Ricks Hanna, M.D. - Arkansas Academy of Family Physicians

What To Do When You Are 911!!
W Ricks Hanna Jr MD
Office Emergencies
 Pediatric offices surveyed report 1-38 emergencies per
AAP survey in 2003-73% of offices had one
patient/week requiring emergency treatment or
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
Hospital or
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
 Where are the nearest emergency facilities?
 What local EMS services are available? How are they
 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
 “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
 Document plans to enhance emergency preparedness.
Office Preparation: EMS
 Can assist in office emergency care and transport
 EMS levels
 First responders, BLS
 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
 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
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
Epinephrine (1:1,000) 0.1 ml/kg up to 0.3 ml SQ or IM
Antihistamines-H1 and H2
IV fluids
Special considerations:
 Beta blockers
 Injection or sting
 Remains a cause of significant pediatric morbidity and
 Not a disease in itself but a symptom of another
 Is on the hypovolemic shock spectrum
 Infants at risk due to large water content, increased
metabolism, renal immaturity and dependence on
Dehydration: Etiology
 Diarrhea
 Hemorrhage-internal and external
 Vomiting
 Inadequate fluid intake
 Osmotic shifts-DKA
 Third space losses
 Burns
Dehydration: Signs &
 “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)
 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
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
Protect the patient
C collar if trauma suspected
Identify and treat known causes
Anticonvulsant therapy for seizures lasting longer than 5-10
 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
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
 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:
 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
Feeding is important consideration in disposition
Respiratory Emergencies:
 Treatment
 Oxygen
 Nasal suction
 Albuterol if a family history of asthma
 Nebulized epinephrine if no family history of asthma
 Observation
 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
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 =
 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”.

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