Emergencies management in office practice puja fianlllll
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Dr. Puja DhuparMD DNB
BALGOPAL CHILDREN HOSPITAL
EMERGENCIES MANAGEMENT IN OFFICE PRACTICE
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Office of paediatric primary care provider often entry site to emergency care system
Capabilities and limitations in office practice
Early recognition and stabilisation of emergencies in office
Timely transfer to appropriate facility for definitive care
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Common views
EMERGENCIES ARE NOT VERY COMMON.
WILL INCREASE LIABILITY.EXPENSIVE.TIME CONSUMING.REQUIRES TRAINING.
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Standardised office based self assessment
What emergencies have you experienced?
How often?Resources outside your office availableEmergency readiness training of OPD staff
How far is your office from nearest ED?Do you practice children with special health care needs?
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Good Resuscitation Knowledge And Skills Are Essential For Best Chances Of Survival
First Person To Assess Patient Is Often Least Clinically Experienced Receptionist
Teach Them Symptoms And Signs Of Emergency
Periodically Check Waiting Area
Pediatric Office Based Protocols For 5-10 Top Emergency Conditions
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RECEPTION DESK EMERGENCY CARD
THE FOLLOWING SIGNS AND SYMPTOMS MAY SIGNAL AN EMERGENCY:
Laboured BreathingBlue Or Pale Colour (Cyanosis)Noisy Breathing (Wheezing Or Stridor)Altered Mental StatusSeizureAgitation (In The Parent)Vomiting After A Head InjuryUncontrolled Bleeding
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Aims of Assessment
LIFE THREATENING
Not Life Threatening
Potentially Life Threatening
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Initial Assessment
Begins Before You Touch The Patient
Form A General Impression.
Determine A Chief Complaint.
The Pediatric Assessment Triangle Can Help.
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EQUIPMENT FOR ASSESSMENT
LOOKBehaviourInteractivityConsolabilityTone &Posture
LISTENCryResp soundsSpeechmother
FEELPulsesSkinextremities
MEASURETempPulse oximeterCapillary glucose
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Key Question
What are the elements of the assessment that are most useful?
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Pediatric Assessment Triangle
A P P E A R A N C E
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B R E A T H I N G
Pediatric Assessment Triangle
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C I R C U L A T I O N
A P P E A R A N C E W O R K O F BREATHING
Pediatric Assessment Triangle
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Howsick?
How quick?
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Triangle: Respiratory Distress
NormalAppearance
IncreasedWork of Breathing
MEANS RESPIRATORY DISTRESS
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Triangle: Respiratory Failure
Abnormal Appearance
MEANS RESPIRATORY FAILURE
Increased orDecreased Work of Breathing
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Triangle: Shock
Poor Circulation to Skin
MEANS SHOCK
AbnormalAppearance
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Triangle:
Poor Circulation to Skin
M E A N S O B S E R V E
NormalAppearance
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Triangle: Brain Dysfunction
Normal Circulation to Skin
MEANS BRAIN DYSFUNCTION
AbnormalAppearance
Normal Work of Breathing
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Key Points1. The Triangle is a “quick look” of overall
severity and urgency of treatment.
2. primary survey in a rapid ordered, stepwise evaluation of cardiopulmonary and neurologic function to prioritize treatment.
