Original article 107
Prehospital paediatric emergencies in Belgium: an epidemiologic study Laurent Houtekiea, Philippe Meerta, Fre´de´ric Thysa, Vanessa Guy-Viterbob and Ste´phan Clement de Cletya Objectives In Belgium, emergency medical services (EMS) are staffed with a medical team if mandatory according to the regulation authority procedures. Children are involved in interventions, but no extensive data are available in the country. We analysed the characteristics of the children involved in EMS to gain better knowledge of the pathologies and the needs of these patients.
Conclusion Prehospital paediatric emergencies are rarely life-threatening conditions and seldom need advanced medical interventions. However, the outcome of real life-threatening conditions is poor, therefore emphasizing the need for better trained teams. European Journal of c 2015 Emergency Medicine 22:107–110 Copyright Wolters Kluwer Health, Inc. All rights reserved.
Materials and methods A retrospective review of all patients under 16 years of age dealt with by our EMS team during a 2-year period.
European Journal of Emergency Medicine 2015, 22:107–110
Results During the 2010–2011 period, our EMS performed 229 paediatric missions. Most of the patients (76.0%) presented medical conditions. Seizure was the most common diagnosis (34.1%), including febrile convulsions in 55.1% of the cases. Five patients (2.2%) suffered a cardiac arrest. All of them died despite advanced life support. Two more patients died before or just after admission to the emergency room. In the subgroup of patients admitted to our hospital, 26.6% needed drug administration and 43.2% were discharged home after emergency room management.
Departments of aAcute Medicine and bPediatrics, St-Luc University Hospital, Brussels, Belgium
Introduction
improve the training of physicians involved in EMS, we decided to identify the real characteristics of the children requiring EMS more clearly and to analyse the outcome of these interventions.
In Belgium, the organization of the emergency medical service (EMS) is co-ordinated by provincial centres. These centres call on EMS teams from specific hospitals with which they collaborate. The selection of the team is based on various criteria. These teams consist of a physician and a nurse and should be able to deal with all types of medical or traumatic situations that may involve both adults and children. A specific paediatric EMS does not exist in our country. The physician in charge may be an emergency physician, an anaesthetist, an internist or a general practitioner with additional training in emergency medicine. The mandatory training to obtain this qualification includes theoretical paediatric lessons. Despite those lessons, most of the physicians are not confident about caring for children under emergency medical conditions. This lack of confidence in the approach towards paediatric patients may possibly be harmful for some of these patients.
Keywords: emergency medical services, organization, paediatrics, prehospital
Correspondence to Laurent Houtekie, MD, Department of Acute Medicine, Paediatric Intensive Care Unit, St-Luc University Hospital, Avenue Hippocrate 10, Brussels B-1200, Belgium Tel: + 32 2 764 27 23; fax: + 32 2 764 89 28; e-mail: [email protected] Received 22 October 2013 Accepted 13 December 2013
Materials and methods Study design
Some previous studies tend to show that most children involved in EMS suffer from benign conditions and do not require advanced support. However, in the small number of children with life-threatening illnesses, the outcome is poor [1–3]. These findings are not necessarily true in the current Belgian organization of EMS. Therefore, to
We performed a retrospective analysis of all the intervention charts completed by the EMS of our hospital for the 2010–2011 period. Our hospital is a tertiary academic hospital in Brussels, an urban area. The mean admission rate of the emergency room (ER) for the period was 61 338 admissions per year, including 13 636 (22.2%) children under 16 years of age. The coordinator of two provincial centres could request our EMS on the basis of different criteria. The main criteria were proximity and availability of our team. The hospital of patient destination depends on the decision of the on-field physician and/or the provincial regulator, and is based on criteria such as proximity, availability of ER and availability of some specialized settings that are not offered by all of the hospitals. The patient can also ask to be transferred to a specific hospital; the medical team always evaluates this request. In our hospital, we try to complete our medical team with a
c 2015 Wolters Kluwer Health, Inc. All rights reserved. 0969-9546 Copyright
DOI: 101097/MEJ?0000000000000116
Copyright © 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of the article is prohibited.
