The document provides guidance on choosing protocols and dispositions for various pediatric patient cases presented to a telehealth triage nurse. It describes 9 calls involving children with various complaints such as crying, eye irritation, ear pulling, mouth bleeding, wheezing, swallowed objects, abdominal pain, limited arm movement, and provides the guidelines and rationales chosen by the nurse. It emphasizes the importance of actively ruling out serious conditions, considering 911 in some respiratory cases, and giving instructions to reduce injuries like subluxed joints if emergency department access is not possible.

1. What Protocol Would You
Choose?
Orientation RPTC- Source: Barton Scmitt, MD, as presented at Reach
for the Stars 2011 National Telehealth Conference

2. How to Choose
• You are the triage nurse for PhoneRN. It is 8pm on a weekday
evening.
• Triage: Sort the patient into one of the following 3 levels of care:
• God to ED Now
• See in office tomorrow
• Home care

3. Call 1: Tucker, 6 Week Old Male
• Presenting Complaint: “crying more than usual”
• Fussier than normal for 2 days
• Difficult to console; cries more when held
• Popping sound of right rib cage with movement
• Alert, feeding well, normal urine output, breathing well
• Choose the best guideline and disposition

4. Tucker, 6 Week Old
• Guideline: Crying- before 3 months old
• Disposition: Go to ED Now
• Reason: Injury suspected (r/o child abuse)

5. ED Findings
• 3 rib fractures
• Skeletal survey: negative for other fractures
• Head CT: no subdurals
• FOC (father of child): Admitted squeezing baby hard when he was
crying a few days ago

6. Child Abuse and Crying
• Inconsolable crying is the #1 trigger for lethal-outcome child
abuse.
• Usual mechanism: Shaken baby syndrome
• SBS main symptoms: extreme irritability, vomiting, seizure, apnea,
bulging AF
• Goal: Detect minor inflicted injuries before SBS occurs

7. Clues to High Risk for SBS
• Inconsolable crying
• Angry comments about baby
• Admits fear of hurting baby
• Has spanked baby
• Unexplained bruise, swelling, or mark
• Paradoxical response to being held or moved
• Bruises before 4 months old
• Pierce MC, Pediatrics 2010; 125: 67-74

8. Call 2: Greg, 12 Year Old Boy
• Presenting complaint: “Blisters on eyeball”
• Present x 1 hour, Started during a bike ride
• Eyes very itchy, bloodshot and watery, blisters on sclera
• Nasal symptoms also present. Has hay fever and didn’t take
anything today
• Best guideline?

9. Greg, 12 Year Old Boy
• Eye allergy guideline
• Serious causes to consider: Chemical eye, FB
• Disposition: See tomorrow in office
• Reason: Sacs of clear fluid (blisters) on whites of eyes or inner lids
• R/O: chemosis or allergic cysts

10. Chemosis and Allergic Conjunctivitis
• Definition: sever reaction of the eye to allergen, manifested by
edema of the bulbar conjunctiva
• Cause: high pollen count or pollen load
• CC: whites of eyes look swollen or have clear blisters. Cyst size: 4
to 10 mm
• Treatment: cold wet cloth, oral antihistamines, and purchased
special eyedrops
• Ketotifen (OTC Zaditor) eyedrops can usually eliminate chemosis

11. Call 2: Jada, 2 year old girl
• Presenting Complain: “Pokes at her right ear. Could she have an
ear infection?”
• Onset: 3 days ago
• No fever, cold, cough, runny nose, ear discharge
• No pain, crying, or night awakenings
• PMH: otisis media once at 7 months
• Best Guideline?

12. Jada, 2 Year Old Girl
• Ear: Pulling at or itching guideline
• Disposition: Home care
• Reason: Ear pulling without other symptoms is not a sign of an ear
infection
• Additional history: Uses Q-tips
• Risk: perforated eardrum

13. Ear Pulling in Young Children
• 1992 study: 100 children with ear pulling as the chief complaint where
examined.
• Age: 11 months median (SD 8 months)
• Challenge: most children under age 2 unable to confirm or deny
presence of an earache.
• Challenge: most children under age 2 unable to confirm or deny
presence of an earache.
• Results (diagnostic groups): normal ear canal and eardrum 69%,
impacted earwax 12%, acute otitis media 12%, serious OM 7%, FB none.
• Conclusion: simple ear pulling without other symptoms of an illness or
infection was never associated with an ear infection.
• Baker RB Pediatrics. 1992: 1006-1007

14. Call 4: Sandy, 3 Year Old Girl
• Presenting complaint: “lip wont stop bleeding”
• Fell 20 minutes ago at her BD party
• Location: Inside the upper lip
• Amount: small, but hasn’t stopped
• Also small scrape on outer lip. Denies head trauma
• Best guideline?

15. Sandy, 3 Year Old Girl
• Trauma- Mouth Guideline
• Caller denies serious symptoms:
• Fall with object in mouth
• Gaping cut of outer lip
• Tooth damage
• Best disposition?

16. Cut of Upper Labial Frenulum
• Disposition: Home Care
• Reason: Torn upper labial frenulum always heals perfectly without
sutures
• Reassurance: bleeding from the site always stops
• Caution: Do not pull the lip out again to look at it (Reason: the
bleeding will start again)
• It’s safe to look at it after 3 days

17. Call 5: Zack, 4 Month Old
• Presenting complaint: “Hard to clean out his nose.”
• First cold started 8 days ago
• Mild cough, no fever, cloudy nasal discharge, nose seems blocked,
cries when uses bulb syringe
• Drinking less but wet diapers every 4 hours, alert, not in pain
• Best guideline?

