Pediatric considerations in prehospital care

INTRODUCTION — The general approach to providing online medical direction and pediatric prehospital care considerations, including management, field triage, and transport decisions will be reviewed here.

A general understanding of the components of an effective EMS system for children, including personnel roles and capabilities and necessary preparation and equipment for providing prehospital pediatric care are discussed separately. (See "Prehospital pediatrics and emergency medical services (EMS)".)

BACKGROUND — Appropriate prehospital assessment and management of children is challenging and requires dedicated resources to ensure the best outcomes [1]. In the past, it was common for emergency medical service (EMS) agencies to employ the "load and go" philosophy when providing prehospital care to an ill or injured child without strong emphasis on the provision of pediatric-specific stabilization. More recently, many agencies have improved the level of prehospital pediatric care and invested in training and equipment for their prehospital providers (eg, emergency medical technicians, paramedics).

In the United States, the federally supported Emergency Medical Services for Children (EMSC) program has been and continues to be a major factor in promoting more intensive prehospital care within existing EMS systems [2]. The EMSC program's performance measures inform its priorities and are described on the EMSC Innovation and Improvement Center's (EIIC) website [3]. The EMSC program has supported prehospital pediatric research, developed educational tools for prehospital providers, and assessed the availability of equipment, online medical direction, and offline protocols for pediatric patients [4]. As a result, pediatric-focused offline protocols where providers can reference assessment tools, management pathways, or pediatric medication dosing or equipment types and sizing are more widely available. In addition, online medical direction by pediatric emergency medicine specialists with expertise in prehospital care is occurring in select EMS agencies throughout the United States. The EMS for Children program is integrating quality improvement methodology into its work through the EIIC [2].

ONLINE MEDICAL CONTROL — Online medical control consists of physician direction, supervision, and authorization of prehospital treatment by phone, radio, or on the scene in real time. The physician may be located at a base station that is not located at the facility that will eventually receive the patient. In some settings, online medical control implies 24-hour availability of physicians to provide prehospital medical direction. (See "Prehospital pediatrics and emergency medical services (EMS)", section on 'Base station personnel'.)

Physicians who will provide online medical control should have pediatric emergency medicine knowledge and skills, specific training in online medical direction, and detailed knowledge of pediatric protocols in use in their region. Medical control physicians must have a clear understanding of the abilities and limitations of the prehospital providers and overall system constraints. Although prehospital providers share this responsibility, medical control physicians must be careful not to direct prehospital personnel to act outside their scope of practice, which may be determined by the emergency medical services (EMS) medical director or state and county-wide protocols.

While online medical control does allow for customized prehospital medical care, relying on it for every encounter delays transport to definitive care and is labor-intensive. In many systems, much of prehospital care is provided through standard protocols. (See 'Offline medical control' below.)

Medical direction training — To be most effective, physicians who provide online pediatric medical control should have a proper understanding of how to fulfill that role as well as specific knowledge of their local and regional EMS. Key actions to optimize their online medical direction include (see 'Additional resources' below):

●Maintain pediatric emergency medicine knowledge and skills with emphasis on the specific types of critical illnesses and injuries that commonly require prehospital intervention (eg, respiratory diseases, seizures, trauma, poisoning). (See "Prehospital pediatrics and emergency medical services (EMS)", section on 'Epidemiology'.)

●Develop a general understanding of the structure of EMS in their region including how the EMS system is accessed (eg, United States: 911; European Union: 112; Australia: 000), dispatch protocols, and the scope of practice of specific transport personnel. (See "Prehospital pediatrics and emergency medical services (EMS)", section on 'The EMS system' and "Prehospital pediatrics and emergency medical services (EMS)", section on 'Dispatch personnel' and "Prehospital pediatrics and emergency medical services (EMS)", section on 'Scope of practice'.)

●Obtain specific education on how to provide online medical direction. Many emergency physicians receive specific training during their emergency medicine residencies, fellowships in pediatric emergency medicine, or fellowships in emergency medical services. Others may take online medical direction courses offered by various organizations (eg, the National Association of EMS Physicians or the American College of Emergency Physicians).

●Understand the local system or systems in which they practice including the following:

•Type of system (eg, public, private or volunteer systems). (See "Prehospital pediatrics and emergency medical services (EMS)", section on 'Types of EMS systems'.)

