Approximately 30 million children are seen in Emergency Departments in the US each year, and over 80% of these visits are to community hospital EDs. The number of pediatric visits to a community hospital may be small, and the number of pediatric resuscitations even smaller. This makes it difficult for ED personnel to recall pediatric protocols and drug dosages, or to remember formulas to determine appropriate sized equipment.

Treatment interventions are usually based on the weight of the child, but studies have documented unreliability at estimating children’s weights. Other studies have documented a high rate of errors made when performing drug calculations, and a loss of valuable resuscitation time secondary to computing drug dosages and selecting equipment, many times at the expense of more urgent priorities. Many emergency providers have recognized the unique challenge of treating children of various sizes, and some have developed strategies to address this challenge.

Color Coding System

One system created to simplify the complexities of pediatric resuscitation is the Broselow-Luten length based color-coding system for the emergency care of children. This system assigns children to a color zone based on their length. This color zone then has appropriate medication doses for resuscitation drugs and equipment sizes listed on a tape. The accuracy of this system in choosing drugs and equipment has been validated. Other studies have documented how this system has improved organization and provider comfort when dealing with pediatric emergencies.

The Broselow-Luten system is widely used in the pre-hospital setting, and in North Carolina the system has been introduced to pediatric primary care providers to help organize and prepare for pediatric emergencies in the office setting. In a pilot study of 3 ED's in the state, the color-coded system was found to increase provider confidence and comfort with the emergency care of children in the acute setting as well as during resuscitation. Preliminary data suggests that the use of the color-coded system of pediatric emergency care throughout the continuum (pre-hospital, office, ED) can improve the experience for both children and the multi-disciplinary team of providers who care for them.

Preparing the ED for the Pediatric Patient

Although full pediatric cardiopulmonary arrest is a rare occurrence, pediatric emergencies are frequently seen in the ED setting. The most common pediatric emergencies are those that involve the airway and respiratory system: asthma, bronchiolitis, and croup. DKA, dehydration and shock, closed head injury, poisoning, seizures and anaphylaxis are also relatively common. All of these disorders can become life-threatening if not managed rapidly and appropriately.

In any emergency, the ABC’s must be addressed immediately. The sooner basic and advanced life support is initiated, the greater the child’s chance for complete recovery. Knowledge and skills required at the time of a pediatric emergency are not those that the emergency care provider uses on a daily basis, so an effort must be made to maintain these skills. Mock codes have been shown to be effective educational tools for resuscitation situations. These drills can help the entire ED team develop confidence and proficiency in clinical care, as well as communication and organizational skills that are required for good patient outcome.

The mock code presented in this course represents "a typical scenario" that could occur in any emergency department setting. The equipment used and the number of people who participate will vary according to each location and practice style. The purpose of the drill is to review priorities and overall techniques required during pediatric emergency stabilization.

Goals for Individual Staff Members

1. Triage nurse, receptionist or other staff who see the patient initially can identify signs and symptoms of an impending emergency ("Red Flags"): Respiratory Distress, Cyanosis, Seizures, Altered Mental Status, Poor Perfusion, etc.
2. Emergency nurse, physician or both will review equipment needs, organize equipment, and familiarize staff with its location and proper use.
3. Providers can identify medications used in cardiopulmonary emergencies.
4. Equipment and supplies are organized in a resuscitation room or code box using a color-coded system (i.e., Broselow-Luten system).
5. Receptionist, nurse or other staff will document during resuscitation.
6. Emergency providers will maintain current resuscitation skills (through PALS, etc.).

Suggestions for Organizing ED Mock Codes

1. Schedule mock code on a regular interval (monthly, quarterly) when all the staff is able to participate.
2. Involve all members of the staff - Physicians, Nurses, Secretaries, Clerks, Nurse Practitioners, Physician assistants, etc. Consider inviting local EMS personnel to participate.
3. Choose scenarios that relate to severe presentations of relatively common problems: severe wheezing, dehydration, meningitis, head injury, DKA, etc.
4. Evaluate the code afterward to identify strengths and weaknesses. Make necessary changes to address identified weaknesses or deficiencies.
5. Develop a system to check equipment and medications at regular intervals. Be sure equipment is easily accessible and medications are not outdated.