Decision making in pediatric emergency medicine
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Decision Making in Pediatric Emergency Medicine. Ivan Steiner MD, MCFP-EM, FCFP University of Alberta, Edmonton, Canada. Goal for today. To review a simple, personal, time tested tool for decision making in the ED. Game plan. Look at the difference between ED, wards and clinics.

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Decision Making in Pediatric Emergency Medicine

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Decision making in pediatric emergency medicine

Decision Making in Pediatric Emergency Medicine

Ivan Steiner MD, MCFP-EM, FCFP

University of Alberta,

Edmonton, Canada


Goal for today

Goal for today

To review a simple, personal, time tested tool for decision making in the ED.


Game plan

Game plan

  • Look at the difference between ED, wards and clinics.

  • Review the components of decision making process in the ED.

  • Outline my template for decision making.

  • Answer questions.

  • Provide a summary.


Warm up

Warm up

15 patients waiting in the waiting room when a 7

month old baby boy is brought by his parents into the E.D. of

A peripheral hospital. He is unresponsive and is visibly

covered by a rash. His BP = 60/?, P = 160, RR = 50, to = 40o,

O2% = 96% on R.A.

What is the problem?

What are your priorities in this case?


The ed a distinct environment

The ED a distinct environment

Question:

In what way is the ED different than the wards and clinics?


The ed a distinct environment1

The ED a distinct environment

  • Lack of control over volume of patients.

  • Variable acuity and availability of resources.

  • Triage.

  • Unknown patients.

  • Short intervention time.

  • Limited information.

  • “One shot” approach.

  • Uncertainty of dealing with unknown, or previously not encountered problems.

    So what does this mean to the clinician?


The ed a distinct environment2

The ED a distinct environment

Functioning in an environment with limited , variable resources AND dealing withfrightened, possibly hostile patients and families .

Key skills and attitude/behaviours required to be successful in the ED:

  • Prioritized, organized approach to each situation.

  • Empathy, respect, tact.

  • On going, two - way communication.


Take home message for part 1

Take home message for Part 1.

  • Decision making may have to start with the little or no information.

  • The “traditional” approach to patient management does not work in the ED.

  • A PEP is a “people person”. Rapport!


Decision making key questions to ask oneself

Decision making: key questions to ask oneself

The three “Stop” signs:

1st “Stop” sign

What are the first four key questions to ask oneself ?


Back to our case

Back to our case

A 7 month old baby boy is brought into the

E.D. of a peripheral hospital by his parents.

He is unresponsive and is visibly covered by a

rash. His BP = 60/?, P = 160, RR = 50, to =

40o, O2% = 96% on R.A.

What are the first 4 key questions to ask ?


Decision making key questions to ask oneself1

Decision Making: Key Questions to Ask Oneself

  • Is the patient in the right institution ?

  • Is the patient in the right part of the ED?

  • Is there a need for immediate resuscitation, or potential for resuscitation of LIFE, limb or salvage of function?

  • What immediate information/resources are required to start management of the patient?

    These questions lead to good triage and care!


How do we make decisions

How do we make decisions

Presumption for PEP: the worst case scenario.


How do we make decisions1

How do we make decisions

  • First step: trust your eyes, smell, hearing, touch.

  • Second step: check vital signs.

  • Third step: asses chief complaint.


How do we make decisions2

How do we make decisions

  • Start with patient presentation and NOT diagnosis.

  • Anatomy and physiology are great guides!!!!


Back to our case1

Back to our case

Where do we start here based on the

4 key questions?


Take home message part 2

Take home message Part 2.

  • A good PEP anticipates problems.

  • In the ED, the clinician is first and foremost a clinical physiologist.

  • He/she is an expert at managing multiple, often limited resources.


Template to decision making

Template to decision making

The 7 step approach.

How to get “Steinerized”


Template the first 7 steps

Template: the first 7 steps

  • Resuscitation.

  • Monitoring.

  • Symptomatic treatment.

  • Investigations.

  • Diagnosis/definitive treatment.

  • Disposition.

  • Social.


Template step 1

Template: step 1

  • Does the patient need resuscitation or stabilization of physiological parameters ?

    The 1st “Stop” sign

    Life = resuscitate.

    Limb = reestablish circulation.

    Function = prevent further injury. (P.R.I.C.E.)


Back to our case2

Back to our case.

Does he need resuscitation?


Template step 2

Template: step 2

  • Does the patient need monitoring?

    Life = VS=BP, P, RR, to, O2%, weight, sugar, (Co2).

    Limb = pulses, colour, sensation.

    Function = as above or specific (Visual Acuity)


Back to our case3

Back to our case.

Does he need monitoring?


Template step 3

Template: step 3

  • Is there a need for symptomatic treatment?

    Provide symptomatic treatment based on

    need and using the most effective route!

    Offer it to the patient even though he/she

    may choose not to accept it.


Back to our case4

Back to our case.

Does he need symptomatic treatment?


Template step 4

Template: step 4

  • Does the patient need prioritized investigations?

    The 2nd “Stop” sign

    Body fluids = blood & allother.

    Diagnostic imaging = simple & complex.

    Other = things that start with “E”.


Back to our case5

Back to our case.

Does he need prioritized investigations?


Template step 5

Template: step 5

  • Do we know what is definitively wrong with the patient and what the definitive treatment options may be?

    Usually the answer is NO.


Back to our case6

Back to our case.

Do we know what is wrong and what the definitive treatment options are?


Template step 6

Template: step 6

  • Do we know where this patient will end up?

    Too sick to go home = ward vs intensive care.

    Will go home = only obvious cases.

    Not sure = most patients fit in to this category.

    Remember: Starting presumption is that you are

    dealing with the worst case scenario.


Back to our case7

Back to our case.

Do we know where he will end up?


Template step 7

Template: step 7

  • Are there any immediate social issues ?

    Consider these issues early and use the

    appropriate resources: social worker, etc.


Back to our case8

Back to our case.

Did you consider the parents here ?


Template the first 7 steps1

Template: the first 7 steps

  • Resuscitation.

  • Monitoring.

  • Symptomatic treatment.

  • Investigations.

  • Diagnosis/definitive treatment.

  • Disposition.

  • Social.


Template the first 7 steps2

Template: the first 7 steps

How do I make it work?

A = Asses.

I = Intervene.

R = Reassess.

The sicker the patient, the more often one repeats A.I.R. and charts each intervention.


Template the final 7 steps

Template: the final 7 steps

The 3rd “Stop” sign

  • Resuscitation.

  • Monitoring.

  • Symptomatic treatment.

  • Investigations.

  • Diagnosis/definitive treatment.

  • Disposition.

  • Social.


Template the 3 stop signs

Template: the 3 “Stop” signs

  • Before triage & resuscitation

  • Before ordering all investigations

  • Before disposition of the patient


Take home message part 3

Take home message Part 3.

  • The 7 point template provides a simple and safe starting point.

  • The 7 point template provides a safe exit strategy.

  • The number of A.I.R. are dictated by the clinical status of the patient.

  • The 3 “STOP” signs help PEP slow down and make good decisions!


Questions

Questions


Distilled summary

Distilled summary

  • Good PEP use a patient/family centered approach in decision making.

  • Early decisions are based on patient presentation and NOT diagnosis.

  • Physiology and anatomy never lie!

  • The 7 point template used on entry and exit + A.I.R. + the 3 STOP signs have been proven, useful and simple to use tools over time.

  • Teaching Pediatric EM to all medical students and residents who are treating children is essential.


The end

The End


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