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Pediatric Emergency Medicine
Emergency Care Tailored to the Needs of Children
New York, NY (Sep 25, 2009)
Dr. Shari Platt
Following is the first in a series of articles focusing on Pediatric Emergency Medicine. Shari L. Platt, MD, Chief of Pediatric Emergency Medicine at the Phyllis and David Komansky Center for Children's Health at NewYork-Presbyterian Hospital/Weill Cornell Medical Center, addresses a range of topics, beginning with how a Pediatric Emergency Department is uniquely prepared to provide emergency care and treatment for infants, children and adolescents, when to bring a child to an Emergency Department, and the most common injuries and conditions treated, including lacerations and broken bones.
Childhood injury is the leading preventable problem in children's healthcare today, and according to the Centers for Disease Control and Prevention, and accounts for 40 percent of the 16 million Emergency Department visits in the United States each year. In an emergency situation, it is important to seek immediate medical attention, which may mean contacting your child's pediatrician, or getting your child to an Emergency Department as soon as possible.
What is a Pediatric Emergency Department?
"A Pediatric Emergency Department is staffed by physicians, trained and board certified in the subspecialty of Pediatric Emergency Medicine, as well as skilled emergency nurses and other healthcare professionals who are uniquely trained to care for children," says Shari L. Platt, MD, Chief of Pediatric Emergency Medicine at the Phyllis and David Komansky Center for Children's Health. "Children are not just small adults. You want a staff that is experienced in treating children and equipped to offer expert critical care for young patients."
The Pediatric Emergency Department at the Komansky Center for Children's Health provides just such an environment. Recently renovated in 2007, it is a Level 1 Trauma and Regional Burn Center that is open 24/7 for the treatment of ill or injured children. Designed with children and families in mind, the Pediatric ED is warm and welcoming, with a child-friendly waiting area and children's artwork adorning the walls. In addition to the pediatric emergency medicine faculty, Dr. Platt and her team call on a full range of pediatric subspecialists with expertise in areas such as gastroenterology, cardiology, cardiac surgery, endocrinology, pulmonology, orthopedics, plastic surgery, and intensive care, as necessary. The Pediatric ED team also includes a child life specialist, who offers expertise in child advocacy and in promoting a family-centered experience. Emergency social workers,who offer support systems to patients in need, and patient care advocates, who help to ensure the patient's comfort during the emergency visit, are available at all hours. "We want the children to be happy, and if they're happy, so are their parents," says Dr. Platt. "In addition to providing excellent clinical care, we also take care of the psychosocial needs of the patient and their family. Our focus is on the whole family, not just the patient."
When to Come to an Emergency Department
The physicians at the Pediatric Emergency Department at the Komansky Center for Children's Health treat life-threatening illnesses, traumatic injuries and less-serious conditions that include:
- Abdominal pain, dehydration, fever, severe vomiting or diarrhea
- Broken bones
- Head injuries
- Food allergies
- Foreign bodies lodged in the airway or gastrointestinal tract
In an emergency situation, Dr. Platt advises parents to call 911 if their child has any difficulty breathing, change in normal mental status, lethargy, loss of consciousness, sudden rash with fever, severe abdominal pain with vomiting, or any significant type of traumatic injury, burn or accidental ingestion. "Parents should start by contacting their pediatrician," she says, "unless it appears to be something serious, in which case, they should seek immediate medical attention in an emergency center." Common Childhood Injuries
Most youngsters do not escape childhood without an injury at some point. Following are some common injuries that bring children to an Emergency Department and some tips from Dr. Platt on how to deal with each situation.
"Lacerations are a very common injury resulting from falling in the playground, running into walls or falling off furniture at home," says Dr. Platt. "The first thing to do is apply pressure to stop the bleeding. If you are concerned about a head or neck injury, it's very hard to immobilize a baby or child, but just hold them in a comforting position and try to keep him as still as possible until help arrives. Knowing how to call for help, and having emergency phone numbers readily available is essential."
If the child doesn't lose consciousness, and appears happy and well, continue to apply pressure to stop the bleeding. Consider ice, but only if it doesn't upset the child further. "Keep the child calm, that's most important," notes Dr. Platt. "Parents also need to remain calm and supportive. Many times parental anxiety or hysteria makes the child much worse. Children take their cues from their parent. Try distracting your child with a song or story."
If a child has been impaled with an object, do not remove it, and get to the ED as soon as possible. "It's best to leave things in place," says Dr. Platt. "Internally, you don't know what you are dealing with and the object could have nicked a vein or artery. Removing it would cause bleeding. It's best to have the ED physicians evaluate such an emergency."
