Successfully reported this slideshow.
We use your LinkedIn profile and activity data to personalize ads and to show you more relevant ads. You can change your ad preferences anytime.
Upcoming SlideShare
Office Preparedness For Pediatric Emergencies
Next
Download to read offline and view in fullscreen.

Share

Pediatric Office Emergencies

Download to read offline

Related Books

Free with a 30 day trial from Scribd

See all

Related Audiobooks

Free with a 30 day trial from Scribd

See all

Pediatric Office Emergencies

  1. 1. Pediatric Office Emergencies Mark E. Siegel, MD Division of Pediatric Critical Care Hackensack University Medical Center
  2. 2. Background <ul><li>Pediatrics, August 1991, Vol. 88:2 </li></ul><ul><li>427/1000 office based Pediatricians surveyed </li></ul><ul><li>>90% within 5 miles of ER </li></ul><ul><li>58% PALS/APLS certified </li></ul><ul><li>77% had ever seen ‘severe asthma’, 66% in past year </li></ul><ul><li>67% had ever seen ongoing seizure, 45% in past year </li></ul><ul><li>22% had an arrest in office, 6% in past year </li></ul>
  3. 3. Background <ul><li>Arch Ped Adolesc Med, March 1996, Vol 150 </li></ul><ul><ul><li>Fairfield County, Connecticut </li></ul></ul><ul><ul><li>51/52 practices surveyed by phone: 114 MDs, 127 RNs </li></ul></ul><ul><ul><li>2400 ‘lfe threatening emergencies’/year </li></ul></ul><ul><ul><li>24 emergency visits/practice/year – wide variation </li></ul></ul><ul><ul><ul><li>Status asthmaticus, trauma, shock most common </li></ul></ul></ul><ul><ul><li>16% had cardiac arrest </li></ul></ul><ul><ul><li>17% RN/MD PALS certified </li></ul></ul><ul><ul><li>86% had Epi, only 2% had pulse oximeter </li></ul></ul>
  4. 4. Background <ul><li>Prehospital Emerg Care, April/June 1999, Vol 3:2 </li></ul><ul><ul><li>Rochester, NY </li></ul></ul><ul><ul><li>Mail survey: 119/199 practices (Peds (70%) /FP/IM-Peds) </li></ul></ul><ul><ul><li>16% initiated resuscitation in office </li></ul></ul><ul><ul><li>27% PALS certified </li></ul></ul><ul><ul><li>269 ‘recalled’ events </li></ul></ul><ul><ul><ul><li>r/o epiglottitis, foreign body, severe asthma, severe dehydration, meningococcal disease, active seizures </li></ul></ul></ul><ul><ul><li>Mean Distance to ER: 10-12 minutes </li></ul></ul><ul><ul><li>48% sent via EMS, 38% family car, 9% MD car, 4% taxi </li></ul></ul>
  5. 5. Preparation: Training <ul><li>Training </li></ul><ul><ul><li>MD vs. RN vs. Ancillary staff </li></ul></ul><ul><li>Options </li></ul><ul><ul><li>BLS </li></ul></ul><ul><ul><li>NRP (NALS) </li></ul></ul><ul><ul><li>PALS </li></ul></ul><ul><ul><li>APLS </li></ul></ul><ul><ul><li>ACLS (kids come with parents!) </li></ul></ul><ul><li>Renewals </li></ul>
  6. 6. Preparation: Response Plan <ul><li>Triage protocols </li></ul><ul><ul><li>Receptionist </li></ul></ul><ul><ul><ul><li>Office Empty </li></ul></ul></ul><ul><ul><li>Assign Roles </li></ul></ul><ul><ul><ul><li>Primary </li></ul></ul></ul><ul><ul><ul><li>Assistant </li></ul></ul></ul><ul><ul><ul><li>Medications </li></ul></ul></ul><ul><ul><ul><li>Documentation </li></ul></ul></ul><ul><ul><li>Call 911 </li></ul></ul><ul><ul><ul><li>Information given </li></ul></ul></ul><ul><ul><li>Call ER </li></ul></ul>
  7. 7. Preparation: Maintenance of Skills <ul><li>Mock scenarios </li></ul><ul><li>Review </li></ul><ul><ul><li>Skills </li></ul></ul><ul><ul><li>equipment location </li></ul></ul><ul><ul><li>equipment use </li></ul></ul><ul><li>Monitor expiration dates </li></ul>