•Organization of the dispatch system and prehospital response to an emergency call (eg, tiered versus non-tiered). In the context of EMS, tiered response refers to level of provider training and timing to dispatch of providers to a scene. Examples of tiered systems include:

-Single-tiered: Dispatch of either a basic life support (BLS) or an advanced life support (ALS) team

-Two-tiered: Dispatch of a BLS team initially followed by an ALS team, if needed

-Three-tiered: BLS and ALS dispatched per two-tiered; dispatch of on-scene physician as needed

Aside from mass-casualty incidents and prehospital personnel deaths, it remains rare for physicians in North America to be dispatched to the scene of an emergency, though this varies by region. This is in contrast to countries in Europe, where physicians may be routinely dispatched directly to the scene to provide care for the critically ill or injured patient [5].

•Level of preparedness for pediatric encounters based upon initial and ongoing prehospital provider education, training, and experience.

•The policies, capabilities and capacities of the region's EMS agencies and hospitals. For example, some hospitals may be more equipped than others to stabilize the acutely ill or injured child. Additionally, there are often regionalized centers to provide specific care to pediatric patients (eg, trauma centers, burn centers).

•The regional laws governing EMS and emergency department (ED) operations. For example, consent and do-not-resuscitate laws are not consistent across jurisdictions and ignorance of the law does not protect the clinician from prosecution [6].

•Communication channels and equipment used to connect providers on scene with medical directors and hospitals.

•Policies and procedures for safe patient delivery at the hospital and safe transfer of patient care to the accepting medical teams.

General approach — The approach to every prehospital notification of transport should be organized and consistent. The medical control physician should always be cordial during prehospital communications and available for updates during prehospital transport. Medical control physicians should:

●Identify themselves to the caller as a medical control physician

●Identify the callers and clarify their capabilities (ie, scope of practice) – The medical control physicians may be contacted by different prehospital personnel including:

•Dispatcher, base station, EMS medical director, or provider on scene. (See "Prehospital pediatrics and emergency medical services (EMS)", section on 'Dispatch personnel'.)

•Basic life support (BLS) personnel (eg, emergency medical responder [EMR], first responder [FR], emergency medical technician [EMT]), advanced life support (ALS) providers (advanced EMT, paramedic, supervisor, nurse or physician) – If not already established, the medical control physician needs to assess the prehospital provider's ability to respond to medical direction for patient management and social, legal, or administrative issues during the transport. (See "Prehospital pediatrics and emergency medical services (EMS)", section on 'Scope of practice'.)

●Request patient information – Key information includes age, brief history, physical assessment with vital signs, and treatment provided and response. Prehospital providers often use physical assessment tools and scores such as the pediatric assessment triangle, the pediatric Glasgow coma scale (table 1), or trauma triage scores (table 2) to rapidly communicate the severity of illness. (See "Initial assessment and stabilization of children with respiratory or circulatory compromise", section on 'Pediatric assessment triangle' and "Classification of trauma in children".)

The length of this exchange will depend upon many variables including the safety of the scene, the provider's level of training, and the condition of the patient. It may be necessary to interrupt the prehospital provider during the communication to reorient the priorities to stabilization of the airway, breathing, and circulation. For example, a field report that the child is intubated does not ensure that the endotracheal tube (ETT) is properly placed. The clinician may need to stop and ask the provider what confirmatory measures have occurred to prove that the ETT is in the trachea, such as qualitative end-tidal carbon dioxide measurement or auscultation, before proceeding with the rest of the exchange.

When time permits, it is often necessary to remind the prehospital provider to involve the caregiver in the patient's assessment, especially when the patient is a child with special health care needs. Often the caregiver's assessment of mental status, respiratory effort, or color relative to the child's normal baseline is essential to determine proper prehospital interventions.

Although there is key patient information the medical control physician needs to assist with care, it is critical to ensure that these communications are private. Some EMS radio communications are on public airwaves or channels; one should never use any patient identifiers on this type of call. Know the privacy status of EMS communications before engaging in online medical control.

●Ensure provider safety – The environment in which EMS providers practice is often not as safe and controlled as that of the medical control physician. The providers will typically ensure that their surroundings are safe from physical harm before proceeding with patient assessment and management. However, occasionally the medical control physician may recognize risk that was not noted by the provider (eg, exposure to transmittable infection diseases or toxins) and should remind the provider to don appropriate personal protective equipment. When a serious infectious disease exposure has occurred, the EMS agency's infection control officer should also be contacted once patient transport has been completed.