What to Expect on Arrival at the ED
Depending on the mechanism and extent of injury, the child may require an X-ray or a CT scan (computed tomography scan – a series of detailed pictures of areas inside the body, taken from different angles).
"If a child falls from a height, we're also concerned about what's going on inside the head, and not only the visible laceration," says Dr. Platt. "What justifies concern are mood alteration, lethargy, if the child is inconsolable or loses consciousness or alertness, is vomiting, or has a severe headache. A large bump or mass, called a "hematoma" implies that there might be a break in the skull or bleeding inside the head. Clear liquid coming from the ears or nose may be spinal fluid, which would suggest a skull fracture. In these cases, we will perform a CT scan of the head. If the child exhibits none of these symptoms, then he or she may be just observed in the ED for several hours, and sent home. At home, parents should keep a close watch of their child for 24 to 36 hours, but they do not have to wake the child up during the night."
When Plastic Surgery is Required
According to Dr. Platt, a plastic surgeon should be called upon when there is a complex laceration, particularly on the face. "Any laceration around the mouth or the eyes or in areas where cosmetic concern is warranted would best be managed by an experienced plastic surgeon," she says. Especially for children, deep or jagged lacerations that require complex closure, or layers of sutures should also be performed by a plastic surgeon. "ED physicians can manage most small straight lacerations, and anything on the head or scalp," she says. "The ED physician is the best judge of when a plastic surgeon is appropriate." It is helpful to know in advance whether your pediatric ED has a plastic surgeon available to come in for an emergency. Plastic surgery is one of the many specialty services available around the clock at the Komansky Center.
Healing lacerations will always cause a scar, as the two edges of the skin fuse together. It takes at least six months to see what the final result will be. "Children's skin heals very well because it's still immature and rapidly growing," explains Dr. Platt. "What we see initially may not be what it's going to ultimately look like. Every child is different – however, you can reduce the appearance of a scar by using emollient or moisturizer, and by avoiding sun exposure for six months with either an occlusive dressing or sunscreen."
Broken bones are among the most common injuries seen in children, resulting from any type of fall or sporting injury. The limb is most likely broken if it appears twisted or deformed. Significant swelling and tenderness in one specific spot can also indicate a broken bone. A sprain will also cause swelling, but the whole area may be tender. If the tenderness is localized in one spot, it is probably broken.
"First, keep the limb still by immobilizing it if possible with a board, a ruler, or something firm that you can wrap a cloth around," says Dr. Platt. "Next, apply ice and elevate the limb. Call 911 immediately if the child's fingers turn blue, are numb or tingling, or if the child cannot move them. Call an ambulance unless you can safely transport your child quickly to the nearest pediatric ED."
Dr. Platt cautions that if a broken bone is suspected, do not give the child anything to eat or drink. The ED staff may need to administer medicine to sedate the child or give pain medication in order to repair the fracture.
What to Expect on Arrival at the ED
"When the child comes into the ED, our first priority is to assess their level of pain and give pain medication," says Dr. Platt. "It's not going to make the fracture better, but it will make the child better. Next we will take X-rays to evaluate the fracture. Sometimes really bad sprains can look like a broken bone, particularly around the ankle. If there is a break, we will consult with an orthopedic surgeon. Knowing if your ED has orthopedic surgeons available during all hours of the day is important so that you can make sure your child is in a place where he can receive the best possible care."
The type of fracture determines how it is managed in the ED. "If it is a straight break, the patient will probably just get a cast applied," notes Dr. Platt. "If it's angled, crooked, or displaced, the child will need intravenous medications for pain and sedation so that the orthopedic surgeon can reset the bones so they align and heal properly." In some cases, surgery is required, and the child would be admitted to the hospital.
In most cases, the child may go home after the bone is reset. Once the broken bone is stable in a cast, acetaminophen or Motrin is usually sufficient to control pain. Generally the healing time is three to six weeks depending on which bone is broken. Waterproof casts are not applied in the Emergency Department. A waterproof cast may be applied later at the patient's follow-up visit with a pediatric orthopedic surgeon. When a cast is put on, parents should check the child's fingers or toes to make sure they are pink, warm, and move easily. If they become pale, blue, swollen or painful, the cast may be too tight, and the child be evaluated by a physician immediately.
Every emergency situation is unique, but Dr. Platt emphasizes the importance of always having a plan. "Being prepared for an emergency is the best first step. Know who to call and when to call," she adds. "If you have a question, call your pediatrician, but always know where your emergency services are located and how to call for help."
Contributing faculty for this article:
Shari L. Platt, MD, Chief of Pediatric Emergency Medicine at the Phyllis and David Komansky Center for Children's Health at NewYork-Presbyterian Hospital/Weill Cornell Medical Center, and Associate Professor, Emergency Medicine, Weill Cornell Medical College.