Chapter 36: Emergency Care – Systems, PEMS, Prehospital & ED

Pediatric emergency medical service (PEMS) · Community education · Prehospital care · Emergency department services · Data/audit cycle · Injury prevention · Triage & stabilization
🚑 Key principles: Integrated PEMS reduces morbidity/mortality. Data-driven problem identification (injury surveillance). Community education (first aid, prevention). Prehospital stabilization (ABC, spinal motion restriction). ED services: triage, team training, family-centered care.

📘 Chapter 36 – Emergency care systems & delivery

🚑 PEMS (Pediatric Emergency Medical Service)
Specialized system: trained personnel, pediatric equipment, protocols for children. Reduces mortality and secondary injury.
🏠 Home setting & community education
Most pediatric emergencies occur at home. Injury prevention: smoke alarms, safe sleep, poison control, car seats. First aid training for parents.
📊 Data analysis / problem identification
Injury surveillance (death certificates, hospital data, EMS run sheets). Identify high-risk groups, mechanisms, geographic clusters.
⚙️ Devising & implementing strategy
Develop evidence-based interventions (legislation, education, environmental modification). Trauma system development, pediatric readiness.
🔄 Re‑audit & quality improvement
Continuous feedback loop: measure outcomes, reassess interventions, update protocols. Benchmarking with national standards.
🚨 Prehospital care
Field triage, spinal motion restriction, oxygen, hemorrhage control, rapid transport to appropriate facility (trauma center vs. community hospital).
🏥 Emergency department services
Triage (ESI system), team-based resuscitation, pediatric-specific supplies, family presence policies, transfer protocols.
📊 Core evidence: Regionalized PEMS improves survival after major trauma. Community CPR training increases bystander CPR rates. Re‑audit identifies gaps (e.g., delay in defibrillation, pediatric medication errors).

🔍 Systems approach – building a pediatric emergency care system

1
Needs assessment / data analysis – Collect local injury & illness data: EMS run reports, death certificates, hospital discharge data. Identify leading causes (e.g., falls, MVC, drowning, poisoning).
2
Problem prioritization – High mortality, high frequency, modifiable risk factors (e.g., lack of child restraints, unlocked firearms, unsafe playgrounds).
3
Strategy development – Multidisciplinary team: EMS, trauma surgeons, pediatricians, public health. Interventions: legislation (car seat laws), environmental (fencing pools), education (CPR in schools).
4
Implementation – Pilot programs, PEMS protocols, pediatric readiness in EDs, telemedicine for rural areas, disaster drills.
5
Re‑audit & quality improvement – Measure time to definitive care, survival to discharge, complication rates. Feedback to refine protocols and training.

📋 Stepwise management – Prehospital & emergency department

1
Dispatch & response – Prioritize calls (EMD protocols). ALS vs BLS based on complaint. Provide pre‑arrival instructions (bleeding control, CPR).
2
Scene safety & primary survey (prehospital) – Ensure safety (traffic, violence). Apply C‑spine immobilization if mechanism suggests. Airway, breathing, circulation, hemorrhage control. Pulse oximetry.
3
Triage & transport decision – Use field triage criteria (physiologic, anatomic, mechanism, special considerations). Transport to trauma center if major injury; otherwise nearest ED.
4
ED arrival – team activation & triage – ESI level 1-2 → resuscitation bay. Trauma team / pediatric code team notified. Handoff communication (SBAR).
5
ED resuscitation & stabilization – Secondary survey, imaging, lab studies. Family presence support. Initiate transfer if needed (pediatric ICU or tertiary trauma center).
6
Post‑resuscitation & disposition – Admission, transfer, or discharge with safety net. Injury prevention education (car seat, fall prevention, poison control number).
⚡ Quality reminders: Pediatric equipment (Broselow tape, pediatric airway supplies) must be available in all ambulances and EDs. Regular drills (e.g., pediatric arrest, septic shock) improve team performance.

🧠 Reflex prompts – emergency systems & prehospital

📊 First step in developing a PEMS?
Community needs assessment & data analysis (injury surveillance).
🚸 Most common location of pediatric emergencies?
Home. Prevention: smoke alarms, safe storage, window guards.
🔄 Core component of quality improvement in EMS?
Re‑audit (closing the loop by reassessing interventions).
📞 Pre‑arrival instructions by dispatchers include:
CPR guidance, bleeding control, recovery position, anaphylaxis epinephrine use.
🏥 ED triage system for children – common tool?
Emergency Severity Index (ESI) – determines priority and resource needs.
🚁 Indication for helicopter transport?
Time‑sensitive critical illness/injury; prolonged ground transport; limited ground ALS availability.