The approach to children in the emergency department (ED) is completely different than for the adult. The physician gets one attempt to engage the patient, greet the parent, perform the examination, and formulate a treatment plan. This chapter focuses on deconstructing the visit and empowering the emergency physician to be comfortable with and competently treat the child.

Knowledge of age-specific biologic variables is required to identify abnormalities. Tables 1-1, 1-2, 1-3^1–3 provide quick reference for normal pediatric respiratory rate, heart rate, and blood pressure.

The ED must be prepared for the pediatric patient.⁴ The American Academy of Pediatrics and the American College of Emergency Physicians have established a list of recommended pediatric resuscitation equipment and emergency medications.⁵ Dosing medication for children is challenging, especially in a dire situation. Several tools are available to help providers with weight-based dosing. These include the length-based Broselow tape and chart with corresponding colors for dosing, the Best Guess and APLS methods, which involve calculations based on age, computer support programs such as the PEMSOFT calculator software package with dosing calculators and algorithms, and Pediatric Advanced Life Support (PALS) or regional children’s hospital code cards. Having a pharmacist present at pediatric codes is invaluable.

Consider a visit by first-time parents with their sick infant. They have had little sleep; their baby has been crying for 2 hours and has fed poorly today. They are referred to the ED by their pediatrician. They repeated their story to the triage nurse. Once back in the waiting room, they wait for the nurse, then the physician, and then repeat their story another time. The repetition and waiting game can turn into fear and anger. Consideration of in-room triage is a nice option in pediatrics, thus getting the child into an available room and out of the waiting room sooner.

After ensuring that the child does not have an impending emergency that requires immediate intervention, conduct a quick chart review. It is crucial to know if there is a chronic illness or a rare or genetic syndrome. Use and review of a critical information note from a patient’s subspecialist can aid the emergency provider in proper management for that patient’s specific condition. A basic text review or Internet search can prepare the physician for what may be normal for the child or what special problems the child may have. Remember, to the parents, syndrome X is their life and they may know more on the topic than the physician. Listen to the parents, as the child likely has had a similar presentation in the past, and obtain their history of prior management for this problem.

Is the required equipment available in the room? There is nothing worse than a child having a sore throat, and no light source or throat swab in the room. Children have high anxiety, and when the physician leaves the room, the child thinks the anxiety-provoking things are going to be done. When that turns out not to be true, the child may be more uncooperative.

Talk with the parents and determine their main concern. Outline the expectations of the family early in the visit. Discuss what issues you are going to address in the ED and what you will leave for the primary care physician. One must also expect to patiently relay information to multiple concerned parties. For example, the physician talks to the father and is then handed the cell phone to repeat the same information to the mother.