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Pediatric Office EmergenciesPediatric Office Emergenciesandand

The Makenna David PediatricThe Makenna David PediatricEmergency DepartmentEmergency Department

Cr i T C rt r D OCr i T C rt r D OCraig T. Carter, D.O.Craig T. Carter, D.O.Medical Director Medical Director -- Pediatric Emergency MedicinePediatric Emergency Medicine

Assistant Professor Assistant Professor -- Emergency Medicine and PediatricsEmergency Medicine and PediatricsUniversity of KentuckyUniversity of Kentucky

Contemporary Pediatrics Contemporary Pediatrics -- April 9, 2010April 9, 2010

OutlineOutline 1. History/EBM1. History/EBM

2. Office Emergency Plan2. Office Emergency Plan Staff and trainingStaff and training EquipmentEquipment

3. Primary Office Emergencies3. Primary Office Emergencies

Allergic ReactionAllergic ReactionSOA ( h )SOA ( h ) SOA (asthma, croup, etc)SOA (asthma, croup, etc)

Seizure Seizure

4. Transfer 4. Transfer -- Higher Level of CareHigher Level of Care

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HistoryHistory

Preparedness of Practicing Pediatricians to Manage Emergencies Preparedness of Practicing Pediatricians to Manage Emergencies

SchweichSchweich , P MD, P MD et al , et al , Pediatrics, Aug. 1991, Vol. 88:2Pediatrics, Aug. 1991, Vol. 88:2

427/1000 office based Pediatricians surveyed427/1000 office based Pediatricians surveyed

>90% within 5 miles of ER>90% within 5 miles of ER

58% PALS/APLS certified58% PALS/APLS certified

77% had seen ‘severe asthma’ 66% in past year77% had seen ‘severe asthma’ 66% in past year 77% had seen severe asthma , 66% in past year77% had seen severe asthma , 66% in past year

67% had seen ongoing seizure, 45% in past year67% had seen ongoing seizure, 45% in past year

22% had an arrest in office, 6% in past year22% had an arrest in office, 6% in past year

Office PreparednessOffice Preparedness

Office trainingOffice training

PhysicianPhysician

NurseNurse

TechTech

Ancillary StaffAncillary Staff

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Office PreparednessOffice Preparedness

Certification/Training/CoursesCertification/Training/Courses

Basic First AidBasic First Aid BLS/CPRBLS/CPR ACLSACLS PALSPALS NALSNALS APLSAPLS ATLSATLS

Office PreparednessOffice Preparedness

Plan of ActionPlan of Action

Protocols (set up in advance!)Protocols (set up in advance!)

Clearly defined staff rolesClearly defined staff roles PrimaryPrimary SecondarySecondary Medications/equipment (O2 tank, nebulizer etc)Medications/equipment (O2 tank, nebulizer etc) IVIV Make the call Make the call –– 911911 Notify EDNotify ED

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Office PreparednessOffice Preparedness PracticePractice

Run mock scenariosRun mock scenarios Run mock scenariosRun mock scenarios Run mock scenariosRun mock scenarios

SimBabySimBaby Contact UK Physician Liaison Contact UK Physician Liaison

C l nd r/ R tin h kC l nd r/ R tin h k Calendar/ Routine checkCalendar/ Routine check Equipment Equipment

O2 tanks are fullO2 tanks are full\\ Equipment location and comfort with use and setEquipment location and comfort with use and set--upup

Medication Medication Expiration dateExpiration date dosing dosing

UK EM UK EM by the numbers…by the numbers…

Current ED Volume Total Current ED Volume Total -- @ 48,000/yr@ 48,000/yr

Pediatric EM Volume Pediatric EM Volume -- @ 12,000+/yr@ 12,000+/yr

UK UK is only one of two Level 1 is only one of two Level 1 Pediatric Trauma Pediatric Trauma CC ii hhCenters Centers in in the statethe state

UK has the second Pediatric ED in the UK has the second Pediatric ED in the

state state –– Opened September, Opened September, 20072007

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Pediatric ED at UK ?...Pediatric ED at UK ?...