●Provide patient care recommendations – When making patient care recommendations, the clinician must understand the capabilities and constraints of the prehospital provider and the medications and equipment available to them. For example, it is not appropriate to order a BLS provider to perform endotracheal intubation because they are not licensed or trained to perform this procedure. Prehospital providers also typically operate under protocols that have been approved by their offline medical director. Depending upon the jurisdiction, they may or may not be able to perform actions that are not part of their protocol unless their medical director gives online approval. (See 'Offline medical control' below.)

When the medical control physician is unsure about the prehospital provider's capabilities, medications, or supplies, the best course of action is to ask the provider directly. In most EMS systems, it is ultimately the prehospital provider's responsibility to know and function within their scopes of practices.

Additional considerations when making prehospital care recommendations include:

•Request length weight estimates (recommended) or, if length-based estimates are not available, age-based estimates when the actual weight is not known to provide appropriate pediatric drug dosing. (See "Initial assessment and stabilization of children with respiratory or circulatory compromise", section on 'Estimation of weight'.)

•For safety, order by medication and patient weight (eg, milligrams, micrograms, or grams per kilogram) whenever possible. Ordering by volume may be problematic because medications may come in different concentrations. Some exceptions exist, including inhaled epinephrine, which is typically a standard volume updraft that does not vary by the weight of the child. If you must order by volume, make sure to ask for the concentration of the medication they carry.

The prehospital provider should repeat the drug and dose back to the medical control physician to ensure the order has been received and understood.

•Recognize that the availability of equipment that is specific to children is often limited in the prehospital environment. In the United States, a recommended list of pediatric-sized equipment for ambulances has been developed [7]. Unfortunately, not all United States EMS agencies have the resources to comply with those recommendations.

•Balance the benefits of carrying out physician orders on scene versus the risks of delaying transport to definitive care. (See 'Timing of prehospital interventions' below.)

•Allow time for the recommendation to be carried out before requesting a status update.

•Remind the provider to reassess the child for changes in condition throughout transport.

●Confirm the receiving hospital and estimated time of arrival (ETA) – In some circumstances (eg, level 1 trauma patients (algorithm 1)), the receiving hospital is predetermined by local or regional jurisdictions. In many systems, the prehospital providers have a good understanding of the facilities with the best pediatric resources. Otherwise, the medical control physician should select the receiving hospital that will provide the best care for the pediatric patient's condition while also limiting ambulance transport time. (See 'Hospital destination' below.)

●Perform administrative duties – The medical control physician should ensure documentation of communication with the prehospital provider, including the correct transcription of any medication orders or recommended interventions. The requirements for documenting physician direction and medical management vary by system. The use of a recorded phone line is optimal for accurate documentation of physician involvement. A recorded system is also helpful when reviewing cases as part of quality improvement activities or managing complaints.

In some jurisdictions, the physician may bill for online ALS medical direction. The physician typically must be working in a hospital emergency department or critical care unit and provide documentation to support the appropriate billing. Patient billing should not be submitted for offline medical control. Billing for online medical control may be independent from the remainder of the ED evaluation and hospital services (eg, EMS ALS online direction is done at a hospital other than the receiving one) [8].

●Ensure compliance with legal requirements – The medical control physician should provide the prehospital provider with recommendations that are in accordance with laws in that particular jurisdiction regarding (see 'Difficult situations' below):

•Reporting of child abuse

•Honoring of "do not resuscitate" orders

•Ability of a patient to refuse treatment

•Actions to take if a legal guardian refuses medical transport

OFFLINE MEDICAL CONTROL — Offline medical control refers, in part, to the administration of emergency medical services (EMS) by an emergency medical services physician director using standardized prehospital care protocols [9]. These protocols are in place to direct prehospital care and authorize specific medical treatments within a field provider's scope of practice without the need for real time communication. The prehospital provider often also has the ability to directly contact a medical control physician during prehospital treatment for care outside a written protocol, if questions arise, when directed by a protocol, or if a protocol does not specifically apply to the patient’s condition. (See "Prehospital pediatrics and emergency medical services (EMS)", section on 'Base station personnel' and "Prehospital pediatrics and emergency medical services (EMS)", section on 'EMS direction'.)

