the emergency physician to be comfortable with and competently treat the child.

Knowledge of age-specific biologic variables is absolutely required to identify abnormalities. Tables 1-2 to 1-5^2–6 provide quick reference for normal pediatric respiratory rate, heart rate, blood pressure, and weight.

The ED must be prepared for the pediatric patient.⁶ The American Academy of Pediatrics and the American College of Emergency Physicians have established a list of recommended pediatric resuscitation equipment and emergency medications.⁷ Dosing medication for children is challenging, especially in a dire situation. There are several tools available to help a provider with weight-based dosing. These available items range from low to high tech and include the following: the length-based Broselow tape and chart with corresponding colors for dosing, computer support programs such as the PEMSOFT calculator software package with dosing calculators and algorithms, and Pediatric Advanced Life Support (PALS) or regional children's hospital code cards. Having a pharmacist present at pediatric codes can be invaluable.

Consider a visit by first-time parents with their young infant. They have had little sleep; their baby has been crying for 2 hours and has fed poorly today. They are referred to the ED by their pediatrician. They repeated their story to the triage nurse. Once back to the waiting room, they wait for the nurse, then the physician, and then repeat their story another time. The repetition and waiting game can turn into fear and anger.

After ensuring that the child does not have an impending emergency that requires immediate intervention, conduct a quick chart review. It is crucial to know if there is a chronic illness or if there is rare or a genetic syndrome. A basic text review or Internet search can prepare the physician for what may be normal for the child or what special problems the child may have. Remember, to the parents, syndrome X is their life and they may know more on the topic than the physician. Listen to the parents, as the child may have had a similar presentation in the past and obtain their recollection for the management at that time.

Is the required equipment available in the room? There is nothing worse than a child having a sore throat, and no light source or throat swab in the room. Children have high anxiety, and when the physician leaves the room, the child thinks the anxiety-provoking things are done. When that turns out not to be true, the child may be more uncooperative.

Talk with the parents and determine their main concern. One must also expect to patiently relay information to multiple concerned parties. For example, the physician talks to the father and is then handed the cell phone to repeat the same information to the mother.

The emergency physician should consider what the young patient's role should be during the history taking and physical examination. Knowledge of developmental stages is paramount for this decision. There are several charts and tables regarding month-by-month development of children.^8,9 Table 1-6¹⁰ is included for reference of developmental milestones.

There are several qualities that enhance the assessment of children in the ED. Flexibility is paramount. Interview the parent while the child plays. Concomitant observation provides much insight regarding the severity of the child's affliction. Often, the best examination occurs while the parent is holding the child in her lap or arms.

If the child has a respiratory or cardiac complaint, examine the lungs and heart before the history taking. If the child is screaming, it is difficult to hear heart murmurs or crackles. If the child is very resistant to the examination, showing him the process on a parent, sibling, or stuffed animal can decrease anxiety. Let the child know what to expect during the examination: scratch his hand with the ear curette or blow a puff of air from the otoscope insufflator onto his face so that he is less surprised when his ear is examined.

It is best to examine the painful or injured part last. Crying may occur during the entire examination. In these cases, the examiner has to rely on differential crying, or comparing crying when touching different locations. This is extremely important in toddlers.

Dedicated child life personnel can be invaluable particularly during procedures. They bring their arsenal of age-appropriate books, spinning toys, DVDs, and a calming third-party presence to the room. They can minimize the need for sedation in many patients.

Honesty is very important and there is a delicate balance of enough information with too much information. The setting of laceration repair illustrates this dilemma. Show the child the saline, let him/her feel it, and show him how the irrigation works. Telling the child “OK, now a big bee sting” is counterproductive. He knows that they hurt. A better choice is to tell the child: “Some kids think the medicine feels hot and some thinks it feels cold, what do you think it feels like?” Talk to the child during the procedure—about school, her brother or sister, or her pet, anything but the pain.

The emergency physician has to gauge the parents' attitude. Will the parent be a help or a hindrance? The parent can be the best ally, explaining the process and steps to the child. However, the parent can also be an obstacle. An example is in the setting of laceration repair—if the parent is in tears and visibly upset, the child will be more distressed. This parent can be coached, however, outside of the room as to the counterproductive nature of her behavior—often being able to return to the room or send another family member in for the procedure.

Sometimes important historical information can only be teased out by two or three different questions designed to obtain the same information. For example, not simply “Does your child have asthma?” but also “Has he ever used albuterol?” and “Do you give breathing treatments at home?” The same is true with immunization status: not “Are her immunizations up to date?” but also “Did she get her 6-month shots yet?”

The emergency physician should attempt to obtain the child's personal input as soon as his patient is developmentally able. Many pre-schoolers are capable of providing at least some historical data and involving the child is a respectful approach. If the parent is dominating the conversation, a gentle “And what do you think about all of this?” to the patient is often helpful. A parent, especially of teenagers, doing all of the talking is a red flag. Excuse the parent from the room to conduct a sensitive and thorough interview. Having the parent leave the room can be challenging but focusing on the patient's right to autonomy and its impact on the care of the child is often helpful.

A unique situation in pediatrics is the presence of siblings. Approaches to facilitate examination include: turn down the TV, ask one adult to step out with the other children, or give them something to do.

Good history taking can minimize the need for blood work as the child's age, immunization status, and past medical history all impact the need for this investigation. This is especially important in younger children because obtaining the specimen can be challenging and the procedure provokes anxiety.

Imaging studies require special consideration because of the detrimental effect of radiation upon young children with developing brains and reproductive organs. Minimizing radiation exposure, the “as low as reasonably achievable” (ALARA) principle is particularly important in children.¹¹ One should strongly consider whether that closed head injury really merits a CT scan. Could that abdominal pain be addressed by a radiation-free modality such as ultrasound?

Consider the parents' role in the child's treatment. Is the treatment plan reasonable for a parent to follow or is there an easier way to achieve the same goal? The physician must listen to what the parent is saying. Is it possible to prescribe a medication once a day instead of twice a day? Is it possible to teach the parent how to use an inhaler instead of a cumbersome nebulizer? Can the physician prescribe an epinephrine auto-injector for both mom and dad's individual houses?

Enlisting the support of the parent in the child's care is important for education, clear discharge instructions, and answering questions. Adult learners use several modalities to learn, so visual teaching, written instructions, and verbal review of the plan all increase the chance of compliance. The discharge instructions must be clear and written out for the parent. Leave follow-up phone numbers, names of subspecialists, if appropriate, and a time frame for follow-up. Give the parent symptoms to look for as reasons to return to the ED. Finally, allow the parents a final chance to ask questions.

Finally, address any remaining concerns and reward the child. It can be a material reward such as a sticker or stuffed animal, a pat on the back for being such a good patient, or simply a statement complimenting the child's maturity level or behavior. The ED is a scary place for a child, and a reward lets her know that the physicians are here to help her.

Children as ED patients present a wonderful, yet challenging opportunity. Break down the visit into components; consider the challenges the physician will face during preparation, history, physical examination, assessment, and management plan. Preparation for the examination of the child, enlisting the role of the parent, decreasing anxiety of all parties, and educating with clear instructions will make the encounter a successful one.