“ I’ll believe it when I see it.”“ I’ll believe it when I see it.”

“We have been hearing that for “We have been hearing that for

20 years…”20 years…”

The Makenna David Pediatric ED The Makenna David Pediatric ED Opens July 14, 2010Opens July 14, 2010

The Pediatric ED The Pediatric ED @ roughly 7,600 sf. @ roughly 7,600 sf.

The total area of the ED is @ 37,000 The total area of the ED is @ 37,000

(length is size of football field plus end zones)(length is size of football field plus end zones)

Plus additional Plus additional 4,600 sf. for Radiology 4,600 sf. for Radiology

12 /+ 4 fl12 /+ 4 fl 12 core /+ 4 flex rooms 12 core /+ 4 flex rooms

Separate EntranceSeparate Entrance

Separate waiting room and triageSeparate waiting room and triage

Separate StaffSeparate Staff

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The Makenna David Pediatric The Makenna David Pediatric Emergency DepartmentEmergency Department

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Office Emergency Equipment/SuppliesOffice Emergency Equipment/Supplies

Suction/suction cathetersSuction/suction catheters

Magill ForcepsMagill Forceps remo e foreign bodiesremo e foreign bodies Magill Forceps Magill Forceps –– remove foreign bodiesremove foreign bodies

Pulse oximeter/Cardiac monitorPulse oximeter/Cardiac monitor

Nebulizer Nebulizer –– single or ‘continuous’single or ‘continuous’

Face masks Face masks –– various sizesvarious sizes

Oral/Nasopharyngeal airwayOral/Nasopharyngeal airway

AmbubagsAmbubags AmbubagsAmbubags

Intubation equipmentIntubation equipment

•• Laryngoscope, blades & Endotracheal tubesLaryngoscope, blades & Endotracheal tubes

•• EZ capEZ cap

•• LMALMA

•• tapetape

Emergency Equipment/SuppliesEmergency Equipment/Supplies

Portable Oxygen tankPortable Oxygen tank Flow metersFlow meters

Masks/tubingMasks/tubing

Albuterol Albuterol –– inhaledinhaled

Nebulizer EquipmentNebulizer Equipment

Racemic EpinephrineRacemic Epinephrine –– inhaledinhaled Racemic Epinephrine Racemic Epinephrine –– inhaledinhaled

Terbutaline Terbutaline –– SQ or IVSQ or IV

Decadron Decadron –– PO, IM or IVPO, IM or IV

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Emergency Equipment/SuppliesEmergency Equipment/SuppliesVascularVascular

Automatic defibrillatorAutomatic defibrillator

IV, IOIV, IO EZEZ--IOIO

Single or multi useSingle or multi use

IV tubing/setupIV tubing/setup IV tubing/setupIV tubing/setup

IV boardsIV boards

Normal SalineNormal Saline

SyringesSyringes

Emergency Equipment/Supplies Emergency Equipment/Supplies --Broselow TapeBroselow Tape--

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Emergency Equipment/Supplies Emergency Equipment/Supplies ––CommercialCommercial

BroselowBroselow® Pediatric ® Pediatric Resuscitation SystemResuscitation System

ThTh B lB l S t iS t i The The BroselowBroselow System is System is designed with children's care designed with children's care in mind. The system supplies in mind. The system supplies you with all the information you with all the information and equipment you need for and equipment you need for your young patients' your young patients' emergency resuscitation emergency resuscitation requirements, all contained requirements, all contained q ,q ,in a color coded, easyin a color coded, easy--toto--use use kit.kit.