108
European Journal of Emergency Medicine 2015, Vol 22 No 2
paediatric intensivist when the coordinator informs us that the intervention is requested for a child. We cannot offer this help all the time as the number of intensivists is not sufficient to cover both the ER and the paediatric ICU (PICU) in all circumstances. Children admitted to the PICU are given priority. All patient files from the missions performed by our EMS team between January 2010 and December 2011 were reviewed and those concerning children under 16 years of age were extracted. Data obtained were age, sex, date and time of intervention, duration of the intervention, qualification of the medical staff, final destination of the patient, diagnosis at discharge, final diagnosis, the type of pathology (medical or trauma) and death. For the patients admitted to our hospital, the files were more detailed. We were therefore able to analyse additional data: drug administration during the intervention, paediatric ward or PICU admission rate and hospital length of stay (LOS). Statistical analysis
Data were entered in an Excel (Microsoft Corporation, Richmond, Virginia, USA) chart. Statistical analysis included means and medians, SDs and confidence intervals. w2-tests were performed using SPSS (IBM Corp., Armonk, New York, USA) for statistical analysis of distributions.
Results During the 2-year period, our EMS performed 3622 interventions: 229 (6.3%) of them concerned patients under 16 years of age. The mean duration of the paediatric interventions was 44 min (95% confidence interval: 23–65). Most of these interventions occurred in the afternoon, with a maximum between 4 and 6 p.m. (Fig. 1, P < 0.001). All days of the week were equally represented. There was no seasonal variation except for a nonsignificant increase during Fig. 1
the month of June. A paediatric intensivist accompanied the medical team in 86 (37.6%) interventions. Children under 4 years of age represented 55.5% of the patients, whereas children under 1 year of age represented 21.0% of the patients (Fig. 2, P < 0.001). Boys and girls were equally represented (sex ratio: M/F 1.14/1). A medical condition was diagnosed in 174 patients (76.0%), whereas 55 patients presented trauma (24.0%). Convulsions were the most common pathology (n = 78, 34.1%), whereas febrile convulsions were the most frequent diagnosis (n = 43/78, 55.1%). Thirty patients (13.1%) suffered from a malaise and 10 (4.4%) presented with intoxication. Overall diagnoses are listed in Table 1. Five patients (2.2%) had a cardiac arrest upon arrival of the EMS: three of them were diagnosed as sudden infant death (three boys aged 2, 2 and 5 months, respectively). As the other two patients were much older (a 12-month-old girl and a 34-month-old boy) to fit the usual definitions of sudden infant death, they were classified as ‘unexplained cardiac arrest’. They all died despite advanced life support. Two more patients died before or just after ER admission: one from multiple trauma (a 15-year-old girl) and one from severe septic shock (a 10-month-old girl). A total of seven patients (3.0%) died during these 2 years. In the subgroup of children admitted to our hospital (n = 169, 73.9%), only 45 (26.6%) patients needed drug administration during the intervention. Seventy-three patients (43.2%) were discharged home after ER management, 19 (11.2%) were admitted for less than 24 h in the observation unit of the ER, and 69 (40.8%) were hospitalized with 60 (35.5%) being admitted to the paediatric ward and nine (5.3%) to the PICU. Two infants were born at home and were hospitalized in the maternity ward. The remaining six patients were pronounced dead in the ER. The mean hospital LOS for the 60 children admitted to the paediatric ward was 3.5 days (median 2 days), whereas the mean PICU LOS was 1.4 days (median 1 day).
Hour distribution
40 35
Fig. 2
30 Age distribution
25
60
20
50
15
40
10
Time distribution. y-axis, number of patients; x-axis, daytime hour (P < 0.001).
10 0 0− 1 1− 2 2− 3 3− 4 4− 5 5− 6 6− 7 7− 8 8− 9 9− 10 10 − 11 11 − 12 12 − 13 13 −1 14 4 − 15 15 −1 6
10−12 p.m.
8−10 p.m.
6−8 p.m.
4−6 p.m.
2−4 p.m.
12 a.m.−2 p.m.
10−12 a.m.
8−10 a.m.
6−8 a.m.
4−6 a.m.
20
2−4 a.m.
30 0−2 a.m.
5 0
Age distribution. y-axis, number of patients; x-axis, age (years) (P < 0.001).
Copyright © 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of the article is prohibited.
Prehospital paediatric emergencies in Belgium Houtekie et al.
