Pediatric Critical Care and Emergency Medicine

The evolution of pediatric critical care medicine has been a long process of progress in ventilation and resuscitation, physiology and anatomy, anesthesia, anesthesiology, neonatology, pediatric general and cardiac surgery, and pediatric cardiology. The role of nursing is absolutely central to the evolution of critical care units. Pediatric critical care physicians have made remarkable achievements in the understanding and treatment of critically ill children. We have seen great progress in the national and international organization of pediatric critical care medicine as well as in education and research in the field.  Better and increased use of technology has advanced the care of critically ill children but has also created an environment with increasing errors, complications, and sequelae and a greater need for humane, caring environments for the patients and their families.

The role of procedures in a practice of primary care differs markedly in the care of children vs. the care of adults. This phenomenon is partially the result of the more challenging aspects of the care of infants and small children with regard to the ability to maintain a sterile field for procedures, and the relative infrequency with which procedures are performed on children relative to adults.The scope of practice for pediatricians in the community has changed over time and is likely to continue to change.

Dealing with medical emergencies. (These often require special techniques and procedures.) Providing treatment that meets the unique medical needs of infants, children, teens, and young adults. This includes giving medications and using special equipment in specific ways. Detecting problems in children who are unable to be patient and cooperative. Easing the pain and anxiety that a medical emergency can cause families. Research and education in pediatric emergency medicine.

There  are a number of reasons for our involvement with the surgical patients. Surgical patients are excellent examples of organisms under stress, and a great deal of acute physiology can be learned by caring for them--airway and pulmonary issues, fluid/electrolyte issues, neuroendocrine response to stress, pain and sedation, etc. The patient in ICU must be cared for in a collaborative fashion with the primary surgical service. In general, pediatricians know about infants and children, and “medical” issues, and surgical attendings/residents know about “surgical/technical” issues. If a collaborative relationship is formed, the patients will receive the best of both sets of knowledge. Finally, because of the potential for miscommunication to lead to mis-understandings and problems with care, these patients present excellent opportunities to practice the art of communication and finesse.

Infectious diseases are caused by pathogenic microorganisms, such as bacteria, viruses, parasites or fungi; the diseases can be spread, directly or indirectly, from one person to another. Zoonotic diseases are infectious diseases of animals that can cause disease when transmitted to humans.

Pediatric dermatology is an exciting area of medicine. When children are young, they cannot give a history. In fact, pediatrics is said to be much like veterinary medicine! The practitioner must use sharp observational skills to assess a problem. For example, rather than asking a 1 year old if they scratch or if a rash itches, merely observing the child scratching in the office or seeing excoriations on the skin will lead a physician to the correct conclusion. Thus, looking for clues further sharpens one’s visual skills. 

The suspicion of a cardiovascular abnormality may be raised initially by specific symptoms, but more commonly the presenting feature is the discovery of a cardiac murmur. Many children with a cardiac abnormality are asymptomatic because the malformation does not result in major hemodynamic alterations. Even with a significant cardiac problem, the child may be asymptomatic because the myocardium is capable of responding normally to the stresses placed upon it by the altered hemodynamics. A comparable lesion in an adult might produce symptoms because of coexistent coronary arterial disease or myocardial fibrosis. In obtaining the history of a child suspected of cardiac disease, the physician seeks three types of data: those suggesting a diagnosis, assessment of severity, and indicating the etiology of the condition.

Neurologic emergencies arise frequently and, if not diagnosed and treated quickly, can have devastating results, with high rates of long-term disability and death. Prompt recognition is an important skill. This article provides detailed analyses of acute stroke, subarachnoid hemorrhage, status epilepticus, and other neurologic emergencies for physicians who are not neurologists.

Pediatric ophthalmologists focus on the development of the visual system and the various diseases that disrupt visual development in children. Pediatric ophthalmologists also have expertise in managing the various ocular diseases that affect children. Pediatric ophthalmologists are qualified to perform complex eye surgery as well as to manage children's eye problems using glasses and medications. Many ophthalmologists and other physicians refer pediatric patients to a pediatric ophthalmologist for examination and management of ocular problems due to children's unique needs. In addition to children with obvious vision problems, children with head turns, head tilts, squinting of the eyes, or preferred head postures (torticollis) are typically referred to a pediatric ophthalmologist for evaluation. Pediatric ophthalmologists typically also manage adults with eye movement disorders (such as nystagmus or strabismus) due to their familiarity with strabismus conditions.