Price: $1,950.00Price: $1,950.00

Emergency Equipment/Supplies Emergency Equipment/Supplies --CommercialCommercial--

BanyonBanyon ––

700 Pedi Stat Kit 700 Pedi Stat Kit Price: $845Price: $845

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Emergency MedicationsEmergency Medications CardiacCardiac

EpinephrineEpinephrine 1:1000 for SQ (allergic reactions)1:1000 for SQ (allergic reactions) 1:10000 (for cardiac/IV treatment)1:10000 (for cardiac/IV treatment)

RespiratoryRespiratory AlbuterolAlbuterol RacemicRacemic

Other Other DecadronDecadron AtivanAtivanAtivanAtivan Valium/DiastatValium/Diastat CeftriaxoneCeftriaxone NarcanNarcan GlucoseGlucose BenadrylBenadryl

Laryngeal Mask Airway (LMA)Laryngeal Mask Airway (LMA)

The LMA consists of two parts:The LMA consists of two parts: TheThe maskmask TheThe tubetube

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Laryngeal Mask Airway (LMA)Laryngeal Mask Airway (LMA)

Designed to surround and cover the supraglottic Designed to surround and cover the supraglottic area.area.

Does not constitute a definitive airway unless an Does not constitute a definitive airway unless an ETT is successfully passed.ETT is successfully passed.

They do not prevent regurgitation or protect They do not prevent regurgitation or protect airway from aspirationairway from aspirationairway from aspirationairway from aspiration

Patients must be significantly obtunded to Patients must be significantly obtunded to tolerate insertion tolerate insertion

LMA Size SelectionLMA Size Selection

Recommended Size guidelines:Recommended Size guidelines:

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Insertion Insertion TechniqueTechnique

1. Lubricate the 1. Lubricate the posterior side of theposterior side of theposterior side of the posterior side of the LMA with waterLMA with water--soluble soluble lubricantlubricant

2. Completely deflate 2. Completely deflate the cuff after testingthe cuff after testingthe cuff after testingthe cuff after testing

3. Open the airway 3. Open the airway

using head tiltusing head tilt

4 h d i4 h d i 4. Press the device 4. Press the device onto the hard palate onto the hard palate and advance over the and advance over the back of the tongue.back of the tongue.

5. Inflate the collar 5. Inflate the collar with airwith air

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Problems with LMA InsertionProblems with LMA Insertion Failure to press the Failure to press the

deflated mask up against deflated mask up against the hard palate or the hard palate or inadequate lubrication orinadequate lubrication orinadequate lubrication or inadequate lubrication or deflation can cause the deflation can cause the mask tip to fold back on mask tip to fold back on itself.itself.

Once the mask tip has Once the mask tip has t t d t f ld thit t d t f ld thistarted to fold over, this started to fold over, this

may progress, pushing the may progress, pushing the epiglottis into its downepiglottis into its down--folded position causing folded position causing mechanical obstruction mechanical obstruction

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Emergency Department 

Adult Pod C

Adult Pod B

Adult Pod A

Peds Pod

Swing Rooms

Fast Track Rooms

Education, Office, Support

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Pediatric Emergency Floor PlanPediatric Emergency Floor Plan

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Office Emergency ReviewOffice Emergency Review

4 primary Office Emergencies4 primary Office Emergencies4 primary Office Emergencies4 primary Office Emergencies

Allergic Reaction*Allergic Reaction*

SOA (asthma, croup, etc)*SOA (asthma, croup, etc)*

Seizure*Seizure*

SepsisSepsis

Case Review Case Review -- true storytrue story

Mother of three year old male calls her childs Mother of three year old male calls her childs physician and asks about a possible peanut physician and asks about a possible peanut llllallergy.allergy.

…she is concerned about a mild reaction child had …she is concerned about a mild reaction child had the day before which included facial redness and the day before which included facial redness and itching after he ate a peanut butter sandwich.itching after he ate a peanut butter sandwich.itching after he ate a peanut butter sandwich.itching after he ate a peanut butter sandwich.

The pediatrician replies….The pediatrician replies….

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Case Review Case Review -- true storytrue story

Come on in tomorrow with the child and we Come on in tomorrow with the child and we will check him outwill check him outwill check him out….will check him out….

