Pediatric Emergencies in the Office

1. PediatricEmergencies in the Office What To Do When You Are 911!! W Ricks Hanna Jr MD

2. Office Emergencies • Pediatric offices surveyed report 1-38 emergencies per year • AAP survey in 2003-73% of offices had one patient/week requiring emergency treatment or hospitalization • AAP policy statement 2007-52 practices surveyed 24 emergencies/year (median) • AAP policy statement 2007-82% 1 emergency/month • An older study 62% of pediatricians and family physicians in urban settings more than 1 patient/week required hospitalization or urgent stabilization

3. Office Emergencies • Respiratory emergencies most common 75%: • Bronchiolitis, Respiratory distress, Asthma and Croup • Dehydration • Febrile illnesses/Sepsis • Seizures • Anaphylaxis

4. Office Emergencies • Less common presentations: • Respiratory failure • Severe trauma • Foreign body/Obstructed airway • Shock • Meningitis • Sepsis • Apnea

5. The Emergency-Go-Round

6. Parent and Patient Education • Anticipatory guidance • EMS access • Poison Control • Consent for treatment • Constraints from health plans for treatment • Emergency facility access • Advance directives • Summary of information • Training in CPR

7. Office Considerations • Practice type • What are probable/possible emergencies that may arise? • Where are the nearest emergency facilities? • What local EMS services are available? How are they accessed? • Can stabilization occur in the office?

8. Office Personnel: Preparation • Emergency care is a team effort. • Staff and physicians need knowledge, training, resources and practice in “pertinent” emergency care. • Receptionist • Response plan with clearly defined roles

9. Office Personnel: Preparation • Basic emergency skills including: • Recognition of a patient in distress • Basic airway management • Bag-valve-mask ventilation • Initiate treatment of shock • Initiate trauma care • Mock codes or simulation exercises • Documentation • Debriefing

10. Office Preparation: Mock codes • Readiness through practice • The mock code begins with the patient presentation and concludes with stabilization and transfer. • Hands on practice facilitates learning. • Record the events of the mock code for review, especially if implementing change in equipment or procedures. • “Scavenger hunt”

11. Office Preparation: Documentation • Risk management tool • Document: • Steps for office readiness • Training provided • Policies and practices • Simulation exercises • During true emergencies document: • Date/Time • Estimated or actual weight • Medications, fluids given • Information given to family • Patient condition at time of departure from office

12. Office Preparation: Debriefing • Discuss the events of the emergency or mock code. • Formulate a plan for making changes in protocols and/or equipment needed in the event of another emergency. • Document plans to enhance emergency preparedness.

13. Office Preparation: EMS • Can assist in office emergency care and transport • EMS levels • First responders, BLS • ALS • Pediatric transport teams • Can’t help, if not called • Call sooner rather than later • EMS can assist in educational endeavors

14. Emergency supplies: Medications • Designate a “Resuscitation Room” • Have a “Resuscitation Cart” • Essential • Oxygen • Albuterol for inhalation • Epinephrine 1:1,000 for anaphylaxis

15. Emergency supplies: Medications • Strongly Recommended • Antibiotics-Rocephin • Anticonvulsants-Valium, Ativan • Corticosteroids-Parenteral/Oral • Benadryl-Parenteral/Oral • Epinephrine 1:10,000 for resuscitation • Atropine • Fluids-Normal saline and D5 ½ NS, 25% dextrose, oral rehydration fluids • Naloxone • Sodium Bicarbonate

16. Emergency supplies: Equipment • Airway Management • Oxygen delivery equipment • Bag-Valve Mask • Oxygen masks • Nonrebreather masks • Suction device • Nebulizer and/or MDI with spacer/mask • Oropharyngeal airways • Pulse oximeter

17. Emergency Supplies: Equipment • Vascular Access and Fluid Management • Butterfly needles • Catheter-over-needle device • Arm boards, tape, tourniquet • Intraosseous needles • Intravenous tubing

18. Emergency supplies: Equipment • Miscellaneous • Broselow tape • Backboard • Blood pressure cuffs • Splints, sterile dressings • Defibrillator • Accucheck device • Rigid C collars

19. Anaphylaxis • Acute, immediate hypersenitivity reaction involving more than one organ system • Result of “re-exposure” • IgE mediated release of mast cell and basophil mediators which initiate cascade of effects • Exposure can be inhalation, transdermal, oral or intravenous. • Most common causes: food, medications, exercise and insect venom • May not be able to determine a cause

20. Anaphylaxis: Signs & Symptoms • Oral • Cutaneous • Gastrointestinal • Respiratory • Cardiovascular • Central Nervous System • Other

21. Anaphylaxis: Treatment • True medical emergency • A,B,Cs • Positioning • Epinephrine (1:1,000) 0.1 ml/kg up to 0.3 ml SQ or IM • Albuterol • Antihistamines-H1 and H2 • Steroids • IV fluids • Special considerations: • Beta blockers • Injection or sting

22. Dehydration • Remains a cause of significant pediatric morbidity and mortality • Not a disease in itself but a symptom of another process • Is on the hypovolemic shock spectrum • Infants at risk due to large water content, increased metabolism, renal immaturity and dependence on caregivers

23. Dehydration: Etiology • Diarrhea • Hemorrhage-internal and external • Vomiting • Inadequate fluid intake • Osmotic shifts-DKA • Third space losses • Burns

24. Dehydration: Signs & Symptoms • “Quiet” tachypnea • Tachycardia • Sunken eyes • Weak or absent peripheral pulses • Delayed capillary refill • Changes in mental status • Cool skin, Tenting of the skin • Oliguria • What is missing from the list?

