PediatricEmergencies in the Office

What To Do When You Are 911!!

W Ricks Hanna Jr MD

Office EmergenciesPediatric offices surveyed report 1-38 emergencies

per yearAAP 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/monthAn older study 62% of pediatricians and family

physicians in urban settings more than 1 patient/week required hospitalization or urgent stabilization

Office EmergenciesRespiratory emergencies most common 75%:

Bronchiolitis, Respiratory distress, Asthma and Croup

DehydrationFebrile illnesses/SepsisSeizuresAnaphylaxis

Office EmergenciesLess common presentations:

Respiratory failureSevere traumaForeign body/Obstructed airwayShockMeningitisSepsisApnea

The Emergency-Go-Round

PediatricEmergen

cy

PCP’s Office

EMS

Emergency

Department

Hospital or

TertiaryCenter

Parent and Patient EducationAnticipatory guidance

EMS accessPoison ControlConsent for treatmentConstraints from health plans for treatmentEmergency facility access

Advance directivesSummary of informationTraining in CPR

Office ConsiderationsPractice typeWhat 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?

Office Personnel: PreparationEmergency care is a team effort.Staff and physicians need knowledge,

training, resources and practice in “pertinent” emergency care.

ReceptionistResponse plan with clearly defined roles

Office Personnel: PreparationBasic emergency skills including:

Recognition of a patient in distressBasic airway managementBag-valve-mask ventilationInitiate treatment of shockInitiate trauma care

Mock codes or simulation exercisesDocumentationDebriefing

Office Preparation: Mock codesReadiness through practiceThe 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”

Office Preparation: DocumentationRisk management toolDocument:

Steps for office readinessTraining providedPolicies and practicesSimulation exercises

During true emergencies document:Date/TimeEstimated or actual weightMedications, fluids givenInformation given to familyPatient condition at time of departure from office

Office Preparation: DebriefingDiscuss 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.

Office Preparation: EMSCan assist in office emergency care and

transportEMS levels

First responders, BLSALSPediatric transport teams

Can’t help, if not calledCall sooner rather than laterEMS can assist in educational endeavors

Emergency supplies: MedicationsDesignate a “Resuscitation Room”Have a “Resuscitation Cart”Essential

OxygenAlbuterol for inhalationEpinephrine 1:1,000 for anaphylaxis

Emergency supplies: MedicationsStrongly Recommended

Antibiotics-RocephinAnticonvulsants-Valium, AtivanCorticosteroids-Parenteral/OralBenadryl-Parenteral/OralEpinephrine 1:10,000 for resuscitationAtropineFluids-Normal saline and D5 ½ NS, 25%

dextrose, oral rehydration fluidsNaloxoneSodium Bicarbonate

Emergency supplies: EquipmentAirway Management

Oxygen delivery equipmentBag-Valve MaskOxygen masksNonrebreather masksSuction deviceNebulizer and/or MDI with spacer/maskOropharyngeal airwaysPulse oximeter

Emergency Supplies: EquipmentVascular Access and Fluid Management

Butterfly needlesCatheter-over-needle deviceArm boards, tape, tourniquetIntraosseous needlesIntravenous tubing

Emergency supplies: EquipmentMiscellaneous

Broselow tapeBackboardBlood pressure cuffsSplints, sterile dressingsDefibrillatorAccucheck deviceRigid C collars

AnaphylaxisAcute, immediate hypersenitivity reaction

involving more than one organ systemResult of “re-exposure” IgE mediated release of mast cell and basophil

mediators which initiate cascade of effectsExposure can be inhalation, transdermal, oral

or intravenous.Most common causes: food, medications,

exercise and insect venom May not be able to determine a cause

Anaphylaxis: Signs & SymptomsOralCutaneousGastrointestinalRespiratoryCardiovascularCentral Nervous SystemOther

Anaphylaxis: TreatmentTrue medical emergencyA,B,CsPositioningEpinephrine (1:1,000) 0.1 ml/kg up to 0.3 ml SQ or IMAlbuterol Antihistamines-H1 and H2

SteroidsIV fluidsSpecial considerations:

Beta blockersInjection or sting

DehydrationRemains a cause of significant pediatric

morbidity and mortalityNot a disease in itself but a symptom of

another processIs on the hypovolemic shock spectrumInfants at risk due to large water content,

increased metabolism, renal immaturity and dependence on caregivers

Dehydration: EtiologyDiarrheaHemorrhage-internal and externalVomitingInadequate fluid intakeOsmotic shifts-DKAThird space lossesBurns

Dehydration: Signs & Symptoms“Quiet” tachypneaTachycardiaSunken eyesWeak or absent peripheral pulsesDelayed capillary refillChanges in mental statusCool skin, Tenting of the skinOliguriaWhat is missing from the list?