…and bring a peanut butter sandwich, he can …and bring a peanut butter sandwich, he can eat it in the office and we will see if he has a eat it in the office and we will see if he has a reaction…reaction…

So the next day…So the next day…

Case Review Case Review -- true storytrue story

Anaphylaxis to peanut butterAnaphylaxis to peanut butterSOASOA SOASOA

WheezingWheezing HivesHives PruritisPruritis Periorbital edemaPeriorbital edema

Luckily Luckily –– the physician office was in the office the physician office was in the office park of hospital and had easy access to the EDpark of hospital and had easy access to the ED

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Allergic Reaction/AnaphylaxisAllergic Reaction/AnaphylaxisSeverity of ReactionSeverity of Reaction

MildMild PruritisPruritis

Topical rashTopical rash Localized reactionLocalized reaction

UrticariaUrticaria

ModerateModerate Diffuse rashDiffuse rash -- severe pruritissevere pruritis Diffuse rash Diffuse rash severe pruritissevere pruritis

coughcough

anxiousanxious

Facial edemaFacial edema PeriorbitalPeriorbital

Allergic Reaction/AnaphylaxisAllergic Reaction/Anaphylaxis

Severity of ReactionSeverity of Reaction

SevereSevere SOA SOA retraction, NF, grunting, striderretraction, NF, grunting, strider

WheezingWheezing Angioedema Angioedema ––

d li i d i hd li i d i h drooling, tripod, voice changesdrooling, tripod, voice changes Severe agitationSevere agitation N/VN/V CV compromise/hypotensionCV compromise/hypotension

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Allergic Reaction/AnaphylaxisAllergic Reaction/AnaphylaxisInterventionIntervention

ABC’sABC’s IV access and IVFIV access and IVF MedicationMedication MedicationMedication

EpinephrineEpinephrine 1:1000 at 0.01 mg/kg SQ, max dose 0.3 mg SQ1:1000 at 0.01 mg/kg SQ, max dose 0.3 mg SQ

AntihistaminesAntihistamines Benadryl Benadryl –– PO, IVPO, IV Non Non –– sedating antihistamines (samples)sedating antihistamines (samples)

Corticosteroids Corticosteroids –– prelone, prednisone, prednisilone, prelone, prednisone, prednisilone, p p pp p pdecadrondecadron IV, IM, POIV, IM, PO

Albuterol MDI or HHNAlbuterol MDI or HHN H2 blockerH2 blocker

Asthma / RADAsthma / RAD Severe ExacerbationSevere Exacerbation

SOASOA WheezingWheezing RetractingRetracting Nasal FlaringNasal Flaring GruntingGrunting AMSAMS

4 i f h i4 i f h i 4 questions for every asthmatic 4 questions for every asthmatic 1. Have you ever been to ICU?1. Have you ever been to ICU? 2. Have you ever been intubated?2. Have you ever been intubated? 3. Last hospital admission/ED visit?3. Last hospital admission/ED visit? 4. Last time on oral steroids?4. Last time on oral steroids?

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Status AsthmaticusStatus AsthmaticusTreatment/InterventionTreatment/Intervention

Pulse OximetryPulse Oximetry IV AccessIV Access MonitorMonitor Supplemental OxygenSupplemental Oxygen MedicationsMedications

Bronchodilators Bronchodilators –– B2 agonistB2 agonist AlbuterolAlbuterol XopenexXopenex

CorticosteroidsCorticosteroids DecadronDecadron

S l d lS l d l 1 /k IV IM1 /k IV IM Solumedrol Solumedrol –– 1mg/kg IV or IM1mg/kg IV or IM Prelone/Prednisone 2 mg/kg load poPrelone/Prednisone 2 mg/kg load po

Magnesium Sulfate Magnesium Sulfate –– MgSO4MgSO4 1mg/kg IV1mg/kg IV

TerbutalineTerbutaline 0.01 mg/kg SQ (max 0.4 mg)0.01 mg/kg SQ (max 0.4 mg)

