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.
Ivan Steiner MD, MCFP-EM, FCFP
University of Alberta,
To review a simple, personal, time tested tool for decision making in the ED.
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?
In what way is the ED different than the wards and clinics?
So what does this mean to the clinician?
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:
The three “Stop” signs:
1st “Stop” sign
What are the first four key questions to ask oneself ?
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 ?
These questions lead to good triage and care!
Presumption for PEP: the worst case scenario.
Where do we start here based on the
4 key questions?
The 7 step approach.
How to get “Steinerized”
The 1st “Stop” sign
Life = resuscitate.
Limb = reestablish circulation.
Function = prevent further injury. (P.R.I.C.E.)
Does he need resuscitation?
Life = VS=BP, P, RR, to, O2%, weight, sugar, (Co2).
Limb = pulses, colour, sensation.
Function = as above or specific (Visual Acuity)
Does he need monitoring?
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.
Does he need symptomatic treatment?
The 2nd “Stop” sign
Body fluids = blood & allother.
Diagnostic imaging = simple & complex.
Other = things that start with “E”.
Does he need prioritized investigations?
Usually the answer is NO.
Do we know what is wrong and what the definitive treatment options are?
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.
Do we know where he will end up?
Consider these issues early and use the
appropriate resources: social worker, etc.
Did you consider the parents here ?
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.
The 3rd “Stop” sign