Dehydration: TreatmentA,B,CsStidham’s Rule: Air goes in and out and the

blood goes round and round. Assess the degree of dehydration/shockEstablish vascular access-IV and/or IOFluid boluses in 20 ml/kg aliquots of 15-30

minutes with reassessment Repeat till correction or stabilizationOral rehydration therapy (ORT)

SeizuresTransient, 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

Seizures: TypesGeneralized-both cerebral hemispheres

involvedTonic-clonic, absence, myoclonic, tonic, clonic,

atonicPartial-one cerebral hemisphere involved

Simple-no impairment of consciousnessComplex-impaired consciousnessMay progress to generalized activity-Jacksonian

marchFebrile seizuresPost traumatic seizures

Seizures: TreatmentA,B,CsProtect the patientC collar if trauma suspectedIdentify and treat known causesAnticonvulsant therapy for seizures lasting longer than

5-10 minutesRectal valium-0.5 mg/kg

PremixedCan use IV form of the drug

Ativan-0.05-0.1 mg/kgCan be repeated 1-2 times

Anticonvulsants

Respiratory EmergenciesCardiac arrest in pediatric patients is usually a

progression of respiratory failure and/or shock.Abnormal respiratory rates

Too fast-tachypneaToo slow-bradypneaNot at all-apnea

Posture/mental statusNasal flaringRetractionsHead bobbing

Respiratory EmergenciesAuscultation

StridorGruntingGurglingWheezingCrackles

A,B,Cs

Respiratory Emergencies: Asthma5-10% of children affectedFour components

Airway edemaAirway constrictionIncreased mucus productionMust be reversible

Many and varied presentations

Respiratory Emergencies: AsthmaTreatment

OxygenAlbuterol

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

Respiratory Emergencies: CroupMost common cause of stridor in the febrile

childChildren 6-36 months most commonly affectedFever and URI symptoms followed by

respiratory distress and “croupy” coughMay have been asymptomatic prior to onset of

respiratory distress and “croupy” coughMay have “resolved” at presentationOther considerations: epiglottitis, bacterial

tracheitis, and retropharyngeal abscess

Respiratory Emergencies: CroupTreatment

OxygenNebulized epinephrine (1:1,000) 3ml in 1-2 ml

of salineDexamethasone 0.6 mg/kg po or IM up to 16

mgObservation

Respiratory Emergencies: BronchiolitisAcute viral infection of the lower respiratory

tract most commonly secondary to RSVUsually affects infants 2-12 months of agePresentation 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

Respiratory Emergencies: Bronchiolitis Treatment

OxygenNasal suctionAlbuterol if a family history of asthmaNebulized epinephrine if no family history of

asthmaObservation

Fever/SepsisComplete clinical pictureKnow 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 failureGive antibiotics sooner rather than laterOxygenIV fluids

Fever DefinitionFever > 38c (100.4F) taken reliablyFever at home, fever in office = feverFever at home measured reliably, afebrile in

office = feverSubjective fever at home and given

antipyretics, afebrile in office = feverSubjective fever at home, no antipyretics,

afebrile in office = afebrile

Fever Workup/TreatmentTreat “sick” kids appropriately at any age0-28 days of age

Full septic workup and admission1-3 months of age

Blood and urine studies and culturesCSF as indicated

3-36 months of ageTemperature threshold increases to > 39c

Urine studies as indicatedCSF studies as indicatedTreatment guidelines for clinical conditions

Fever Workup/Treatment3-36 months of age “occults”

BacteremiaPneumoniaUrinary tract infection

In all appropriate age groups RSV, Flu, Strep, Mono, Stool studies etc. as appropriate

Fever Workup/TreatmentNo perfect “recipe” for the detection of

febrile children with SBIOur 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”.