LMA / RSILMA / RSI

All asthma may not wheeze…and all All asthma may not wheeze…and all wheezing is not asthmawheezing is not asthma

FB aspiration/ingestionFB aspiration/ingestion

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All wheezing is not asthma…All wheezing is not asthma…

Differential DiagnosisDifferential Diagnosis FB aspirationFB aspiration

CroupCroup

EpiglottitisEpiglottitis

Allergic Reaction/AnaphylaxisAllergic Reaction/Anaphylaxis Allergic Reaction/AnaphylaxisAllergic Reaction/Anaphylaxis

CHFCHF

Congenital Heart DiseaseCongenital Heart Disease

PneumoniaPneumonia

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Status EpilepticusStatus Epilepticus

serial seizure activity without recovery or serial seizure activity without recovery or prolonged, continuous seizure activity that lasts prolonged, continuous seizure activity that lasts over 30 minutesover 30 minutes

Estimated 100,000 Estimated 100,000 –– 150,000 per year in US150,000 per year in US

M t lit 1M t lit 1 10%10% Mortality 1Mortality 1--10% 10%

Status Epilepticus: CausesStatus Epilepticus: Causes

Metabolic encephalopathyMetabolic encephalopathy

Infectious encephalopathy Infectious encephalopathy

CNS lesionsCNS lesions

Intoxications / Toxic IngestionsIntoxications / Toxic Ingestions

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Status Epilepticus: Benzodiazapine Status Epilepticus: Benzodiazapine TreatmentTreatment

DiazapamDiazapam

Adult: 0.2mg/kg at 2 mg/min up to 20 mgAdult: 0.2mg/kg at 2 mg/min up to 20 mg

Peds: 0.2Peds: 0.2--0.5mg/kg up to 20mg IV/IO/ET0.5mg/kg up to 20mg IV/IO/ET

0.50.5--1.0mg/kg PR (Diastat)1.0mg/kg PR (Diastat)

411 on the 911411 on the 911 ABC’s ABC’s –– back to basicsback to basics

Airway Airway Breathing Breathing

Ci l iCi l i CirculationCirculation

Call 911Call 911

Attempt to stabilize but keep the transfer process moving Attempt to stabilize but keep the transfer process moving forward to get patient to higher level of careforward to get patient to higher level of care Local EMSLocal EMS Neonatal transport teamNeonatal transport team Helicopter scene flightHelicopter scene flight

NPONPO

Stay Calm!Stay Calm!

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TransportTransport When do you need to call an ambulance :When do you need to call an ambulance :

•• ShockShock•• Risk of deteriorationRisk of deterioration•• Need for monitoring Need for monitoring •• Airway issue/compromiseAirway issue/compromise•• Oxygen requirement to maintain Oxygen requirement to maintain satssats•• Rapid transportRapid transport•• If you need to think about itIf you need to think about it –– you probably need anyou probably need anIf you need to think about it If you need to think about it you probably need an you probably need an

ambulance!ambulance!

Consider riding along, depending on severityConsider riding along, depending on severity Call ahead to Emergency Room to give historyCall ahead to Emergency Room to give history

go to nearest Emergency Departmentgo to nearest Emergency Department

Important Local NumbersImportant Local Numbers

University of Kentucky University of Kentucky -- EmergencyDepartmentEmergencyDepartment General ED : 859 General ED : 859 –– 323 323 -- 59015901 Direct Physician Line : 859 Direct Physician Line : 859 –– 257 257 –– 36663666 My personal Cell My personal Cell –– 859859--806806--67536753

Neonatal Transport Team Neonatal Transport Team 859859--257257––5522 (UKMD’s)5522 (UKMD’s)11--800 800 –– 777777-- 85378537

Helicopter ServicesHelicopter ServicesPHiPHi 11--888888--807807--06820682LifeNetLifeNet 11--800800--678678--98119811StatCareStatCare 11--888888--729729--91119111

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Questions?Questions?