  8. 8. Preparation: Families <ul><li>Prepare parents </li></ul><ul><ul><li>Handouts for Emergencies </li></ul></ul><ul><ul><li>Instructions on handling during/after office hours </li></ul></ul><ul><ul><li>Phone Numbers to call </li></ul></ul><ul><ul><ul><li>EMS, Poison Control, Hospital </li></ul></ul></ul><ul><ul><li>Avoiding emergencies- Prevention! </li></ul></ul><ul><li>Medically complex children </li></ul><ul><ul><li>Medical Information Sheet </li></ul></ul>
  9. 9. Preparation: Equipment <ul><li>Multiple sizes </li></ul><ul><ul><li>High costs? </li></ul></ul><ul><ul><li>Storage space </li></ul></ul><ul><li>Periodic checks </li></ul><ul><ul><li>Working </li></ul></ul><ul><ul><li>Expiration </li></ul></ul><ul><ul><li>Batteries </li></ul></ul>
  10. 10. Emergency Equipment Airway Equipment <ul><li>Face masks – various sizes </li></ul><ul><li>Oral/Nasopharyngeal airway </li></ul><ul><li>Ambubags </li></ul><ul><li>Intubation equipment </li></ul><ul><ul><li>Laryngoscope, blades & Endotracheal tubes </li></ul></ul><ul><ul><li>EZ cap </li></ul></ul><ul><ul><li>tape </li></ul></ul><ul><li>Suction/suction catheters </li></ul><ul><li>Magill Forceps – remove foreign bodies </li></ul><ul><li>Pulse oximeter/Cardiac monitor </li></ul><ul><li>Nebulizer – single or ‘continuous’ </li></ul>
  11. 11. Emergency Equipment Cardiovascular <ul><li>Automatic defibrillator </li></ul><ul><li>IV, IO </li></ul><ul><li>IV tubing/setup </li></ul><ul><li>IV boards </li></ul><ul><li>Normal Saline </li></ul><ul><li>Syringes – multiple sizes </li></ul>
  12. 12. Emergency Medications <ul><li>Keep weight based dosing chart handy </li></ul><ul><li>Monitor expiration dates </li></ul><ul><li>Route of administration </li></ul><ul><ul><li>IV vs. IM </li></ul></ul><ul><li>Broselow Pediatric Emergency tape </li></ul>
  13. 13. Emergency Medications Respiratory <ul><li>Portable Oxygen tank </li></ul><ul><ul><ul><li>Flow meters </li></ul></ul></ul><ul><ul><ul><li>Masks/tubing </li></ul></ul></ul><ul><li>Albuterol – inhaled </li></ul><ul><li>Racemic Epinephrine – inhaled </li></ul><ul><li>Terbutaline – SQ or IV </li></ul><ul><li>Decadron – PO, IM or IV </li></ul>
  14. 14. Emergency Medications Cardiac & Other <ul><ul><li>Epinephrine </li></ul></ul><ul><ul><li>Diphenhydramine IV </li></ul></ul><ul><ul><li>Glucose 50% </li></ul></ul><ul><ul><li>Diazepam/Lorazepam </li></ul></ul><ul><ul><li>Narcan </li></ul></ul><ul><ul><li>Corticosteroids IV/IM </li></ul></ul><ul><ul><li>Ceftriaxone </li></ul></ul>
  15. 15. Commercial Products <ul><li>Broselow/Hinkle Resuscitation System (Armstrong Medical) </li></ul><ul><li>Statkits ( Banyan International) </li></ul>
  16. 16. Emergency Universal Rules <ul><li>Airway </li></ul><ul><li>Breathing </li></ul><ul><li>Circulation </li></ul><ul><li>Initiate stabilization </li></ul><ul><li>Call 911 </li></ul><ul><li>NPO </li></ul>
  17. 17. Office Emergencies <ul><li>Anaphylaxis </li></ul><ul><li>Respiratory Distress </li></ul><ul><ul><li>Asthma </li></ul></ul><ul><ul><li>Foreign Body </li></ul></ul><ul><li>Seizures </li></ul><ul><li>Sepsis/Shock </li></ul>
  18. 18. Anaphylaxis <ul><li>Multi-systemic allergic reaction </li></ul><ul><ul><li>medications, foods, insect bites, latex, cryptogenic </li></ul></ul><ul><li>Range of reactions </li></ul><ul><ul><li>Urticaria </li></ul></ul><ul><ul><li>Upper Airway: laryngeal edema, stridor </li></ul></ul><ul><ul><li>Lower Airway: coughing, wheezing </li></ul></ul><ul><ul><li>Cardiovascular collapse </li></ul></ul>