Table 1
End-of-mission diagnoses, frequencies and related
deaths Pathology Medical Cardiac arrest Convulsions Hyperthermic Others Malaise ALTE Hypoglycemia Vagal reaction Anxiety attack Sobbing spasms Hysterical conversion Others Intoxication Ethylic Cocaine Haloperidol Drug suicide attempt Respiratory conditions Laryngitis Bronchiolitis Asthma attack Others Sepsis – septic shock Allergic reaction Birth Cardiac conditions Cyanotic malformation Rhythm anomaly Thoracic pain Gastroenterologic conditions Vomiting Hematemesis Foreign body ingestion Fire – smoke inhalation Suicide attempt Insect bite Encephalitis Influenza-like illness Trauma Minor fall Road accident Concussion – minor head trauma Limb trauma Fracture Polytrauma Burn Aggression Knife wound Ocular trauma Dog bite Near-drowning Back pain
na (%) 5 78 43 35 31 7 6 5 4 3 1 5 10 7 1 1 1 13 5 4 2 2 8 7 5 5 3 1 1 4 2 1 1 3 2 1 1 1
(2.2) (34.1) (18.8) (15.2) (13.5) (3.1) (2.6) (2.2) (1.7) (1.3) (0.4) (2.2) (4.4) (3.1) (0.4) (0.4) (0.4) (5.7) (2.2) (1.7) (0.9) (0.9) (3.5) (3.1) (2.2) (2.2) (1.3) (0.4) (0.4) (1.7) (0.9) (0.4) (0.4) (1.3) (0.9) (0.4) (0.4) (0.4)
14 12 12 10 5 3 3 2 1 1 1 1 1
(6.1) (5.2) (5.2) (4.4) (2.2) (1.3) (1.3) (0.9) (0.4) (0.4) (0.4) (0.4) (0.4)
Death 5
109
pathology. Seizures were the most commonly observed disease, in particular febrile seizures. Our study also shows the relative benignity of the pathologies with an admission rate of 40.8% and a mortality rate of 3.0%. Less than 30% of the children required drug administration during EMS management. As in other studies, the prognosis of patients suffering from life-threatening conditions is poor [4,5]. The most common symptom was seizure (34.1% of all patients). This differs from the Belgian national registry of EMS (adults + children) where only 8.4% of the patients suffered from neurological conditions other than stroke as the main diagnosis (http://www.health.belgium.be/ filestore/19081134_FR/SMUREG-SMUREG-RAPPORTNATIONAL-ANNUEL-2011-fr.pdf). This can be explained by the higher prevalence of this condition in children. Forty-three episodes of seizure (55.1%) were diagnosed as febrile seizures, a common and benign problem in young children [6].
1
1
ALTE, apparent life-threatening event in the infant. a The total is more than 229 because the same patient can present with different conditions at the same time (e.g. road accident and polytrauma).
In our emergency service, during the study period, 1.37% of the paediatric admissions followed an EMS intervention. Of these, the proportion of children brought to our hospital by our own EMS team was 61.56%. In adult patients, the proportion of admissions consecutive to an EMS intervention was 3.27% during the same period.
Discussion Our study shows that the majority of children requiring an intervention by an EMS team presented a medical
Less than half of the patients needed more than a 24-h observation in a hospital setting and when hospitalization was required, the mean LOS was 3.5 days. Few patients required drug administration. These two findings emphasize the general impression that paediatric EMS seldom concerns critically ill children with potentially life-threatening conditions. This can be partly explained by the EMS triage system in our country. It may be difficult for the coordinator, who is not a physician, to correctly interpret the information given by telephone by the parents or by the paramedics when they are on the spot. The coordinator may prefer to send a medical team rather than to take a medical risk. In the subgroup of patients admitted to our tertiary hospital, 5.3% required PICU admission. This may result from a selection bias, as our hospital has a PICU. Critically ill children are probably transferred more frequently to our ER than to other hospitals, even if the distance by ambulance is greater. In all, 2.2% of the children had a cardiac arrest and asystole upon arrival of the EMS team. Despite advanced life support, spontaneous circulation was not restored in any of these children. The same results are reported in other series [1,3]. Seven children were pronounced dead during or just after EMS support. It was not possible to determine whether these children had received bystander resuscitation before arrival of the EMS team. Furthermore, the adequacy of the resuscitation manoeuvres performed by the EMS team could not be compared with the latest paediatric advanced life support guidelines [7]. We were astonished by the absence of seasonal variations in the number of paediatric EMS interventions. We had expected to find a slight increase during fall and winter because of the higher prevalence of infections, in
Copyright © 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of the article is prohibited.