3. Begin resuscitation immediately when you identify a life-threatening problem in the primary survey.
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Vital Signs by Age Age Respirations
(breaths/mi)Pulse (beats/min)
Systolic Blood Pressure (mm Hg)
Newborn: 0 to 1 mo 30 to 60 90 to 180 50 to 70
Infant: 1 mo to 1 yr 25 to 50 100 to 160 70 to 95
Toddler: 1 to 3 yr 20 to 30 90 to 150 80 to 100
Preschool age: 3 to 6 yr 20 to 25 80 to 140 80 to 100
School age: 6 to 12 yr 15 to 20 70 to 120 80 to 110
Adolescent: 12 to 18 yr 12 to 16 60 to 100 90 to 110
Older than 18 yr 12 to 20 60 to 100 90 to 140
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Key values in practice
Pulse > 220/min consider SVT
Cap refill > 2 seconds is not normal
BP in kids > 1 year = 70 + (2 x age)
RR > 60/min NB, > 50/min till 1yr, > 40 /min till 5 yrs
PULSE OXIMETRY<92 In room air
CAPILLARY BLOOD SUGAR <60
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COMMON PEDIATRIC OFFICE EMERGENCIES
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ANAPHYLAXISAn acute clinical syndrome caused by exposure to
a foreign substance to which patient has been previously sensitised
Fatal food reactions cause respiratory arrest after 30-35 min
Insect stings cause collapse from shock in
10-15 min
Death after parenteral medication occur within
5 min
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Causes of Anaphylaxis Food allergy eg peanuts,egg white,seafood,soya,food
additives
Medications (penicillin,NSAIDS,cephalosporins,quinolones,sreptomycin,iron dextran)
Insect stings,tick bites
Biological products( vaccines ,antisera,blood products)
Contrast medias
Idiopathic
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C R I T E R I A
1. Acute onset of an illness (minutes to several hours) with involvement of the skin, mucosal tissue, or both (eg, generalized hives, pruritus or flushing, swollen lips-tongue-uvula)
AND AT LEAST ONE OF THE FOLLOWING
A. Respiratory compromise (eg, dyspnea, wheeze-bronchospasm, stridor, hypoxemia)
B. Reduced BP* or associated symptoms of end-organ dysfunction (eg, hypotonia, collapse, syncope, incontinence)
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ALLERGIC REACTIONS AND ANAPHYLAXISMild Moderate Severe
(anaphylaxis)
Hives,rash
No respiratory distress
Hives,rash
Abdominal cramping
Swelling of mucous membrane
Normotensive
Mild bronchospasm
Altered mental status
Angioedema
Abdominal cramping
Hypoperfusion
Respiratory distress-grunting,flaring,stridor,bronchospasm
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DIAGNOSING ANAPHYLAXISDiagnosis based on clinical presentation and
exposure history
Flushing and tachycardia invariably present other cutaneous symptoms hives and itch may be absent
Very rarely may present only with profound hypotension
Exposure to some inciting agent is one key to diagnose in such rare cicumstances
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Anaphylaxis: Causes of Death
Upper and / or Lower Airway Obstruction (70%)
Cardiac Dysfunction (24%)
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Treatment Mild ModerateConsider benadryl 1mg/kgMax 50mg
Oxygen
Benadryl
Epinephrine SC(1:1000) .,01ml/kg,Max 0.3 ml
Resp symptoms salbutamol nebulisation 2.5mg/3ml NS may repeat if no improvement
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GENERAL MANAGEMENT OF ANAPHYLAXISAirway
Breathing
Circulation
But use epinephrine promptly
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Prehospital care Advise patient with airway obstruction or resp
distress position of airway comfort.
If feeling faint,unable to sit stand,make him in trendelberg position.
Hypotensive pts could rapidly go into cardiac arrest if they remain upright.
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Epinephrine (adrenaline) is first line treatment.
Epinephrine preferably given IM
Antihistamines & bronchodilators are not first line treatment but may be given after epinephrine.
Transportation to hospital should not be
delayed to administer these once epinephrine has been given.
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Management of anaphylaxis
Epinephrine 0.01ml/kg (1:1000)IM X3, every 5-20min as needed.