Offline prehospital protocols facilitate rapid and effective treatment, standardize management actions for prehospital providers and provide a reference for EMS practice standards [10,11]. The use of patient care protocols has also been shown to be effective in monitoring processes in medical care and providing a mechanism to provide feedback to emergency medical services personnel [12].

Many pediatric prehospital protocols exist, and there may be tremendous variation from region to region. In the United States, one of the most comprehensive collection of peer-reviewed model pediatric prehospital protocols has been developed by the National Association of State EMS Officials (NASEMSO). This set of clinical EMS guidelines specifically addresses pediatric age groups and included pediatric stakeholders in their development [13]. Adoption of these guidelines by local medical directors is voluntary; successful incorporation of evidence-based materials depends upon multiple factors.

Most protocols that EMS systems use are developed using expert opinion or consensus. The lack of high quality evidence from randomized trials in the prehospital setting reflects a limited number of prehospital researchers and the challenges associated with obtaining consent in the prehospital setting; this is especially true in the pediatric population [14,15].

TIMING OF PREHOSPITAL INTERVENTIONS — If the decision is made to prolong on-scene time rather than expediting transport, recommendations should only include treatments that are time sensitive, have established benefit, and contribute to the safe transport of patients to the hospital.

It is essential that prehospital providers address life-threatening conditions such as threats to airway, breathing, and circulation immediately (eg, apnea, hypoxemia, hypoglycemia, or external hemorrhage). It is not typically appropriate for prehospital providers to delay the transport of a stable patient for elective procedures (eg, intravenous access in stable patients) [16].

Examples of appropriate on-scene prehospital interventions are shown in the table (table 3).

En route recommendations should include the continuation of those treatments started on scene and those that may add additional benefit without delaying transport time or further injury to child.

Examples include:

●Establishing vascular access (see "Vascular (venous) access for pediatric resuscitation and other pediatric emergencies" and "Intraosseous infusion")

●Administration of corticosteroids or magnesium sulfate for status asthmaticus (see "Acute asthma exacerbations in children younger than 12 years: Emergency department management", section on 'Elements of treatment')

●Administration of additional medications after epinephrine for anaphylaxis (see "Anaphylaxis: Emergency treatment", section on 'Pharmacologic treatments')

PREHOSPITAL INTERVENTIONS

Medical and surgical emergencies — Evidence for improved outcomes with specific interventions in the prehospital setting is limited [14]. Selected examples of pediatric evidence-based protocols that have been developed and implemented for large EMS regions are available in the state EMS protocols for Maine, Vermont, New Hampshire, and Ohio. These include protocols such as airway management, allergic reactions, asthma, bronchiolitis, croup, seizures, shock, spinal care, and traumatic pain and can be found at the following websites:

●Maine

●Vermont

●New Hampshire

●Ohio

Pediatric procedures — Common prehospital pediatric procedures include cervical spine immobilization, basic and advanced airway management, and vascular access.

●Cervical spine motion restriction – Children with potential or suspected cervical spine injury by history, physical exam, or mechanism of injury or those that meet criteria for C-spine immobilization per the EMS system's protocols should undergo spinal motion restriction in a cervical collar. The prehospital provider must ensure the use of appropriately sized pediatric equipment to avoid excess motion of the cervical spine and potential airway compromise from inadequate padding under the shoulders or improperly sized cervical spine collars. (See "Pediatric cervical spinal motion restriction".)

Young athletes wearing helmets and shoulder pads (eg, American football players) should have the helmet left on with the face mask removed during cervical spine immobilization. Children wearing helmets without shoulder pads (eg, dirt bike riders, cyclists) should have the helmet removed prior to cervical spine immobilization. (See "Field care and evaluation of the child or adolescent athlete with acute neck injury", section on 'When to remove helmet and/or shoulder pads'.)

Experience suggests that many infants and children who undergo spinal motion restriction for minor trauma could be transported safely without cervical spine precautions. (See "Evaluation and acute management of cervical spine injuries in children and adolescents", section on 'Cervical spine imaging'.)

●Basic airway management – For the prehospital care of children with respiratory compromise, medical control physicians should emphasize appropriate basic airway maneuvers including jaw thrust (trauma patients), head tilt/chin lift (patients without trauma), and bag-mask ventilation augmented by an oropharyngeal airway (unconscious patients) or nasopharyngeal airway (semiconscious patients). (See "Basic airway management in children".)

