Guidelines for paediatric emergency equipment 
and supplies for a physician’s office

M Feldman; Canadian Paediatric Society, Community Paediatrics Committee

Paediatr Child Health 2009;14(6):402-4
Reference No. CP 2009-03

Index of position statements from the Community Paediatrics Committee

Contents

• Method of statement development
• The nature of the emergencies most likely to be encountered
• The nature of the intervention and how difficult it is to acquire and maintain the skills necessary to operate the equipment
• The value of the intervention
• The availability of EMS
• Recommendations
• TABLE 1 Circulation supplies recommended for physicians’ offices
• TABLE 2 Emergency drugs recommended for physicians’ offices
• TABLE 3 Trauma and miscellaneous supplies recommended for physicians’ offices
• TABLE 4 Airway supplies recommended for physicians’ offices
• References
  

The objective of the present revision was to examine recent evidence behind (and adjust accordingly) the recommendations for emergency equipment and supplies, as well as skills that child health care providers should possess in the outpatient setting. It replaces the previous position statement published in 1999 (1).

METHOD OF STATEMENT DEVELOPMENT

PubMed and the Cochrane Library were searched using combinations of the following terms: cardiac arrest, children, emergency, endotracheal intubation skills, laryngeal mask, equipment, etiology, office, outpatient, primary care, pediatric and paediatric, vascular access and intraosseous. Relevant articles were identified from the bibliographies of the articles selected from the database searches. No studies were found that could establish a causal relationship between equipment availability and outcomes. Thus, recommendations were largely based on consensus achieved by the Canadian Paediatric Society’s Community Paediatrics Committee, Allergy Section, Hospital Paediatrics Section and the Paediatric Emergency Section.

Office-based physicians who care for children should have some basic emergency care equipment, supplies and medications available to deal with the infrequent, but life-threatening situations that they may encounter.

The ‘recommended’ equipment, supplies and medications (listed below) are considered to be optimal to support a child until his or her care is assumed by emergency medical services (EMS). The choice of exactly what to obtain was made with consideration of the following principles:

• the nature of the emergencies most likely to be encountered;
• the nature of the intervention and how difficult it is to acquire and maintain the skills necessary to operate the equipment;
• the value of the intervention; and
• the availability of EMS.

THE NATURE OF THE EMERGENCIES MOST LIKELY TO BE ENCOUNTERED

Canadian data from an urban setting demonstrated that only 1.9% of children suffering an out-of-hospital cardiac arrest will survive (2). It appears to be most reasonable for outpatient care providers to focus their preparations on pre-arrest emergencies that may affect children. The most common prearrest conditions affecting children are respiratory emergencies and trauma (3).

THE NATURE OF THE INTERVENTION AND HOW DIFFICULT IT IS TO ACQUIRE 
AND MAINTAIN THE SKILLS NECESSARY TO OPERATE THE EQUIPMENT

Even in high-volume urban centres, among trained EMS personnel, unintentional esophageal intubations occur not infrequently (4). It is unlikely that health care providers, who do not regularly perform endotracheal intubations, will be able to maintain this skill. Inappropriate delays in oxygenation may occur during unsuccessful intubation attempts, and unrecognized esophageal intubation can be catastrophic. Moreover, when endotracheal intubation is compared with self-inflating bag and mask ventilation, the latter has been shown to be the simplest and most successful intervention for gas exchange in simulated models of apnea when used by paramedics (4). A bag and mask approach more rapidly establishes ventilation when compared with laryngeal masks used by critical care nurses (5).

Similarly, vascular access by intravenous catheter placement is difficult to achieve in severely hypovolemic children, and although successful intraosseous access may require less maintenance of skill (6,7), both methods require training and probably ongoing practice to maintain proficiency.

THE VALUE OF THE INTERVENTION

Oxygen by face mask or by bag and valve mask is relatively uncomplicated to administer and may be lifesaving. There does not appear to be an advantage to neurological outcomes among paediatric outpatients who are resuscitated using endotracheal intubation compared with bag and mask ventilation when used by EMS providers in an urban setting (8).