Subcutaneous or inhaled routes not recommended
If child is in shock administer IV adrenaline 0.1ml/kg(1:10000)
along with volume expansion
If there is significant wheezing nebulise with salbutamol
H1 antagonists eg Diphenhydramine (Benadryl) 25-100mg
Corticosteroids hydrocortisone (5-10mg/kg)
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RESPIRATORY EMERGENCIES -
AIRWAY OBSTRUCTION MOST COMMON FOLLOWED BY PARENCHYMAL AND PLEURAL
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General approach
Do not separate child from mother
Avoid changing position of comfort which child has adopted
Help mother to administer oxygen in a non threatening manner
Perform rapidly cardiopulmonary cerebral assessment
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Triage Of These Children Will Depend On -
The severity of obstruction The cause of obstruction which
will give a clue to the rate of narrowing
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Cause Of Obstruction
Where the rate of narrowing is likely to be rapid or critical do not attempt to visualize the throat
Rapid narrowing can be seen in anaphylaxis, foreign body aspiration, burns involving the airway, epiglottitis
Critical narrowing can be suspected when there is extreme dyspnoea, diaphoresis or significant retractions esp suprasternal
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Mild Moderate Severe
GeneralAppearance
Happy Feeds well Interested in surroundings
Fussy, but interactiveComforted by parents
RestlessAgitatedAltered sensorium
Stridor Stridor on coughing & crying No stridor at rest
Stridor at restWorsening with agitation
Stridor at restWorsening with agitation
Respiratory Distress
No distress TachypneaTachycardia & Chest retractions
Marked tachypnea Tachycardia with retractions
Saturation
> 92% in room air > 92% in room air < 92% in room air
MILD - No stridor at rest and able to maintain saturation
MODERATE -Stridor at rest, worsens on agitation but able to maintain oxygenation
SEVERE - Severe stridor, altered mentation and failing to maintain oxygenation
How do you Grade Severity of Obstruction
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CROUP(ALTB)
Presents with history of prodromal URI followed by barking cough,hoarse voice stridor and mild fever
Age 6-36 mths, commonly seen in early winter
Etiology parainfluenza type 1,3 RSV,adenovirus,influenza A
In all cases of stridor always rule out epiglottitis where there is toxic appearance,high fever and sudden onset of symptoms
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Croup Management
Mild
Moderate
Severe
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Mild Croup
Symptomatic treatment +/- single dose of oral steroids
Parental education on symptoms and signs of worsening even at night
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Moderate Croup
Steroids
Nebulised adrenaline
Close monitoring
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Steroids in Croup
Best option is dexamethasone 0.6 mg/kg oral, iv, im
Oral prednisolone - 2 mg/kg
In children who cannot take oral medications a single dose of budesonide nebulised 2 mg
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Adrenaline in Croup
Dose is 0.5 ml/kg upto a maximum of 5 ml of a 1:1000 dilution
Can be repeated every 20-30 minutes for a maximum of 3 nebulisations
Even if croup responds well, observe for at least 2 hours
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Treatment of Severe CroupOxygenRapid transferSteroids Nebulize adrenaline as frequently as needed
Intubate if airway obstruction / work of breathing is worsening
Use a tube half size smaller than optimal
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Foreign body
Sudden attack of respiratory symptoms such as cough, choking gagging ,cyanosis in a previously normal child
Positive history must never be ignored while a negative history may be misleading
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Removing a Foreign Body Airway Obstruction
DEPENDS ON AGE
OVER >1YR HEIMLICH MANEUVER
UNDER < 1YR BACK BLOWS FOLLOWED BY CHEST THRUSTS
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Removing a Foreign Body Airway Obstruction
In a conscious child:Kneel behind the child.
Give the child five abdominal thrusts.
Repeat the technique until object comes out.
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Removing a Foreign Body Airway Obstruction
If the child becomes unconscious, inspect the airway.
Attempt rescue breathing.
If airway remains obstructed, begin CPR.
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Management of AirwayObstruction in InfantsHold the infant facedown.Deliver five back slaps.Bring infant upright on
the thigh.Give five quick chest
thrusts.Check airway.Repeat cycle as often as
necessary.
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Workstation Videos1.mp4
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NEUROLOGICAL EMERGENCIES
FEBRILE SEIZURES AND STATUS EPILEPTICUS
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Useful History for Child with Seizure
Does s/he have a fever?Does s/he have a seizure disorder?