Based upon one randomized trial and one large registry study, children with cardiac arrest who receive prehospital bag-mask ventilation versus artificial airway placement have equivalent or better neurologically intact survival than those who undergo prehospital endotracheal intubation [17,18] or placement of a supraglottic airway (eg, laryngeal mask airway) [18]. In a systematic review of eight studies (one trial and seven observational studies) that include this randomized trial and registry study, four studies found no additional benefit for endotracheal intubation, and four studies found increased mortality [19].

In addition to being a potentially safer approach than prehospital advanced airway management, prehospital bag-mask ventilation also prevents potential complications associated with an inexperienced prehospital provider attempting advanced airway management. However, if a prolonged transport (eg, >30 minutes) is anticipated and the provider is competent in advanced airway techniques, then endotracheal intubation or placement of a supraglottic airway may be warranted, though there is significant geographical variance.

●Advanced airway management – The necessity of prehospital endotracheal intubation in the pediatric patient is unclear [19]. Additional evidence from randomized trials of prehospital use of artificial airways during pediatric prehospital care is needed to determine whether they provide additional benefit over bag-mask ventilation. As noted above, bag-mask ventilation appears to have similar or better outcomes with fewer serious adverse events than endotracheal intubation or supraglottic airway placement in children with cardiac arrest [19-21]. Nevertheless, in systems where transport times are long and when rigorous training and maintenance of advanced airway skills by paramedics can be assured, placement of an artificial airway may be beneficial.

●Vascular access – Prehospital vascular access permits administration of medications that may improve the patient’s condition prior to arrival at the receiving hospital (eg, patients with seizures, anaphylaxis, or hypoglycemia). Establishing peripheral intravenous (IV) access, however, can be difficult in the prehospital setting, particularly in younger, less cooperative children. On scene, two patient care providers should be available, one to perform vascular access and the other to assist with holding and securing the intravenous line. When en route, typically only one provider is available to perform and secure vascular access.

Compared with peripheral intravenous accesses, intraosseous cannulation permits more rapid prehospital vascular access. In situations where immediate vascular access is necessary to address life-threatening illness (eg, cardiac arrest, decompensated shock), intraosseous cannulation should be the first choice of prehospital providers whose scope of practice allows it and who have had the appropriate training. (See "Intraosseous infusion", section on 'Indications'.)

Difficult situations

Disagreement with prehospital provider — When the prehospital provider disagrees or refuses to comply with the medical control physician’s recommendation, the physician should attempt to better understand the situation and, if needed, request immediate communication with the provider's supervisor or the emergency medical services agency's medical director. The physician should keep in mind that this request may significantly extend the on-scene time.

The medical control physician must understand that typically, the prehospital provider is licensed to perform medical care detailed in the protocols and procedures certified by their departments' medical directors. Prehospital providers are obligated to follow protocols and procedures. They may take additional orders from an online medical control physician but are not obligated to do so without their medical directors' input, though this varies by region. Again, the physician should balance on-scene interventions or conflicts with getting the patient to the hospital for timely, definitive care.

Patient refuses treatment — An unemancipated or immature minor cannot refuse emergency medical treatment and the best approach when a legal guardian cannot be identified is to provide prehospital treatment and transportation [9]. The age of consent and refusal for treatment varies dramatically in different jurisdictions [6].

Some jurisdictions recognize a minor to be emancipated and capable of refusing emergency evaluation and treatment if they are married, self-supporting and not living at home, or on active-duty status in the military [6]. Furthermore, some governmental statutes recognize a mature minor exception that allows minors over a certain age, usually 14 years, to make medical decisions. However, the specific aspects of these exceptions vary according to region. Thus, it is critical that all physicians be familiar and in compliance with the laws of the locality in which they practice.

When illness and injury clearly could result in a minor's loss of life or limb, the physician should require transport over the objections of the minor. This, however, often requires the presence of law enforcement to enforce the decision and facilitate safe transport to the hospital.

Transport refusal by legal guardian — Pediatric non-transports should be avoided in most cases, unless discussed with online medical control. Each EMS system should develop policies that address this situation in accordance with legal statutes [6]. In situations where lack of treatment poses a significant risk of harm or death to a child, assistance from law enforcement should be obtained to permit placement in protective custody.