Nebulization of salbutamol for status asthmaticus and of L-epinephrine for children with severe croup (and possibly, outpatients with severe bronchiolitis [9]) may also be lifesaving and requires little training or maintenance of skill.

Intraosseous infusion is of unknown value when used for prehospital vascular access in urban areas (10). However, when EMS are not likely to be readily available, the value of office-based vascular access skills for the care of a hypovolemic child cannot be overstated.

Given that brief seizures usually have good outcomes, the treatment of seizures with benzodiazepines in the prehospital setting must be a balanced approach, taking into consideration the skill and availability of ventilatory support (should benzodiazepine lead to respiratory depression), the duration of the seizure and the availability of EMS.

Mock ‘codes’ in the office setting have been shown to decrease provider anxiety, improve confidence, and lead to further training and written office protocols (11,12).

THE AVAILABILITY OF EMS

A physician whose office is further from EMS will need to stock more of the ‘desirable’ equipment items. Physicians working in remote areas may require more training in paediatric advanced life support and in ongoing maintenance of skills. Often, rural general practitioners participate in local emergency department shifts, and rural paediatricians may participate in on-call coverage for emergency departments and newborn emergencies. It may be more feasible for physicians with these practice opportunities to maintain their acute care skills.

REFERENCES

1. Canadian Paediatric Society, Community Paediatrics Committee [Principal author: D Leduc]. Guidelines for paediatric emergency equipment and supplies for a physician’s office. Paediatr Child Health 1999;4:217-8.
2. Ong ME, Osmond MH, Nesbitt L; OPALS Study Group. Etiology of pediatric out-of-hospital cardiac arrest by coroner’s diagnosis. Resuscitation 2006;68:335-42.
3. Gerein RB, Osmond MH, Stiell IG, Nesbitt LP, Burns S; OPALS Study Group. What are the etiology and epidemiology of out-of-hospital pediatric cardiopulmonary arrest in Ontario, Canada? Acad Emerg Med 2006;13:653-8.
4. Dörges V, Wenzel V, Knacke P, Gerlach K. Comparison of different airway management strategies to ventilate apneic, nonpreoxygenated patients. Crit Care Med 2003;31:800-4.
5. Rechner JA, Loach VJ, Ali MT, Barber VS, Young JD, Mason DG. A comparison of the laryngeal mask airway with facemask and oropharyngeal airway for manual ventilation by critical care nurses in children. Anaesthesia 2007;62:790-5.
6. Banerjee S, Singhi SC, Singh S, Singh M. The intraosseous route is a suitable alternative to intravenous route for fluid resuscitation in severely dehydrated children. Indian Pediatr 1994;31:1511-20.
7. Nijssen-Jordan C. Emergency department utilization and success rates for intraosseous infusion in pediatric resuscitations. CJEM 2000;2:10-4.
8. Gausche M, Lewis RJ, Stratton SJ, et al. Effect of out-of-hospital pediatric endotracheal intubation on survival and neurological outcome: A controlled clinical trial. JAMA 2000;283:783-90.
9. Hartling L, Wiebe N, Russell K, Patel H, Klassen TP. Epinephrine for bronchiolitis. Cochrane Database Syst Rev 2004:CD003123.
10. Seigler RS. Intraosseous infusion performed in the prehospital setting: South Carolina’s six-year experience. J S C Med Assoc 1997;93:209-15.
11. Bordley WC, Travers D, Scanlon P, Frush K, Hohenhaus S. Office preparedness for pediatric emergencies: A randomized, controlled trial of an office-based training program. Pediatrics 2003;112:291-5.
12. Toback SL, Fiedor M, Kilpela B, Reis EC. Impact of a pediatric primary care office-based mock code program on physician and staff confidence to perform life-saving skills. Pediatr Emerg Care 2006;22:415-22.

COMMUNITY PAEDIATRICS COMMITTEE

Disclaimer: The recommendations in this position statement do not indicate an exclusive course of treatment or procedure to be followed. Variations, taking into account individual circumstances, may be appropriate. Internet addresses are current at time of publication.