25. Dehydration: Treatment • A,B,Cs • Stidham’s Rule: Air goes in and out and the blood goes round and round. • Assess the degree of dehydration/shock • Establish vascular access-IV and/or IO • Fluid boluses in 20 ml/kg aliquots of 15-30 minutes with reassessment • Repeat till correction or stabilization • Oral rehydration therapy (ORT)

26. Seizures • Transient, involuntary alteration of consciousness, behavior, motor activity, sensation and/or autonomic function secondary to excessive cerebral activity • Most common neurologic disorder of childhood • Not necessarily a diagnosis but part of a pathologic process

27. Seizures: Types • Generalized-both cerebral hemispheres involved • Tonic-clonic, absence, myoclonic, tonic, clonic, atonic • Partial-one cerebral hemisphere involved • Simple-no impairment of consciousness • Complex-impaired consciousness • May progress to generalized activity-Jacksonian march • Febrile seizures • Post traumatic seizures

28. Seizures: Treatment • A,B,Cs • Protect the patient • C collar if trauma suspected • Identify and treat known causes • Anticonvulsant therapy for seizures lasting longer than 5-10 minutes • Rectal valium-0.5 mg/kg • Premixed • Can use IV form of the drug • Ativan-0.05-0.1 mg/kg • Can be repeated 1-2 times • Anticonvulsants

29. Respiratory Emergencies • Cardiac arrest in pediatric patients is usually a progression of respiratory failure and/or shock. • Abnormal respiratory rates • Too fast-tachypnea • Too slow-bradypnea • Not at all-apnea • Posture/mental status • Nasal flaring • Retractions • Head bobbing

30. Respiratory Emergencies • Auscultation • Stridor • Grunting • Gurgling • Wheezing • Crackles • A,B,Cs

31. Respiratory Emergencies: Asthma • 5-10% of children affected • Four components • Airway edema • Airway constriction • Increased mucus production • Must be reversible • Many and varied presentations

32. Respiratory Emergencies: Asthma • Treatment • Oxygen • Albuterol • Metered dose inhaler • Nebulization • Steroids • Prednisone 1-2 mg/kg po up to 60 mg • Methylprednisolone 1-2 mg/kg IV up to 125 mg • Dexamethasone 0.6m/kg po or IM up to 16 mg • Epinephrine (1:1,000) 0.1 ml/kg up to 0.3 ml SQ or IM • Reevaluation

33. Respiratory Emergencies: Croup • Most common cause of stridor in the febrile child • Children 6-36 months most commonly affected • Fever and URI symptoms followed by respiratory distress and “croupy” cough • May have been asymptomatic prior to onset of respiratory distress and “croupy” cough • May have “resolved” at presentation • Other considerations: epiglottitis, bacterial tracheitis, and retropharyngeal abscess

34. Respiratory Emergencies: Croup • Treatment • Oxygen • Nebulized epinephrine (1:1,000) 3ml in 1-2 ml of saline • Dexamethasone 0.6 mg/kg po or IM up to 16 mg • Observation

35. Respiratory Emergencies: Bronchiolitis • Acute viral infection of the lower respiratory tract most commonly secondary to RSV • Usually affects infants 2-12 months of age • Presentation usually includes low grade fever, COPIOUS rhinnorhea, harsh “painful” cough, and respiratory distress • Apnea within the first 24-72 hours of illness is a major concern • Feeding is important consideration in disposition

36. Respiratory Emergencies: Bronchiolitis • Treatment • Oxygen • Nasal suction • Albuterol if a family history of asthma • Nebulized epinephrine if no family history of asthma • Observation

37. Fever/Sepsis • Complete clinical picture • Know what is “out there” • “Fever phobia” • Occult infections, Serious Bacterial Infection (SBI) are concerns with fever especially with no obvious source • Think of shock and respiratory failure • Give antibiotics sooner rather than later • Oxygen • IV fluids

38. Fever Definition • Fever > 38c (100.4F) taken reliably • Fever at home, fever in office = fever • Fever at home measured reliably, afebrile in office = fever • Subjective fever at home and given antipyretics, afebrile in office = fever • Subjective fever at home, no antipyretics, afebrile in office = afebrile

39. Fever Workup/Treatment • Treat “sick” kids appropriately at any age • 0-28 days of age • Full septic workup and admission • 1-3 months of age • Blood and urine studies and cultures • CSF as indicated • 3-36 months of age • Temperature threshold increases to > 39c • Urine studies as indicated • CSF studies as indicated • Treatment guidelines for clinical conditions

40. Fever Workup/Treatment • 3-36 months of age “occults” • Bacteremia • Pneumonia • Urinary tract infection • In all appropriate age groups RSV, Flu, Strep, Mono, Stool studies etc. as appropriate

41. Fever Workup/Treatment • No perfect “recipe” for the detection of febrile children with SBI • Our hands, eyes, and ears remain our most useful tools especially when paired with clinical experience. • Bacteremia is possibly a dated entity. • Follow up is crucial to “treatment”.