In patients for whom medical transport and treatment is advised but no imminent health threat is present, medical harm to the patient and medicolegal risk can be diminished if the following are true:

●Thorough assessment and evaluation (medical screening examination) has been completed by the prehospital provider and no abnormalities are noted in a developmentally normal child. It is important to remember, however, that studies have raised concerns that the severity of a patient's illness is not always interpreted accurately by prehospital staff [22-24].

●No treatments were administered by any prehospital provider.

●There is no history or perceived risk of abuse or neglect involving any individual on scene.

●The chief complaint is unrelated to any chronic medical condition (eg, wheezing and asthma).

●The person refusing prehospital transportation has the legal authority to refuse treatment and states that they will seek appropriate medical treatment.

●The legal guardian who is refusing transportation is not intoxicated or otherwise incompetent or impaired.

●The prehospital medical record is initiated and recorded and a document equivalent to an "against medical advice" form is signed by the legal guardian.

Observational studies indicate that up to 89 percent of children whose caretaker refuses transport receive medical care within a week of the refusal and typically have good outcomes [25,26]. However, in an observational study of 51 children who sought care within 48 hours of contact with EMS, 9 percent were admitted to the hospital. Thus, prehospital providers and online medical control should make every effort to persuade caregivers to permit prehospital transport for evaluation of the patient in the emergency department.

Advanced directives — Advance directives (ie, do not resuscitate orders) are becoming more and more prevalent in pediatric patients with serious chronic illnesses. In the United States, most states require that legitimate advanced directives be honored by prehospital personnel unless the legal guardian provides explicit agreement to allow resuscitation. In some localities, health care providers can be subject to disciplinary action if they fail to comply with a "do not resuscitate" order [27].

In situations where an emergency call has been placed and the presence of an advanced directive is verified (eg, certified do not resuscitate order or, in regions where legal, "do not resuscitate" medical bracelet), the prehospital provider with support from online medical control should attempt communication with the legal guardian to determine their wishes [9]. Of note, the legal guardian may revoke advanced directives verbally at any time.

Possible outcomes include:

●No transportation or intervention

●Transportation only without intervention

●Transportation with limited intervention such as comfort measures

●Transportation with full intervention including cardiopulmonary resuscitation

●Full intervention including cardiopulmonary resuscitation followed by field termination if permitted by local protocol and if the patient meets criteria for field termination

When the presence of an advance directive cannot be verified, transportation with all appropriate emergency treatment measures is advised.

Suspected child abuse — When a prehospital provider reports a suspicion of child maltreatment, the medical control physician must ensure that all of the following actions have been completed:

●Appropriate prehospital treatment and transport is occurring, and the receiving facility is aware of the prehospital provider's concern for child abuse.

●Law enforcement is notified and responding.

●Where required, a mandatory report is made to child protection agencies in accordance with prevailing laws of the jurisdiction. (See "Child abuse: Social and medicolegal issues", section on 'Reporting suspected abuse'.)

In situations where child abuse is suspected, the caregiver should not be allowed to refuse transport [6]. Police protection may be required to ensure the safety of the prehospital provider and ensure that medical transport occurs.

Withholding or stopping resuscitation in traumatic cardiopulmonary arrest — In April 2014, the American Academy Of Pediatrics (AAP) Committee on Pediatric Emergency Medicine, National Association Of EMS Physicians (NAEMSP), American College Of Emergency Physicians (ACEP) and American College Of Surgeons Committee On Trauma (COT), coauthored a policy statement titled "Withholding Or Termination Of Resuscitation In Pediatric Out-Of-Hospital Traumatic Cardiopulmonary Arrest" [28].

This policy suggests the following [28]:

●"If there is any doubt as to the circumstances or timing of the traumatic cardiopulmonary arrest… resuscitation should be initiated and continued until arrival to the appropriate facility."

●The withholding of resuscitative efforts is warranted in pediatric victims of penetrating or blunt trauma with the following findings:

•Injuries obviously incompatible with life, such as decapitation or hemicorporectomy.

•Evidence of a significant time lapse after pulselessness, including dependent lividity, decomposition and in the absence of severe hypothermia, rigor mortis.

●"If the patient has arrested, resuscitation has already exceeded 30 minutes, and the nearest facility is more than 30 minutes away, involvement of parents and family of these children in the decision-making process with assistance and guidance from medical professionals should be considered as part of an emphasis on family-centered care because the evidence suggests that either death or a poor outcome is inevitable."

