What To Do When You Are 911!! W Ricks Hanna Jr MD Office Emergencies Pediatric offices surveyed report 1-38 emergencies per year AAP 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/month An older study 62% of pediatricians and family physicians in urban settings more than 1 patient/week required hospitalization or urgent stabilization Office Emergencies Respiratory emergencies most common 75%: Bronchiolitis, Respiratory distress, Asthma and Croup Dehydration Febrile illnesses/Sepsis Seizures Anaphylaxis Office Emergencies Less common presentations: Respiratory failure Severe trauma Foreign body/Obstructed airway Shock Meningitis Sepsis Apnea The Emergency-Go-Round PCP’s Office Hospital or Tertiary Center Pediatric Emergency Emergency Department EMS Parent and Patient Education Anticipatory guidance EMS access Poison Control Consent for treatment Constraints from health plans for treatment Emergency facility access Advance directives Summary of information Training in CPR Office Considerations Practice type What 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: Preparation Emergency care is a team effort. Staff and physicians need knowledge, training, resources and practice in “pertinent” emergency care. Receptionist Response plan with clearly defined roles Office Personnel: Preparation Basic emergency skills including: Recognition of a patient in distress Basic airway management Bag-valve-mask ventilation Initiate treatment of shock Initiate trauma care Mock codes or simulation exercises Documentation Debriefing Office Preparation: Mock codes Readiness through practice The 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: Documentation Risk management tool Document: Steps for office readiness Training provided Policies and practices Simulation exercises During true emergencies document: Date/Time Estimated or actual weight Medications, fluids given Information given to family Patient condition at time of departure from office Office Preparation: Debriefing Discuss 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: EMS Can assist in office emergency care and transport EMS levels First responders, BLS ALS Pediatric transport teams Can’t help, if not called Call sooner rather than later EMS can assist in educational endeavors Emergency supplies: Medications Designate a “Resuscitation Room” Have a “Resuscitation Cart” Essential Oxygen Albuterol for inhalation Epinephrine 1:1,000 for anaphylaxis Emergency supplies: Medications Strongly Recommended Antibiotics-Rocephin Anticonvulsants-Valium, Ativan Corticosteroids-Parenteral/Oral Benadryl-Parenteral/Oral Epinephrine 1:10,000 for resuscitation Atropine Fluids-Normal saline and D5 ½ NS, 25% dextrose, oral rehydration fluids Naloxone Sodium Bicarbonate Emergency supplies: Equipment Airway Management Oxygen delivery equipment Bag-Valve Mask Oxygen masks Nonrebreather masks Suction device Nebulizer and/or MDI with spacer/mask Oropharyngeal airways Pulse oximeter Emergency Supplies: Equipment Vascular Access and Fluid Management Butterfly needles Catheter-over-needle device Arm boards, tape, tourniquet Intraosseous needles Intravenous tubing Emergency supplies: Equipment Miscellaneous Broselow tape Backboard Blood pressure cuffs Splints, sterile dressings Defibrillator Accucheck device Rigid C collars Anaphylaxis Acute, immediate hypersenitivity reaction involving more than one organ system Result of “re-exposure” IgE mediated release of mast cell and basophil mediators which initiate cascade of effects Exposure 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 & Symptoms Oral Cutaneous Gastrointestinal Respiratory Cardiovascular Central Nervous System Other Anaphylaxis: Treatment True medical emergency A,B,Cs Positioning Epinephrine (1:1,000) 0.1 ml/kg up to 0.3 ml SQ or IM Albuterol Antihistamines-H1 and H2 Steroids IV fluids Special considerations: Beta blockers Injection or sting Dehydration Remains a cause of significant pediatric morbidity and mortality Not a disease in itself but a symptom of another process Is on the hypovolemic shock spectrum Infants at risk due to large water content, increased metabolism, renal immaturity and dependence on caregivers Dehydration: Etiology Diarrhea Hemorrhage-internal and external Vomiting Inadequate fluid intake Osmotic shifts-DKA Third space losses Burns Dehydration: Signs & Symptoms “Quiet” tachypnea Tachycardia Sunken eyes Weak or absent peripheral pulses Delayed capillary refill Changes in mental status Cool skin, Tenting of the skin Oliguria What is missing from the list? Dehydration: Treatment A,B,Cs Stidham’s Rule: Air goes in and out and the blood goes round and round. Assess the degree of dehydration/shock Establish vascular access-IV and/or IO Fluid boluses in 20 ml/kg aliquots of 15-30 minutes with reassessment Repeat till correction or stabilization Oral rehydration therapy (ORT) Seizures Transient, 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: Types Generalized-both cerebral hemispheres involved Tonic-clonic, absence, myoclonic, tonic, clonic, atonic Partial-one cerebral hemisphere involved Simple-no impairment of consciousness Complex-impaired consciousness May progress to generalized activity-Jacksonian march Febrile seizures Post traumatic seizures Seizures: Treatment A,B,Cs Protect the patient C collar if trauma suspected Identify and treat known causes Anticonvulsant therapy for seizures lasting longer than 5-10 minutes Rectal valium-0.5 mg/kg Premixed Can use IV form of the drug Ativan-0.05-0.1 mg/kg Can be repeated 1-2 times Anticonvulsants Respiratory Emergencies Cardiac arrest in pediatric patients is usually a progression of respiratory failure and/or shock. Abnormal respiratory rates Too fast-tachypnea Too slow-bradypnea Not at all-apnea Posture/mental status Nasal flaring Retractions Head bobbing Respiratory Emergencies Auscultation Stridor Grunting Gurgling Wheezing Crackles A,B,Cs Respiratory Emergencies: Asthma 5-10% of children affected Four components Airway edema Airway constriction Increased mucus production Must be reversible Many and varied presentations Respiratory Emergencies: Asthma Treatment Oxygen Albuterol 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: Croup Most common cause of stridor in the febrile child Children 6-36 months most commonly affected Fever and URI symptoms followed by respiratory distress and “croupy” cough May have been asymptomatic prior to onset of respiratory distress and “croupy” cough May have “resolved” at presentation Other considerations: epiglottitis, bacterial tracheitis, and retropharyngeal abscess Respiratory Emergencies: Croup Treatment Oxygen Nebulized epinephrine (1:1,000) 3ml in 1-2 ml of saline Dexamethasone 0.6 mg/kg po or IM up to 16 mg Observation Respiratory Emergencies: Bronchiolitis Acute viral infection of the lower respiratory tract most commonly secondary to RSV Usually affects infants 2-12 months of age Presentation 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 Oxygen Nasal suction Albuterol if a family history of asthma Nebulized epinephrine if no family history of asthma Observation Fever/Sepsis Complete clinical picture Know 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 failure Give antibiotics sooner rather than later Oxygen IV fluids Fever Definition Fever > 38c (100.4F) taken reliably Fever at home, fever in office = fever Fever at home measured reliably, afebrile in office = fever Subjective fever at home and given antipyretics, afebrile in office = fever Subjective fever at home, no antipyretics, afebrile in office = afebrile Fever Workup/Treatment Treat “sick” kids appropriately at any age 0-28 days of age Full septic workup and admission 1-3 months of age Blood and urine studies and cultures CSF as indicated 3-36 months of age Temperature threshold increases to > 39c Urine studies as indicated CSF studies as indicated Treatment guidelines for clinical conditions Fever Workup/Treatment 3-36 months of age “occults” Bacteremia Pneumonia Urinary tract infection In all appropriate age groups RSV, Flu, Strep, Mono, Stool studies etc. as appropriate Fever Workup/Treatment No perfect “recipe” for the detection of febrile children with SBI Our 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”.