110 European Journal of Emergency Medicine 2015, Vol 22 No 2
particular bronchiolitis. Bronchiolitis increases the rates of ER admissions during epidemical months [8]. It is often a benign disease, but in small infants it can become a serious and potentially life-threatening illness. The absence of an increase in EMS calls related to bronchiolitis and respiratory-related disorders can probably be explained by the presence of slow-onset prodromal symptoms in most children and the good awareness of the disease in the general population. Parents probably contact their physician at an early stage of the disease. In our hospital, a paediatric intensivist accompanies the medical team in more than one-third of the interventions. However, given the small number of critically ill patients, it was not possible to determine whether the presence of a physician more used to paediatric critical care was related to better outcomes in these patients. Nevertheless, according to our experience, adult emergency physicians do not feel confident with the management of paediatric patients. We therefore can only assume that the presence of a trained paediatric physician improves the quality of prehospital management. This study is a retrospective study with all the deficiencies and biases associated with such studies. First, the data analysis is based on the diagnoses made at the end of the mission. This diagnosis can be different from that made in the ER or even at discharge from the hospital. During an out-of-hospital intervention, the physician has information only on the history of the present illness and some on the past medical history. A complete medical examination can sometimes be difficult. As a quarter of the children were admitted to other hospitals, we were unable to determine all the final diagnoses. Second, the data come from intervention charts. Some were missing or could be misreported. It is impossible to determine the proportion of these erroneous data. Third, there are several EMS teams working in the same catchment area as ours and there are several hospitals with paediatric emergencies in this area. The data concern only missions performed by our intervention team (i.e. 61.57% of the children admitted to our hospital after EMS intervention). This group of patients might not be completely representative of the total but the selection of the EMS team is based only on availability and proximity criteria that should not interfere with the pathologies and needs of the patients involved. Fourth, the drug administration and hospitalization rates are based on the subgroup of children admitted to our
hospital. The tertiary design of our hospital can result in a selection bias. Although this study did not evaluate the adequacy of the management of the patients and so the training needs, it does not seem possible, realistic or really necessary, in the Belgian system of health organization to implement dedicated paediatric EMS teams. However, all EMS physicians and nurses should be trained in paediatrics and in particular in the early management of critically ill children. They should follow a training course in paediatric advanced life support. They should also be able to recognize the clinical signs and symptoms of severity usually presented by children. The outcome in children presenting out-of-hospital life-threatening conditions should be improved as much as possible. Conclusion
This study demonstrates that most of the paediatric EMS interventions were for common and benign disorders. However, some children were critically ill or had a cardiac arrest. These conditions require a good knowledge of the paediatric pathophysiology. All physicians and nurses involved in the prehospital care of young patients should have followed training courses in paediatric advanced life support to be able to care for critically ill children. Their stress would also probably decrease if their expertise was increased.
Acknowledgements Conflicts of interest
There are no conflicts of interest.
References 1 2 3 4
5 6 7
8
Applebaum D. Advanced prehospital care for pediatric emergencies. Ann Emerg Med 1985; 14:656–659. Joyce SM, Brown DE, Nelson EA. Epidemiology of pediatric EMS practice: a multistate analysis. Prehosp Disaster Med 1996; 11:180–187. Nagele P, Kroesen G. Pediatric emergencies. An epidemiologic study of mobile care units in Innsbruck. Anaesthesist 2000; 49:725–731. Atkins DL, Everson-Stewart S, Sears GK, Daya M, Osmond MH, Warden CR, et al. Epidemiology and outcomes from out-of-hospital cardiac arrest in children: the Resuscitation Outcomes Consortium Epistry-Cardiac Arrest. Circulation 2009; 119:1484–1491. Kamarainen A. Out-of-hospital cardiac arrests in children. J Emerg Trauma Shock 2010; 3:273–276. Cross JH. Fever and fever-related epilepsies. Epilepsia 2012; 53 (Suppl 4):3–8. Biarent D, Bingham R, Eich C, Lopez-Herce J, Maconochie I, Rodriguez-Nunez A, et al. European Resuscitation Council Guidelines for Resuscitation 2010 Section 6. Paediatric life support. Resuscitation 2010; 81:1364–1388. Alonso A, Andres JM, Garmendia JR, Diez I, Gil JM, Ardura J. Bronchiolitis due to respiratory syncytial virus in hospitalized children: a study of seasonal rhythm. Acta Paediatr 2007; 96:731–735.