Patients who suffer a traumatic cardiopulmonary arrest in the field and who receive at least 30 minutes of resuscitative efforts usually have very poor outcomes (death or persistent vegetative state). Thus, termination of resuscitation is a reasonable option for such patients in jurisdictions where such field decisions are permitted by law and when appropriate measures are in place to support the family/primary caregivers in the prehospital setting.

FIELD TRIAGE AND TRANSPORT DECISIONS

Ground versus air transport — The decision to transport a child by air or ground depends upon the condition of the child, the severity of the emergency condition, the type and location of the emergency facility, local resources, safety, traffic conditions, and weather conditions [29]. For time-sensitive conditions, such as trauma, expediting transport may need to take priority over having a higher level of provider for the transport. As a general rule, ground transport is more readily available if an emergency facility is within 20 to 30 minutes of the scene, and air transport is better if there is rough terrain and/or a long distance between the scene and the emergency facility (which may be the case if a patient requires a specialty center such as a trauma or burn center). Sometimes a combination of air and ground transport is used.

The typical staffing (eg, emergency medical technician or paramedic) and equipment for basic life support (BLS) and advanced life support (ALS) ambulances and the relative advantages of ground versus air prehospital transportation are discussed in detail separately. (See "Prehospital pediatrics and emergency medical services (EMS)", section on 'Air versus ground transport'.)

Hospital destination — Selection of an appropriate receiving hospital is facilitated by detailed knowledge of the pediatric capabilities of different facilities within a region. Designating facilities capable of handling pediatric emergencies as part of a regional system of emergency medical services for children is desirable [30]. As an example, a trauma field triage algorithm with specific pediatric components has been developed by a national expert panel organized by the Centers for Disease Control (algorithm 1). Because optimal care and outcomes occur when the critically injured child is initially resuscitated and subsequently managed in a pediatric trauma center, it is preferable to directly transport children to such facilities from the field, whenever possible. (See "Trauma management: Approach to the unstable child", section on 'Definitive care'.)

In general, the optimal receiving facility for a critically ill or injured child should have large pediatric volume and availability of expertise in the intensive care of children as well as physicians trained in pediatric subspecialties, such as pediatric emergency medicine, pediatric critical care medicine, and pediatric surgery [31]. General emergency departments are typically capable of managing acute airway emergencies and stabilizing other critical pediatric conditions prior to transfer for definitive care. Other factors that may impact the best destination include:

●Hospital diversion status and surge capacity

●Hospital capability

●Availability of pediatric subspecialties

●Suspected abuse and the availability of a suspected child abuse and neglect team

●Need for management in a tertiary pediatric care facility

●Parental or patient choice (eg, history with a particular institution)

●Distance to the definitive care facility

Safe transport

Lights and sirens — Observational studies indicate that the use of lights and siren by ambulances shortens patient transport time on average by only one to three minutes [32-34]. Furthermore, improved medical outcomes for patients undergoing transport with lights and siren has not been shown in limited observational studies [35-37]. The risk for traffic collisions during transport with lights and sirens to circumvent or exceed traffic laws is increased with significant potential for serious injuries and death of the prehospital providers and patient [9,38-42]. Thus, the use of lights and sirens should be limited to the most critically ill patients who remain unstable despite prehospital treatment and to advise other drivers that an emergent situation exists while the ambulance attempts to adhere to traffic rules.

Child restraints — The United States National Highway Traffic Safety Administration has developed detailed guidelines on how children should be safely transported according to their degree of illness with specific recommendations regarding the type of restraint device and how to hand multiple patients within the same family who require transport as shown in the table (table 4) [43].

Decision not to transport — Allowing prehospital personnel to treat children and not offer transport afterwards is controversial. Observational studies in various emergency medical systems (EMS) report that approximately 13 to 27 percent of all pediatric EMS encounters result in no transport occurring [44-47]. Observational studies that evaluated refusal based upon a prehospital protocol or provider clinical judgment suggests that they cannot reliably determine which adult patients do not need ambulance transport [48-50]. In contrast, limited observational evidence in children suggests that paramedics with the support of online medical control can safely identify pediatric patients who do not require ambulance transportation [45,51].