  19. 19. Anaphylaxis Management <ul><li>911 early if airway involvement </li></ul><ul><li>Oxygen </li></ul><ul><li>Consider Securing airway </li></ul><ul><li>Epinephrine 0.01 ml/kg 1:1,000 SQ (max: 0.35ml) </li></ul><ul><li>Albuterol </li></ul><ul><li>Diphendydramine IV or PO </li></ul><ul><li>Steroids </li></ul><ul><li>IVF, inotropic infusion for hypotension </li></ul><ul><li>PICU admission for any airway symptoms </li></ul><ul><li>EpiPen for future use, depending on etiology </li></ul>
  20. 20. Asthma <ul><li>Very common </li></ul><ul><li>Bronchoconstriction </li></ul><ul><li>Subacute or acute </li></ul><ul><li>Signs & Symptoms </li></ul><ul><ul><li>Cough </li></ul></ul><ul><ul><li>Wheezing </li></ul></ul><ul><ul><li>Retractions </li></ul></ul><ul><ul><li>Nasal Flaring </li></ul></ul><ul><ul><li>Peak Flow </li></ul></ul><ul><ul><li>Mental Status changes </li></ul></ul>
  21. 21. Asthma Management <ul><li>Pulse oximetry </li></ul><ul><li>Oxygen </li></ul><ul><li>Albuterol – ‘unit’ dose for all ages </li></ul><ul><ul><li>Continuous albuterol </li></ul></ul><ul><li>Steroids – Prednisone 2mg/kg </li></ul><ul><li>Terbutaline 0.01mg/kg SQ (max 0.4mg) </li></ul><ul><ul><li>infusion </li></ul></ul><ul><li>IVF Fluids </li></ul><ul><li>R/O foreign body, anaphylaxis… </li></ul>
  22. 22. Respiratory Failure <ul><li>Tachypnea </li></ul><ul><li>Tachycardia </li></ul><ul><li>Bradypnea </li></ul><ul><li>Accessory muscle use </li></ul><ul><li>Diaphoresis </li></ul><ul><li>Grunting </li></ul><ul><li>Hypoxemia/Cyanosis </li></ul><ul><li>Irritability </li></ul><ul><li>Somnolence </li></ul>
  23. 23. Foreign Body <ul><li>Presentation varies with location </li></ul><ul><li>Ball valve </li></ul><ul><li>Distal foreign bodies may present late </li></ul><ul><li>Signs & Symptoms </li></ul><ul><ul><li>Acute Respiratory Failure </li></ul></ul><ul><ul><li>Cyanosis </li></ul></ul><ul><ul><li>Cough, gagging </li></ul></ul><ul><ul><li>Stridor </li></ul></ul><ul><ul><li>Focal wheezing </li></ul></ul>
  24. 24. Foreign Body Management <ul><li>911 </li></ul><ul><li>FB may change position – esp. during transport </li></ul><ul><li>Oxygen </li></ul><ul><li>BLS – back blows/Heimlich </li></ul><ul><li>Avoid blind probing oropharynx </li></ul><ul><li>Airway positioning </li></ul><ul><li>Layngoscopy/Magill forceps </li></ul><ul><li>Intubation </li></ul>
  25. 25. Shock <ul><li>Decreased delivery of O 2 and nutrients to tissues </li></ul><ul><li>Infectious common </li></ul><ul><li>Hypovolemic </li></ul><ul><ul><li>Vomiting/Diarrhea </li></ul></ul><ul><ul><li>DKA </li></ul></ul><ul><li>Progression may be rapid </li></ul><ul><li>Compensated  Uncompensated  Irreversible </li></ul>
  26. 26. Shock <ul><li>Signs and Symptoms </li></ul><ul><ul><li>Tachypnea </li></ul></ul><ul><ul><li>Respiratory Distress </li></ul></ul><ul><ul><li>Tachycardia </li></ul></ul><ul><ul><li>Cool or warm extremities </li></ul></ul><ul><ul><li>Decreased perfusion </li></ul></ul><ul><ul><li>Bounding pulses </li></ul></ul><ul><ul><li>Altered mental status </li></ul></ul><ul><ul><li>Blood pressure </li></ul></ul>
  27. 27. Shock Management <ul><li>Oxygen </li></ul><ul><li>Airway control </li></ul><ul><li>IV Access </li></ul><ul><li>Rapid fluid resuscitation </li></ul><ul><ul><li>20 ml/kg NS or LR rapidly </li></ul></ul><ul><ul><li>Repeat </li></ul></ul><ul><ul><li>Repeat </li></ul></ul><ul><li>Antibiotics </li></ul>