Copyright © 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of the article is prohibited.
Prehospital paediatric emergencies in Belgium: an epidemiologic study Laurent Houtekiea, Philippe Meerta, Fre´de´ric Thysa, Vanessa Guy-Viterbob and Ste´phan Clement de Cletya Objectives In Belgium, emergency medical services (EMS) are staffed with a medical team if mandatory according to the regulation authority procedures. Children are involved in interventions, but no extensive data are available in the country. We analysed the characteristics of the children involved in EMS to gain better knowledge of the pathologies and the needs of these patients.
Conclusion Prehospital paediatric emergencies are rarely life-threatening conditions and seldom need advanced medical interventions. However, the outcome of real life-threatening conditions is poor, therefore emphasizing the need for better trained teams. European Journal of c 2015 Emergency Medicine 22:107–110 Copyright Wolters Kluwer Health, Inc. All rights reserved.
Materials and methods A retrospective review of all patients under 16 years of age dealt with by our EMS team during a 2-year period.
European Journal of Emergency Medicine 2015, 22:107–110
Results During the 2010–2011 period, our EMS performed 229 paediatric missions. Most of the patients (76.0%) presented medical conditions. Seizure was the most common diagnosis (34.1%), including febrile convulsions in 55.1% of the cases. Five patients (2.2%) suffered a cardiac arrest. All of them died despite advanced life support. Two more patients died before or just after admission to the emergency room. In the subgroup of patients admitted to our hospital, 26.6% needed drug administration and 43.2% were discharged home after emergency room management.
Departments of aAcute Medicine and bPediatrics, St-Luc University Hospital, Brussels, Belgium
Introduction
improve the training of physicians involved in EMS, we decided to identify the real characteristics of the children requiring EMS more clearly and to analyse the outcome of these interventions.
In Belgium, the organization of the emergency medical service (EMS) is co-ordinated by provincial centres. These centres call on EMS teams from specific hospitals with which they collaborate. The selection of the team is based on various criteria. These teams consist of a physician and a nurse and should be able to deal with all types of medical or traumatic situations that may involve both adults and children. A specific paediatric EMS does not exist in our country. The physician in charge may be an emergency physician, an anaesthetist, an internist or a general practitioner with additional training in emergency medicine. The mandatory training to obtain this qualification includes theoretical paediatric lessons. Despite those lessons, most of the physicians are not confident about caring for children under emergency medical conditions. This lack of confidence in the approach towards paediatric patients may possibly be harmful for some of these patients.
Keywords: emergency medical services, organization, paediatrics, prehospital
Correspondence to Laurent Houtekie, MD, Department of Acute Medicine, Paediatric Intensive Care Unit, St-Luc University Hospital, Avenue Hippocrate 10, Brussels B-1200, Belgium Tel: + 32 2 764 27 23; fax: + 32 2 764 89 28; e-mail: [email protected] Received 22 October 2013 Accepted 13 December 2013
Materials and methods Study design
Some previous studies tend to show that most children involved in EMS suffer from benign conditions and do not require advanced support. However, in the small number of children with life-threatening illnesses, the outcome is poor [1–3]. These findings are not necessarily true in the current Belgian organization of EMS. Therefore, to
We performed a retrospective analysis of all the intervention charts completed by the EMS of our hospital for the 2010–2011 period. Our hospital is a tertiary academic hospital in Brussels, an urban area. The mean admission rate of the emergency room (ER) for the period was 61 338 admissions per year, including 13 636 (22.2%) children under 16 years of age. The coordinator of two provincial centres could request our EMS on the basis of different criteria. The main criteria were proximity and availability of our team. The hospital of patient destination depends on the decision of the on-field physician and/or the provincial regulator, and is based on criteria such as proximity, availability of ER and availability of some specialized settings that are not offered by all of the hospitals. The patient can also ask to be transferred to a specific hospital; the medical team always evaluates this request. In our hospital, we try to complete our medical team with a
c 2015 Wolters Kluwer Health, Inc. All rights reserved. 0969-9546 Copyright
DOI: 101097/MEJ?0000000000000116
Copyright © 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of the article is prohibited.
