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Pediatric Office Emergencies
The document discusses pediatric office emergencies, including preparing for and managing common emergencies like anaphylaxis, asthma, respiratory distress, foreign body obstruction, seizures, and shock. It recommends training staff in BLS, PALS, and having emergency equipment and medications available. Common emergencies are described along with recommended initial management steps prior to emergency transport.
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Pediatric Office Emergencies
- 1. Pediatric Office EmergenciesMark E. Siegel, MD Division of Pediatric Critical Care Hackensack University Medical Center
- 2. Background Pediatrics, August1991, 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 PedAdolesc 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 EmergCare, 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: TrainingTraining MD vs. RN vs. Ancillary staff Options BLS NRP (NALS) PALS APLS ACLS (kids come with parents!) Renewals
- 6. Preparation: ResponsePlan Triage protocols Receptionist Office Empty Assign Roles Primary Assistant Medications Documentation Call 911 Information given Call ER
- 7. Preparation: Maintenanceof Skills Mock scenarios Review Skills equipment location equipment use Monitor expiration dates
- 8. Preparation: Families Prepareparents 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 Multiplesizes High costs? Storage space Periodic checks Working Expiration Batteries
- 10. Emergency Equipment AirwayEquipment 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 CardiovascularAutomatic defibrillator IV, IO IV tubing/setup IV boards Normal Saline Syringes – multiple sizes
- 12. Emergency Medications Keepweight based dosing chart handy Monitor expiration dates Route of administration IV vs. IM Broselow Pediatric Emergency tape
- 13. Emergency Medications Respiratory Portable Oxygen tank Flow meters Masks/tubing Albuterol – inhaled Racemic Epinephrine – 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/HinkleResuscitation System (Armstrong Medical) Statkits ( Banyan International)
- 16. Emergency Universal RulesAirway Breathing Circulation Initiate stabilization Call 911 NPO
- 17. Office Emergencies AnaphylaxisRespiratory Distress Asthma Foreign Body Seizures Sepsis/Shock
- 18. Anaphylaxis Multi-systemic allergicreaction medications, foods, insect bites, latex, cryptogenic Range of reactions Urticaria Upper Airway: laryngeal edema, stridor Lower Airway: coughing, wheezing Cardiovascular collapse
- 19. Anaphylaxis Management 911early 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 commonBronchoconstriction Subacute or acute Signs & Symptoms Cough Wheezing Retractions Nasal Flaring Peak Flow Mental Status changes
- 21. Asthma Management Pulseoximetry 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 TachypneaTachycardia Bradypnea Accessory muscle use Diaphoresis Grunting Hypoxemia/Cyanosis Irritability Somnolence
- 23. Foreign Body Presentationvaries with location Ball valve Distal foreign bodies may present late Signs & Symptoms Acute Respiratory Failure Cyanosis Cough, gagging Stridor Focal wheezing
- 24. Foreign Body Management911 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 deliveryof O 2 and nutrients to tissues Infectious common Hypovolemic Vomiting/Diarrhea DKA Progression may be rapid Compensated Uncompensated Irreversible
- 26. Shock Signs andSymptoms Tachypnea Respiratory Distress Tachycardia Cool or warm extremities Decreased perfusion Bounding pulses Altered mental status Blood pressure
- 27. Shock Management OxygenAirway control IV Access Rapid fluid resuscitation 20 ml/kg NS or LR rapidly Repeat Repeat Antibiotics
- 28. Seizures Status epilepticusTime: > 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 Airwaycontrol 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 & ResourcesOffice 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/ or National: 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.
Editor's Notes
- #3 Emergencies are common. Frequently show up in office
- #4 Note very few MDs/RNs have current training
- #6 Should receptionist be trained? At least BLS. Who pays for courses?
- #7 What if receptionist alone in office? How far is it to the nearest ER? What is the response time to your office if you call 9-1-1?
- #8 Practice, practice, practice Equipment of no use if no one knows where it is or how to use it
- #9 For medically complex kids, a med info sheet can be critical for hospital staff (read: intensivists!) – should list dx, meds (dose—in mg, not tsp, frequency), allergies, specialists, and BASELINE status. Update frequently
- #10 There are several compa
- #11 No need for nasal cannula or variety of masks Pulse ox is probably mandatory in today’s office IF you are not going to intubate with any regularity, it is far more important to have good BVM ventilation skills than it is to have airway equipment in your office. (Gausche study, JAMA 2000)
- #12 Defib – parents? Should be standard now. IVF – may be able to avoid a pump – use syringes to push in
- #13 Meds – need to know drugs, IV, IM, SQ, inhaled, PO dosing chart based on weight needs to be available If keeping IV meds, must have IV equipment!
- #14 Check tank periodically, have 2. Store properly
- #16 Several companies offer kits with medication and equipment. They also offer services to make sure that the equipment is regularly updated, and medications are not expired
- #17 Do not have unlimited supplies, equipment, personnel, etc… so call 911 Do not allow to feed Keep on monitor, if you have one
- #18 Intended to be basic review
- #19 ‘sense of doom’
- #21 Watch for signs of impending respiratory failure
- #22 Sat monitor critical in decision for hospitalization vs. home Continuous albuterol? Terbutaline vs. epi Terbutatine for pt. not moving air
- #23 Sat monitor!
- #27 Bounding pulses in sepsis, thready in hypovolemic Blood pressure late finding
- #28 Fluid, reassess, fluid, reassess…..
- #33 I hope I haven’t put you to sleep!