  28. 28. Seizures <ul><li>Status epilepticus </li></ul><ul><ul><li>Time: > 10 minutes (if Afebrile) </li></ul></ul><ul><ul><li>No recovery between repeated episodes </li></ul></ul><ul><li>Differential </li></ul><ul><ul><li>Low levels </li></ul></ul><ul><ul><ul><li>Non-compliance </li></ul></ul></ul><ul><ul><ul><li>Growth </li></ul></ul></ul><ul><ul><ul><li>New Medications </li></ul></ul></ul><ul><ul><li>Infectious </li></ul></ul><ul><ul><li>Toxins </li></ul></ul><ul><ul><li>Metabolic </li></ul></ul><ul><ul><ul><li>Glucose, Calcium, Sodium, Magnesium </li></ul></ul></ul>
  29. 29. Seizures Management <ul><li>Airway control </li></ul><ul><li>Oxygen (ABCs) </li></ul><ul><li>Bedside glucose </li></ul><ul><ul><li>D 25 W 2-4 ml/kg IVP for hypoglycemia </li></ul></ul><ul><li>IV access if possible </li></ul><ul><li>Medications </li></ul><ul><ul><li>Diazepam: 0.2-0.5 mg/kg IV </li></ul></ul><ul><ul><ul><li>Rectal 0.5mg/kg </li></ul></ul></ul><ul><ul><li>Lorazepam: 0.1 mg/kg IV </li></ul></ul><ul><ul><li>Midazolam: 0.1mg/kg IV/IM </li></ul></ul><ul><ul><li>Dilantin/Fosphenytoin </li></ul></ul><ul><ul><li>Phenobarbital </li></ul></ul>
  30. 30. Transport <ul><li>Ambulance if: </li></ul><ul><ul><li>Airway issue </li></ul></ul><ul><ul><li>Oxygen requirement </li></ul></ul><ul><ul><li>Shock </li></ul></ul><ul><ul><li>Risk of rapid deterioration </li></ul></ul><ul><ul><li>Need for monitoring en route </li></ul></ul><ul><ul><li>Rapid transport </li></ul></ul><ul><li>Call ahead to Emergency Room to give history </li></ul><ul><li>Consider riding along, depending on severity </li></ul><ul><li>NPO </li></ul>
  31. 31. References & Resources Office Emergencies – Mark E. Siegel, MD <ul><li>Pediatric Advanced Life Support (PALS) - American Heart Association </li></ul><ul><ul><ul><li>Hackensack Life Support Training: 201-996-2401 </li></ul></ul></ul><ul><li>Advanced Pediatric Life Support (APLS) - The Pediatric Emergency Medicine Course </li></ul><ul><ul><ul><li>American Academy of Pediatrics, American College of Emergency Physicians </li></ul></ul></ul><ul><li>Childhood Emergencies in the Office, Hospital, & Community - American Academy of Pediatrics </li></ul><ul><li>Emergency Pediatrics: A Guide to Ambulatory Care - Roger Barkin & Peter Rosen </li></ul><ul><li>Handbook of Pediatric Mock Codes - Mark G. Roback </li></ul><ul><li>PedInfo: An Index of the Pediatric Internet – http://www.pedinfo.org/ </li></ul><ul><li>Pediatric Critical Care – http://pedsccm.org </li></ul><ul><li>New Jersey Poison Control – http://www.njpies.org/ or National: http://www.aapcc.org/ </li></ul><ul><ul><ul><li>NATIONAL Phone Number: 800-222-1222 </li></ul></ul></ul><ul><li>Emergency Medical Services for Children - http://www.ems-c.org/ </li></ul><ul><ul><ul><li>Office Preparedness for Pediatric Emergencies - http://www.ems-c.org/PIE/media/b2.pdf </li></ul></ul></ul><ul><li>Emergency Preparedness for Children with Special Health Care Needs </li></ul><ul><ul><ul><li>http://www.aap.org/advocacy/emergprep.htm </li></ul></ul></ul><ul><ul><ul><li>http://www.acep.org/1,374,0.html </li></ul></ul></ul>
  32. 32. The End
  • RenukaKumar7

    Aug. 15, 2019
  • TricianJanTagubaVill1

    Jun. 10, 2019
  • molek5

    Apr. 24, 2016
  • jojojo1984

    Mar. 17, 2012

Views

Total views

3,304

On Slideshare

0

From embeds

0

Number of embeds

8

Actions

Downloads

116

Shares

0

Comments

0

Likes

4

×