108
European Journal of Emergency Medicine 2015, Vol 22 No 2
paediatric intensivist when the coordinator informs us that the intervention is requested for a child. We cannot offer this help all the time as the number of intensivists is not sufficient to cover both the ER and the paediatric ICU (PICU) in all circumstances. Children admitted to the PICU are given priority. All patient files from the missions performed by our EMS team between January 2010 and December 2011 were reviewed and those concerning children under 16 years of age were extracted. Data obtained were age, sex, date and time of intervention, duration of the intervention, qualification of the medical staff, final destination of the patient, diagnosis at discharge, final diagnosis, the type of pathology (medical or trauma) and death. For the patients admitted to our hospital, the files were more detailed. We were therefore able to analyse additional data: drug administration during the intervention, paediatric ward or PICU admission rate and hospital length of stay (LOS). Statistical analysis
Data were entered in an Excel (Microsoft Corporation, Richmond, Virginia, USA) chart. Statistical analysis included means and medians, SDs and confidence intervals. w2-tests were performed using SPSS (IBM Corp., Armonk, New York, USA) for statistical analysis of distributions.
Results During the 2-year period, our EMS performed 3622 interventions: 229 (6.3%) of them concerned patients under 16 years of age. The mean duration of the paediatric interventions was 44 min (95% confidence interval: 23–65). Most of these interventions occurred in the afternoon, with a maximum between 4 and 6 p.m. (Fig. 1, P < 0.001). All days of the week were equally represented. There was no seasonal variation except for a nonsignificant increase during Fig. 1
the month of June. A paediatric intensivist accompanied the medical team in 86 (37.6%) interventions. Children under 4 years of age represented 55.5% of the patients, whereas children under 1 year of age represented 21.0% of the patients (Fig. 2, P < 0.001). Boys and girls were equally represented (sex ratio: M/F 1.14/1). A medical condition was diagnosed in 174 patients (76.0%), whereas 55 patients presented trauma (24.0%). Convulsions were the most common pathology (n = 78, 34.1%), whereas febrile convulsions were the most frequent diagnosis (n = 43/78, 55.1%). Thirty patients (13.1%) suffered from a malaise and 10 (4.4%) presented with intoxication. Overall diagnoses are listed in Table 1. Five patients (2.2%) had a cardiac arrest upon arrival of the EMS: three of them were diagnosed as sudden infant death (three boys aged 2, 2 and 5 months, respectively). As the other two patients were much older (a 12-month-old girl and a 34-month-old boy) to fit the usual definitions of sudden infant death, they were classified as ‘unexplained cardiac arrest’. They all died despite advanced life support. Two more patients died before or just after ER admission: one from multiple trauma (a 15-year-old girl) and one from severe septic shock (a 10-month-old girl). A total of seven patients (3.0%) died during these 2 years. In the subgroup of children admitted to our hospital (n = 169, 73.9%), only 45 (26.6%) patients needed drug administration during the intervention. Seventy-three patients (43.2%) were discharged home after ER management, 19 (11.2%) were admitted for less than 24 h in the observation unit of the ER, and 69 (40.8%) were hospitalized with 60 (35.5%) being admitted to the paediatric ward and nine (5.3%) to the PICU. Two infants were born at home and were hospitalized in the maternity ward. The remaining six patients were pronounced dead in the ER. The mean hospital LOS for the 60 children admitted to the paediatric ward was 3.5 days (median 2 days), whereas the mean PICU LOS was 1.4 days (median 1 day).
Hour distribution
40 35
Fig. 2
30 Age distribution
25
60
20
50
15
40
10
Time distribution. y-axis, number of patients; x-axis, daytime hour (P < 0.001).
10 0 0− 1 1− 2 2− 3 3− 4 4− 5 5− 6 6− 7 7− 8 8− 9 9− 10 10 − 11 11 − 12 12 − 13 13 −1 14 4 − 15 15 −1 6
10−12 p.m.
8−10 p.m.
6−8 p.m.
4−6 p.m.
2−4 p.m.
12 a.m.−2 p.m.
10−12 a.m.
8−10 a.m.
6−8 a.m.
4−6 a.m.
20
2−4 a.m.
30 0−2 a.m.
5 0
Age distribution. y-axis, number of patients; x-axis, age (years) (P < 0.001).
Copyright © 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of the article is prohibited.
Prehospital paediatric emergencies in Belgium Houtekie et al.