18. Zack, 4 Month Old Boy
• Colds guideline
• Disposition: See Tomorrow in Office
• Reason: ear infection suspected by triage nurse
• Nurse discusses how to use saline with a bulb syringe

19. Office Findings
• Office next morning: RR 60, wheezing, mild retractions, o2 sat
86%
• Admitted for bronchitis
• During the night: frequent awakenings, unable to sleep laying
down, parents took turns holding upright all night
• Nurse Error: Did not ask about breathing or respiratory distress

20. Lesson: Child is Unsafe Until Proven
Otherwise
• In office, can usually decide within 10 seconds whether or not a
child is seriously ill
• On the phone, this may take 1 to 2 minutes
• Must actively disprove that the patient has any serious etiologies
or complications for their main symptom (eg. Appendicitis for
abdominal pain)
• Don’t assume the caller knows
• If unsure, refer them in to be examined

21. Respiratory Distress
• Respiratory arrest: the primary cause of death in young children
• Recognizing Respiratory distress: an essential skill for telephone
triagers
• Always assess Respiratory Distress in any respiratory guidelines:
cough, croup, flu, wheezing, even colds
• For cold symptoms with fever, do NOT use fever guideline

22. Respiratory Distress Defined
• Normal breathing: effortless, quiet, slow
• Mild RD: Tachypnea w/o dyspnea
• Moderate RD: working to breath, some retractions, some
wheezing or stridor may be present, but not tight
• Severe RD: Struggling to breathe, severe retractions, difficulty
eating or speaking, worse with walking, grunting to push air out,
too hypoxic to sleep

23. Call 6: Morgan, 8 month old girl
• Presenting complaint: “Wheezing for 2 hours”
• Runny nose, cough and fever to 102F started 8 hours ago
• Difficulty breathing and wheezing. Mom has asthma since
childhood
• Best guideline?

24. Morgan, 8 month old girl
• Wheezing Guideline
• Disposition given: Go to ED now
• Result: Child stops breathing in car while driving in
• Father starts driving through stop signs and hits another car

25. Bronchiolitis
• Lesson 1: Consider 911 option whenever you send a child to ED
• Apnea risk is high for infants <6 months with respiratory infections
• Recognize symptoms of sever respiratory distress: grunting, weak
cry, inability to suck, groaning, moaning
• Lesson 2: Listen to child’s breathing

26. Call 7: Boris, 2 year old boy
• Presenting complaint: “swallowed a dime”
• When: 10 minutes ago
• No swallowing problems, drooling, spitting, gagging, vomiting
• No breathing problems
• Best guideline?

27. Boris- 2 Year old boy
• Swallowed foreign body guideline
• Disposition given: Home Care
• Care Advise: Check stools for dime and call back if FB as not
passed within 3 days or develops symptoms
• Result?

28. Coin or button battery?
• Parent called back in 4 hours
• Inconsolable crying and refusing to eat
• Referred to ED
• Diagnosis: button battery in esophagus
• Risk: Saliva asks as electrolyte bath and battery current can cause
chemical burn, perforation, or even vessel damage

29. Jack, 14 year old boy
• Presenting complain- Stomach ache
• Onset: 3 hours ago, after playing basketball
• Location: Lower left side
• Severity: moderate but constant; hurts to walk
• Denies fever, vomiting, diarrhea
• Best guideline?

30. Jack, 14 year old boy
• Abdominal pain guideline
• Disposition given: Go to ED now
• Reason: Moderate pain (interferes with activities) AND constant
AND present >2 hours R/O appendicitis, other acute abdomen
• ED Diagnosis: Left testicular torsion
• Lesson: males may not give their mom correct location of pain

31. Testicular Torsion
• Definition: testicle twists and cuts off its blood supply
• Peak age: 16 (70% between 12 and 18)
• Symptoms: abrupt onset of scrotal pain and swelling
• Exam: testicle elevated and cremasteric reflex absent
• Surgical Emergency: Infraction and loss of testicle if persists > 8
hours

32. Call 9- Gabby, 3 year old girl
• Presenting complaint: “won’t use right arm”
• Onset: 30 minutes ago while dad was swinging her
• Symptoms: Holds right arm partially flexed at elbow with palm
down. Cries and resists any movement.
• Best Guideline?

33. Gabby, 3 year old girl
• Arm Trauma Guideline
• Disposition: Go to ED now
• Reason: Age<4 and cannot move elbow normally (r/o subluxed
raial head)
• Weather conditions: blizzard, 12 inches of snow so far today,
family lives in foothills
• Plan B?

34. Reducing a Subluxed Radius
• Refer call to PCP or ED managed by telephone
• Last resort: triage nurse gives instructions on how to reduce radius
• Either technique is effective
• Confirmation of success: Click is felt and child uses arm within 10
minutes
• Kaplan, RE, Pediatrics 2002: 110: 171-174

35. Hyperpronation Script
• Support your child’s elbow with one hand
• Grip your child’s wrist with the other hand
• Turn your child’s wrist and forearm until the palm faces entirely
downward
• You should feel a click as the elbow is reduced
• Your child should start using the arm normally within 10 minutes