Endocrine emergencies represent a group of potentially life-threatening conditions that are frequently overlooked, resulting in delays in both diagnosis and treatment, factors that further contribute to their already high associated mortality rates. As such, the true incidence of primary endocrine emergencies is not well defined, which is likely because the disease process is often not recognized. Although endocrine emergencies are often encountered in patients with a known endocrinopathy, the emergency may be the initial presentation in previously undiagnosed individuals. If these endocrine disorders are not rapidly identified or if specific treatment is delayed, significant complications or even death may occur.

Evidence-based medicine (EBM) is an approach to medical practice intended to optimize decision-making by emphasizing the use of evidence from well-designed and well-conducted research. Although all medicine based on science has some degree of empirical support, EBM goes further, classifying evidence by its epistemologic strength and requiring that only the strongest types (coming from meta-analyses, systematic reviews, and randomized controlled trials) can yield strong recommendations; weaker types (such as from case-control studies) can yield only weak recommendations. The term was originally used to describe an approach to teaching the practice of medicine and improving decisions by individual physicians about individual patients. Use of the term rapidly expanded to include a previously described approach that emphasized the use of evidence in the design of guidelines and policies that apply to groups of patients and populations ("evidence-based practice policies").It has subsequently spread to describe an approach to decision-making that is used at virtually every level of health care as well as other fields (evidence-based practice).

Dental emergency is a broad, umbrella term used to describe an issue involving the teeth and supporting tissues that is of high importance to be fixed/treated by the relevant professional. Dental emergencies do not always involve pain, although this is a common signal that something needs to be looked at. Pain can originate from the tooth, surrounding tissues or can have the sensation of originating in the teeth but be caused by an independent source (orofacial pain and toothache). Depending on the type of pain experienced an experienced clinician can determine the likely cause and can treat the issue as each tissue type gives different messages in a dental emergency. Many emergencies exist and can range from bacterial/fungal/viral infections to a fractured tooth or dental restoration, each requiring an individual response and treatment that is unique to the situation. Fractures (dental trauma) can occur anywhere on the tooth or to the surrounding bone, depending on the site and extent of fracture the treatment options will vary.

Natural and man-made emergencies or disasters can occur anywhere in the world including any Minnesota county. Such incidents and their aftermath can affect human health, people’s lives, and the critical infrastructure that supports our society. Disasters can be classified according to their speed of onset (sudden or slow), their scale (minor, moderate or major), and their cause (natural or man-made). The role of environmental health staff in a public health emergency, such as a natural or man-made disaster, will vary according to the type (e.g., terrorist related, fl ood, tornado, fi re, or prolonged power outage) and severity of the situation. Environmental health staff have the primary responsibility for the “health” of a community following a disaster. This includes basic services such as food safety, water supply, shelter, sanitation, and waste management that need to be reestablished.

Total parenteral nutrition (PN) is the feeding of a person intravenously, bypassing the usual process of eating and digestion. The person receives nutritional formulae that contain nutrients such as glucose, salts, amino acids, lipids and added vitamins and dietary minerals. It is called total parenteral nutrition (TPN) or total nutrient admixture (TNA) when no significant nutrition is obtained by other routes, and partial parenteral nutrition (PPN) when nutrition is also partially enteric. It may be called peripheral parenteral nutrition (PPN) when administered through vein access in a limb rather than through a central vein as central venous nutrition (CVN).

Many well-seasoned emergency physicians often find it challenging to assess and treat pediatric patients regardless of the complaint. Because of anatomic and physiologic differences, pediatric patients experience orthopedic injuries that are both unique and specific to this subset of the population. Emergency physicians must be aware of these nuances to properly diagnose and treat these injuries. 

Certain gastrointestinal disorders can be life threatening and require emergency treatment. For many people, emergency treatment involves surgery. Gastrointestinal (GI) emergencies in infants and children often present similarly. Key historical facts alert the emergency physician to these surgical conditions that require immediate interventions.