Table 1
End-of-mission diagnoses, frequencies and related
deaths Pathology Medical Cardiac arrest Convulsions Hyperthermic Others Malaise ALTE Hypoglycemia Vagal reaction Anxiety attack Sobbing spasms Hysterical conversion Others Intoxication Ethylic Cocaine Haloperidol Drug suicide attempt Respiratory conditions Laryngitis Bronchiolitis Asthma attack Others Sepsis – septic shock Allergic reaction Birth Cardiac conditions Cyanotic malformation Rhythm anomaly Thoracic pain Gastroenterologic conditions Vomiting Hematemesis Foreign body ingestion Fire – smoke inhalation Suicide attempt Insect bite Encephalitis Influenza-like illness Trauma Minor fall Road accident Concussion – minor head trauma Limb trauma Fracture Polytrauma Burn Aggression Knife wound Ocular trauma Dog bite Near-drowning Back pain
na (%) 5 78 43 35 31 7 6 5 4 3 1 5 10 7 1 1 1 13 5 4 2 2 8 7 5 5 3 1 1 4 2 1 1 3 2 1 1 1
(2.2) (34.1) (18.8) (15.2) (13.5) (3.1) (2.6) (2.2) (1.7) (1.3) (0.4) (2.2) (4.4) (3.1) (0.4) (0.4) (0.4) (5.7) (2.2) (1.7) (0.9) (0.9) (3.5) (3.1) (2.2) (2.2) (1.3) (0.4) (0.4) (1.7) (0.9) (0.4) (0.4) (1.3) (0.9) (0.4) (0.4) (0.4)
14 12 12 10 5 3 3 2 1 1 1 1 1
(6.1) (5.2) (5.2) (4.4) (2.2) (1.3) (1.3) (0.9) (0.4) (0.4) (0.4) (0.4) (0.4)
Death 5
109
pathology. Seizures were the most commonly observed disease, in particular febrile seizures. Our study also shows the relative benignity of the pathologies with an admission rate of 40.8% and a mortality rate of 3.0%. Less than 30% of the children required drug administration during EMS management. As in other studies, the prognosis of patients suffering from life-threatening conditions is poor [4,5]. The most common symptom was seizure (34.1% of all patients). This differs from the Belgian national registry of EMS (adults + children) where only 8.4% of the patients suffered from neurological conditions other than stroke as the main diagnosis (http://www.health.belgium.be/ filestore/19081134_FR/SMUREG-SMUREG-RAPPORTNATIONAL-ANNUEL-2011-fr.pdf). This can be explained by the higher prevalence of this condition in children. Forty-three episodes of seizure (55.1%) were diagnosed as febrile seizures, a common and benign problem in young children [6].
1
1
ALTE, apparent life-threatening event in the infant. a The total is more than 229 because the same patient can present with different conditions at the same time (e.g. road accident and polytrauma).
In our emergency service, during the study period, 1.37% of the paediatric admissions followed an EMS intervention. Of these, the proportion of children brought to our hospital by our own EMS team was 61.56%. In adult patients, the proportion of admissions consecutive to an EMS intervention was 3.27% during the same period.
Discussion Our study shows that the majority of children requiring an intervention by an EMS team presented a medical
Less than half of the patients needed more than a 24-h observation in a hospital setting and when hospitalization was required, the mean LOS was 3.5 days. Few patients required drug administration. These two findings emphasize the general impression that paediatric EMS seldom concerns critically ill children with potentially life-threatening conditions. This can be partly explained by the EMS triage system in our country. It may be difficult for the coordinator, who is not a physician, to correctly interpret the information given by telephone by the parents or by the paramedics when they are on the spot. The coordinator may prefer to send a medical team rather than to take a medical risk. In the subgroup of patients admitted to our tertiary hospital, 5.3% required PICU admission. This may result from a selection bias, as our hospital has a PICU. Critically ill children are probably transferred more frequently to our ER than to other hospitals, even if the distance by ambulance is greater. In all, 2.2% of the children had a cardiac arrest and asystole upon arrival of the EMS team. Despite advanced life support, spontaneous circulation was not restored in any of these children. The same results are reported in other series [1,3]. Seven children were pronounced dead during or just after EMS support. It was not possible to determine whether these children had received bystander resuscitation before arrival of the EMS team. Furthermore, the adequacy of the resuscitation manoeuvres performed by the EMS team could not be compared with the latest paediatric advanced life support guidelines [7]. We were astonished by the absence of seasonal variations in the number of paediatric EMS interventions. We had expected to find a slight increase during fall and winter because of the higher prevalence of infections, in
Copyright © 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of the article is prohibited.
