Pediatric Office Emergencies

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Transcript of Pediatric Office Emergencies

  • 1. Pediatric Office Emergencies Mark E. Siegel, MD Division of Pediatric Critical Care Hackensack University Medical Center

2. Background

  • Pediatrics, August 1991, Vol. 88:2
  • 427/1000 office based Pediatricians surveyed
  • >90% within 5 miles of ER
  • 58% PALS/APLS certified
  • 77% had ever seen severe asthma, 66% in past year
  • 67% had ever seen ongoing seizure, 45% in past year
  • 22% had an arrest in office, 6% in past year

3. Background

  • Arch Ped Adolesc Med, March 1996, Vol 150
    • Fairfield County, Connecticut
    • 51/52 practices surveyed by phone: 114 MDs, 127 RNs
    • 2400 lfe threatening emergencies/year
    • 24 emergency visits/practice/year wide variation
      • Status asthmaticus, trauma, shock most common
    • 16% had cardiac arrest
    • 17% RN/MD PALS certified
    • 86% had Epi, only 2% had pulse oximeter

4. Background

  • Prehospital Emerg Care, April/June 1999, Vol 3:2
    • Rochester, NY
    • Mail survey: 119/199 practices (Peds(70%) /FP/IM-Peds)
    • 16% initiated resuscitation in office
    • 27% PALS certified
    • 269 recalled events
      • r/o epiglottitis, foreign body, severe asthma, severe dehydration, meningococcal disease, active seizures
    • Mean Distance to ER: 10-12 minutes
    • 48% sent via EMS, 38% family car, 9% MD car, 4% taxi

5. Preparation:Training

  • Training
    • MD vs. RN vs. Ancillary staff
  • Options
    • BLS
    • NRP(NALS)
    • PALS
    • APLS
    • ACLS(kids come with parents!)
  • Renewals

6. Preparation:Response Plan

  • Triage protocols
    • Receptionist
      • Office Empty
    • Assign Roles
      • Primary
      • Assistant
      • Medications
      • Documentation
    • Call 911
      • Information given
    • Call ER

7. Preparation:Maintenance of Skills

  • Mock scenarios
  • Review
    • Skills
    • equipment location
    • equipment use
  • Monitor expiration dates

8. Preparation: Families

  • Prepare parents
    • Handouts for Emergencies
    • Instructions on handling during/after office hours
    • Phone Numbers to call
      • EMS, Poison Control, Hospital
    • Avoiding emergencies- Prevention!
  • Medically complex children
    • Medical Information Sheet

9. Preparation: Equipment

  • Multiple sizes
    • High costs?
    • Storage space
  • Periodic checks
    • Working
    • Expiration
    • Batteries

10. Emergency Equipment Airway Equipment

  • Face masks various sizes
  • Oral/Nasopharyngeal airway
  • Ambubags
  • Intubation equipment
    • Laryngoscope, blades & Endotracheal tubes
    • EZ cap
    • tape
  • Suction/suction catheters
  • Magill Forceps remove foreign bodies
  • Pulse oximeter/Cardiac monitor
  • Nebulizer single or continuous

11. Emergency Equipment Cardiovascular

  • Automatic defibrillator
  • IV, IO
  • IV tubing/setup
  • IV boards
  • Normal Saline
  • Syringes multiple sizes

12. Emergency Medications

  • Keep weight based dosing chart handy
  • Monitor expiration dates
  • Route of administration
    • IV vs. IM
  • Broselow Pediatric Emergencytape

13. Emergency MedicationsRespiratory

  • Portable Oxygen tank
      • Flow meters
      • Masks/tubing
  • Albuterol inhaled
  • RacemicEpinephrine inhaled
  • Terbutaline SQ or IV
  • Decadron PO, IM or IV

14. Emergency Medications Cardiac & Other

    • Epinephrine
    • Diphenhydramine IV
    • Glucose 50%
    • Diazepam/Lorazepam
    • Narcan
    • Corticosteroids IV/IM
    • Ceftriaxone

15. Commercial Products

  • Broselow/Hinkle Resuscitation System(Armstrong Medical)
  • Statkits ( Banyan International)

16. Emergency Universal Rules

  • Airway
  • Breathing
  • Circulation
  • Initiate stabilization
  • Call 911
  • NPO

17. Office Emergencies

  • Anaphylaxis
  • Respiratory Distress
    • Asthma
    • Foreign Body
  • Seizures
  • Sepsis/Shock

18. Anaphylaxis

  • Multi-systemic allergic reaction
    • medications, foods, insect bites, latex, cryptogenic
  • Range of reactions
    • Urticaria
    • Upper Airway: laryngeal edema, stridor
    • Lower Airway: coughing, wheezing
    • Cardiovascular collapse