If yes, is s/he on anti-seizure medications?
If yes, is s/he taking them, or any recent changes?
Any trauma?Any medicines s/he had access to?How was s/he before the seizure started?Is s/he developmentally normal?Family h/o epilepsy/febrile seizures
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TreatmentControl Seizure
IV lorazepam 0.05mg/kg* orIV midazolam 0.2mg/kg intranasal (if immediate IV access is difficult)
4 puffs / 10 kg
* lorazepam loses potency at room temperature and needs to be refrigerated
Treat The Source Of Fever
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If No IV Access…..Lorazepam 0.1 mg/kg IM
Diazepam 0.5 mg/kg PR Midazolam 0.5 mg/kg IM
0.2 mg/kg Intranasal/buccal
0.15 mg/kg PR
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Diagnosis of Status Epilepticus
Monitoring and control of vital parameters:
Airway Breathing CirculationGlucose,
Start O2, secure IV accessLorazepam: 0.05- 0.1 mg/kg i.v.
Phenytoin (20 mg/kg i.v. at 1 mg/kg/min) orFosphenytoin (20 mg/kg at 3mg/kg/min)
Attention:rhythm problems and falling blood pressure
Seizures Continuing?
If seizures continuing, treat as refractory status
Make arrangements
for early transfer
ilae-epilepsy.org
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ZIPPER ENTRAPMENT INJURY
Most common genital injuries in prepubertal boys.
Typically involve the foreskin or redundant penile skin and may occur during the zipping or unzipping process
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Zipper Injury: Treatment
The procedure for entrapment release depends upon the site of entrapment within the zipper.
Entrapment of penile skin between the zipper teeth (and not the zipper mechanism)
Release by cutting across the zipper
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ENTRAPMENT IN ZIPPER MECHANISM
Recommended technique:The median bar may be cut with wire cutters,
bone cutters, or a mini hacksaw Allows the mechanism to fall apart and leads to
release of the entrapped skin Alternate technique:
Thin blade of a small flathead screwdriver Placed between the faceplates on the side of
the mechanism in which the penile skin is not entrapped.
The blade is then rotated toward the median bar This widens the gap between the faceplates,
releasing the skin
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The most common
mechanism is a fall on an outstretched hand.
On examination forearm is held pronated,with partial flexion at elbow
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PROCEDUREDOESNOT REQUIRE SEDATION OR ANALGESIA
RADIOGRAPHY NOT NEEDED TO CONFIRM DIAGNOSIS
GRASP CHILDS HAND IN HAND SHAKING GESTURE AND RAPIDLY ROTATE EXTERNALLY AND FLEXED SIMULTANEOUSLY
PALPABLE CLICK ,POP FOLLOWED BY CRY
RETURN TO NORMAL MOVEMENT IN 5-15 MIN
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REMOVAL OF A NASAL FOREIGN BODY
1.Nasal foreign bodies are most common in 2-3-year-olds and
common foreign bodies include toy parts, beads, insects, paper, and
food items.
2. Symptoms depend on how long the
object has been lodged in the nasal
passages.
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B. PROCEDURE 1. Positive Pressure Techniques: with use of either
mouth-to-mouth by parent, or with AMBU bag and mask applied to mouth of child, occlude the opposite nostril and give a gentle, positive-pressure breath to expel the object.
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2 Instrumental Removal:
1.The child should be lying down and restrained.
2. Visualize the interior of the nose with a nasal speculum.
3. Extract the object with suction, a hook, or alligator forceps.
4. Do not push the foreign body into the posterior nasopharynx
5. After the foreign body has been removed, ora antimicrobial agents may be used in an effort to prevent an infection in the traumatized area.
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Be Prepared Everyday With
MEDICATIONS
TRAINED STAFF EQUIPMENT
MET
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Location of Equipment
All drugs should be kept in emergency equipment container and expiry checked regularly
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EMS
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T H A N K S