110 European Journal of Emergency Medicine 2015, Vol 22 No 2
particular bronchiolitis. Bronchiolitis increases the rates of ER admissions during epidemical months [8]. It is often a benign disease, but in small infants it can become a serious and potentially life-threatening illness. The absence of an increase in EMS calls related to bronchiolitis and respiratory-related disorders can probably be explained by the presence of slow-onset prodromal symptoms in most children and the good awareness of the disease in the general population. Parents probably contact their physician at an early stage of the disease. In our hospital, a paediatric intensivist accompanies the medical team in more than one-third of the interventions. However, given the small number of critically ill patients, it was not possible to determine whether the presence of a physician more used to paediatric critical care was related to better outcomes in these patients. Nevertheless, according to our experience, adult emergency physicians do not feel confident with the management of paediatric patients. We therefore can only assume that the presence of a trained paediatric physician improves the quality of prehospital management. This study is a retrospective study with all the deficiencies and biases associated with such studies. First, the data analysis is based on the diagnoses made at the end of the mission. This diagnosis can be different from that made in the ER or even at discharge from the hospital. During an out-of-hospital intervention, the physician has information only on the history of the present illness and some on the past medical history. A complete medical examination can sometimes be difficult. As a quarter of the children were admitted to other hospitals, we were unable to determine all the final diagnoses. Second, the data come from intervention charts. Some were missing or could be misreported. It is impossible to determine the proportion of these erroneous data. Third, there are several EMS teams working in the same catchment area as ours and there are several hospitals with paediatric emergencies in this area. The data concern only missions performed by our intervention team (i.e. 61.57% of the children admitted to our hospital after EMS intervention). This group of patients might not be completely representative of the total but the selection of the EMS team is based only on availability and proximity criteria that should not interfere with the pathologies and needs of the patients involved. Fourth, the drug administration and hospitalization rates are based on the subgroup of children admitted to our
hospital. The tertiary design of our hospital can result in a selection bias. Although this study did not evaluate the adequacy of the management of the patients and so the training needs, it does not seem possible, realistic or really necessary, in the Belgian system of health organization to implement dedicated paediatric EMS teams. However, all EMS physicians and nurses should be trained in paediatrics and in particular in the early management of critically ill children. They should follow a training course in paediatric advanced life support. They should also be able to recognize the clinical signs and symptoms of severity usually presented by children. The outcome in children presenting out-of-hospital life-threatening conditions should be improved as much as possible. Conclusion
This study demonstrates that most of the paediatric EMS interventions were for common and benign disorders. However, some children were critically ill or had a cardiac arrest. These conditions require a good knowledge of the paediatric pathophysiology. All physicians and nurses involved in the prehospital care of young patients should have followed training courses in paediatric advanced life support to be able to care for critically ill children. Their stress would also probably decrease if their expertise was increased.
Acknowledgements Conflicts of interest
There are no conflicts of interest.
References 1 2 3 4
5 6 7
8
Applebaum D. Advanced prehospital care for pediatric emergencies. Ann Emerg Med 1985; 14:656–659. Joyce SM, Brown DE, Nelson EA. Epidemiology of pediatric EMS practice: a multistate analysis. Prehosp Disaster Med 1996; 11:180–187. Nagele P, Kroesen G. Pediatric emergencies. An epidemiologic study of mobile care units in Innsbruck. Anaesthesist 2000; 49:725–731. Atkins DL, Everson-Stewart S, Sears GK, Daya M, Osmond MH, Warden CR, et al. Epidemiology and outcomes from out-of-hospital cardiac arrest in children: the Resuscitation Outcomes Consortium Epistry-Cardiac Arrest. Circulation 2009; 119:1484–1491. Kamarainen A. Out-of-hospital cardiac arrests in children. J Emerg Trauma Shock 2010; 3:273–276. Cross JH. Fever and fever-related epilepsies. Epilepsia 2012; 53 (Suppl 4):3–8. Biarent D, Bingham R, Eich C, Lopez-Herce J, Maconochie I, Rodriguez-Nunez A, et al. European Resuscitation Council Guidelines for Resuscitation 2010 Section 6. Paediatric life support. Resuscitation 2010; 81:1364–1388. Alonso A, Andres JM, Garmendia JR, Diez I, Gil JM, Ardura J. Bronchiolitis due to respiratory syncytial virus in hospitalized children: a study of seasonal rhythm. Acta Paediatr 2007; 96:731–735.
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