19. Anaphylaxis Management

  • 911 early if airway involvement
  • Oxygen
  • Consider Securing airway
  • Epinephrine 0.01 ml/kg 1:1,000 SQ(max: 0.35ml)
  • Albuterol
  • Diphendydramine IV or PO
  • Steroids
  • IVF, inotropic infusion for hypotension
  • PICU admission for any airway symptoms
  • EpiPen for future use, depending on etiology

20. Asthma

  • Very common
  • Bronchoconstriction
  • Subacute or acute
  • Signs & Symptoms
    • Cough
    • Wheezing
    • Retractions
    • Nasal Flaring
    • Peak Flow
    • Mental Status changes

21. Asthma Management

  • Pulse oximetry
  • Oxygen
  • Albuterol unit dose for all ages
    • Continuous albuterol
  • Steroids Prednisone 2mg/kg
  • Terbutaline 0.01mg/kg SQ(max 0.4mg)
    • infusion
  • IVF Fluids
  • R/O foreign body, anaphylaxis

22. Respiratory Failure

  • Tachypnea
  • Tachycardia
  • Bradypnea
  • Accessory muscle use
  • Diaphoresis
  • Grunting
  • Hypoxemia/Cyanosis
  • Irritability
  • Somnolence

23. Foreign Body

  • Presentation varies with location
  • Ball valve
  • Distal foreign bodies may present late
  • Signs & Symptoms
    • Acute Respiratory Failure
    • Cyanosis
    • Cough, gagging
    • Stridor
    • Focal wheezing

24. Foreign Body Management

  • 911
  • FB may change position esp. during transport
  • Oxygen
  • BLS back blows/Heimlich
  • Avoid blind probing oropharynx
  • Airway positioning
  • Layngoscopy/Magill forceps
  • Intubation

25. Shock

  • Decreased delivery of O 2and nutrients to tissues
  • Infectious common
  • Hypovolemic
    • Vomiting/Diarrhea
    • DKA
  • Progression may be rapid
  • Compensated Uncompensated Irreversible

26. Shock

  • Signs and Symptoms
    • Tachypnea
    • Respiratory Distress
    • Tachycardia
    • Cool or warm extremities
    • Decreased perfusion
    • Bounding pulses
    • Altered mental status
    • Blood pressure

27. Shock Management

  • Oxygen
  • Airway control
  • IV Access
  • Rapid fluid resuscitation
    • 20 ml/kg NS or LR rapidly
    • Repeat
    • Repeat
  • Antibiotics

28. Seizures

  • Status epilepticus
    • Time: > 10 minutes (if Afebrile)
    • No recovery between repeated episodes
  • Differential
    • Low levels
      • Non-compliance
      • Growth
      • New Medications
    • Infectious
    • Toxins
    • Metabolic
      • Glucose, Calcium, Sodium, Magnesium

29. Seizures Management

  • Airway control
  • Oxygen (ABCs)
  • Bedside glucose
    • D 25 W 2-4 ml/kg IVP for hypoglycemia
  • IV access if possible
  • Medications
    • Diazepam: 0.2-0.5 mg/kg IV
      • Rectal 0.5mg/kg
    • Lorazepam: 0.1 mg/kg IV
    • Midazolam: 0.1mg/kg IV/IM
    • Dilantin/Fosphenytoin
    • Phenobarbital

30. Transport

  • Ambulance if:
    • Airway issue
    • Oxygen requirement
    • Shock
    • Risk of rapid deterioration
    • Need for monitoring en route
    • Rapid transport
  • Call ahead to Emergency Room to give history
  • Consider riding along, depending on severity
  • NPO

31. References & Resources Office Emergencies Mark E. Siegel, MD

  • Pediatric Advanced Life Support (PALS)- American Heart Association
      • Hackensack Life Support Training: 201-996-2401
  • Advanced Pediatric Life Support (APLS)-The Pediatric Emergency Medicine Course
      • American Academy of Pediatrics, American College of Emergency Physicians
  • Childhood Emergencies in the Office, Hospital, & Community-American Academy of Pediatrics
  • Emergency Pediatrics: A Guide to Ambulatory Care-Roger Barkin & Peter Rosen
  • Handbook of Pediatric Mock Codes-Mark G. Roback
  • PedInfo: An Index of the Pediatric Internet http://www.pedinfo.org/
  • Pediatric Critical Care http://pedsccm.org
  • New Jersey Poison Control http://www.njpies.org/ orNational:http://www.aapcc.org/
      • NATIONAL Phone Number: 800-222-1222
  • Emergency Medical Services for Children- http://www.ems-c.org/
      • Office Preparedness for Pediatric Emergencies - http://www.ems-c.org/PIE/media/b2.pdf
  • Emergency Preparedness for Children with Special Health Care Needs
      • http://www.aap.org/advocacy/emergprep.htm
      • http://www.acep.org/1,374,0.html

32. The End