It may be helpful for the physician providing the medical direction to speak directly to the patient's family/primary caregiver to determine whether the patient is appropriate for non-transport, to discuss signs and symptoms to monitor for, and to help develop an appropriate follow-up plan. In the author's experience, families' not knowing prehospital providers' capabilities may lead to false assurances when the child appears normal after an event concerning enough to call for help. If parents/primary caregivers are then given the option of being transported by EMS to the hospital, that false assurance may lead them to sign non-transport documentation. Pediatric medical directors need to be aware of the dynamics of these family/prehospital provider interactions to really understand their systems' pediatric "non-transports."

In EMS systems that allow prehospital providers to treat children without transport afterwards on the basis of a non-urgent complaint, the following components are essential [45]:

●Appropriate training of prehospital personnel with an emphasis on accurate pediatric assessment

●Clear policies and procedures to guide prehospital triage decisions

●Required online medical oversight

●Capacity in the local primary care network to provide early follow-up for children who are not transported

●Ongoing quality improvement

ADDITIONAL RESOURCES — The following resources are available to augment online and offline prehospital pediatric care:

●Emergency Medical Service for Children (EMSC)

●National Association of Emergency Medical Services (EMS) Physicians model pediatric protocols

●Physician prehospital pediatrics course

●National Association of EMS Physicians base station course

●National Association of State EMS Officials Model EMS Clinical Guidelines

SUMMARY AND RECOMMENDATIONS

●Online medical control – Online medical control consists of physician direction, supervision, and authorization of prehospital treatment by phone, radio, or at the scene in real time. The physician may be located at a base station that is not located at the facility that will eventually receive the patient. The general approach to real-time communication with a prehospital provider is discussed in detail above. (See 'Online medical control' above and 'General approach' above.)

●Medical direction training – Physicians who provide online medical control should have pediatric emergency medicine knowledge and skills, specific training, a good understanding of the general approach to direction of prehospital treatment, and detailed knowledge of the regulations and pediatric protocols in use in their region. Medical control physicians should also have a clear understanding of the abilities of the prehospital providers, their limitations, and overall system constraints. (See 'Medical direction training' above.)

●Offline medical control – Offline medical control refers, in part, to the administration of emergency medical services (EMS) by an EMS medical director through the use of prehospital care protocols. These protocols are in place to direct prehospital care and authorize specific medical treatments within a field provider's scope of practice without the need for real-time communication. (See 'Offline medical control' above.)

Examples of pediatric protocols developed for specific regions include the following (see 'Medical and surgical emergencies' above):

•Maine

•Vermont

•New Hampshire

●Prehospital interventions – On-scene recommendations should include those treatments that are time sensitive, have clear benefit, are generally quick to perform (table 3). Common prehospital pediatric procedures include cervical spine motion restriction, basic and advanced airway management, and vascular access. En route recommendations should include the continuation of those treatments started on scene and those that may add additional benefit without delaying transport time or further injury to child. (See 'Timing of prehospital interventions' above.)

●Difficult situations – Difficult prehospital situations may warrant engaging supervisors, law enforcement, or departmental medical directors. These include disagreement with a prehospital provider, treatment or transport refusal, advanced directives, and suspected child abuse. (See 'Difficult situations' above.)

●Mode of transport – When deciding the mode of transport and destination hospital, key factors include (see 'Ground versus air transport' above):

•Patient condition

•Type and location of the best facility providing definite care

•Safety of selected mode of transport

•Traffic

•Weather

During ambulance transport, children should be belt-restrained as determined by their medical condition (table 4) (see 'Child restraints' above).

The use of lights and sirens should be reserved for the most critically ill patients who remain unstable despite prehospital treatment. Except for specific traffic circumstances, use of lights and sirens does not save large amounts of time. Reducing its use decreases the risk of traffic collisions. (See 'Lights and sirens' above.)

●Hospital destination – In general, the optimal receiving facility for a critically ill or injured child should take care of large numbers of pediatric patients, have availability of expertise in the intensive care of children, and have trained pediatric subspecialists (eg, pediatric emergency medicine, pediatric critical care medicine, and pediatric surgery). General emergency departments are typically capable of managing acute airway emergencies and stabilizing other critical pediatric conditions prior to transfer for definitive care. (See 'Hospital destination' above.)

ACKNOWLEDGMENT — The UpToDate editorial staff acknowledges Paul E Sirbaugh, DO and Manish Shah, MD, MS, who contributed to earlier versions of this topic review.