Dr. Puja DhuparMD DNB

BALGOPAL CHILDREN HOSPITAL

EMERGENCIES MANAGEMENT IN OFFICE PRACTICE

Office of paediatric primary care provider often entry site to emergency care system

Capabilities and limitations in office practice

Early recognition and stabilisation of emergencies in office

Timely transfer to appropriate facility for definitive care

Common views

EMERGENCIES ARE NOT VERY COMMON.

WILL INCREASE LIABILITY.EXPENSIVE.TIME CONSUMING.REQUIRES TRAINING.

Standardised office based self assessment

What emergencies have you experienced?

How often?Resources outside your office availableEmergency readiness training of OPD staff

How far is your office from nearest ED?Do you practice children with special health care needs?

Good Resuscitation Knowledge And Skills Are Essential For Best Chances Of Survival

First Person To Assess Patient Is Often Least Clinically Experienced Receptionist

Teach Them Symptoms And Signs Of Emergency

Periodically Check Waiting Area

Pediatric Office Based Protocols For 5-10 Top Emergency Conditions

RECEPTION DESK EMERGENCY CARD

THE FOLLOWING SIGNS AND SYMPTOMS MAY SIGNAL AN EMERGENCY:

Laboured BreathingBlue Or Pale Colour (Cyanosis)Noisy Breathing (Wheezing Or Stridor)Altered Mental StatusSeizureAgitation (In The Parent)Vomiting After A Head InjuryUncontrolled Bleeding

Aims of Assessment

LIFE THREATENING

Not Life Threatening

Potentially Life Threatening

Initial Assessment

Begins Before You Touch The Patient

Form A General Impression.

Determine A Chief Complaint.

The Pediatric Assessment Triangle Can Help.

EQUIPMENT FOR ASSESSMENT

LOOKBehaviourInteractivityConsolabilityTone &Posture

LISTENCryResp soundsSpeechmother

FEELPulsesSkinextremities

MEASURETempPulse oximeterCapillary glucose

Key Question

What are the elements of the assessment that are most useful?

Pediatric Assessment Triangle

A P P E A R A N C E

B R E A T H I N G

Pediatric Assessment Triangle

C I R C U L A T I O N

A P P E A R A N C E W O R K O F BREATHING

Pediatric Assessment Triangle

Howsick?

How quick?

Triangle: Respiratory Distress

NormalAppearance

IncreasedWork of Breathing

MEANS RESPIRATORY DISTRESS

Triangle: Respiratory Failure

Abnormal Appearance

MEANS RESPIRATORY FAILURE

Increased orDecreased Work of Breathing

Triangle: Shock

Poor Circulation to Skin

MEANS SHOCK

AbnormalAppearance

Triangle:

Poor Circulation to Skin

M E A N S O B S E R V E

NormalAppearance

Triangle: Brain Dysfunction

Normal Circulation to Skin

MEANS BRAIN DYSFUNCTION

AbnormalAppearance

Normal Work of Breathing

Key Points1. The Triangle is a “quick look” of overall

severity and urgency of treatment.

2. primary survey in a rapid ordered, stepwise evaluation of cardiopulmonary and neurologic function to prioritize treatment.

3. Begin resuscitation immediately when you identify a life-threatening problem in the primary survey.

Vital Signs by Age Age Respirations

(breaths/mi)Pulse (beats/min)

Systolic Blood Pressure (mm Hg)

Newborn: 0 to 1 mo 30 to 60 90 to 180 50 to 70

Infant: 1 mo to 1 yr 25 to 50 100 to 160 70 to 95

Toddler: 1 to 3 yr 20 to 30 90 to 150 80 to 100

Preschool age: 3 to 6 yr 20 to 25 80 to 140 80 to 100

School age: 6 to 12 yr 15 to 20 70 to 120 80 to 110

Adolescent: 12 to 18 yr 12 to 16 60 to 100 90 to 110

Older than 18 yr 12 to 20 60 to 100 90 to 140

Key values in practice

Pulse > 220/min consider SVT

Cap refill > 2 seconds is not normal

BP in kids > 1 year = 70 + (2 x age)

RR > 60/min NB, > 50/min till 1yr, > 40 /min till 5 yrs

PULSE OXIMETRY<92 In room air

CAPILLARY BLOOD SUGAR <60

COMMON PEDIATRIC OFFICE EMERGENCIES

ANAPHYLAXISAn acute clinical syndrome caused by exposure to

a foreign substance to which patient has been previously sensitised

Fatal food reactions cause respiratory arrest after 30-35 min

Insect stings cause collapse from shock in

10-15 min

Death after parenteral medication occur within

5 min

Causes of Anaphylaxis Food allergy eg peanuts,egg white,seafood,soya,food

additives

Medications (penicillin,NSAIDS,cephalosporins,quinolones,sreptomycin,iron dextran)

Insect stings,tick bites

Biological products( vaccines ,antisera,blood products)

Contrast medias

Idiopathic

C R I T E R I A

1. Acute onset of an illness (minutes to several hours) with involvement of the skin, mucosal tissue, or both (eg, generalized hives, pruritus or flushing, swollen lips-tongue-uvula)

AND AT LEAST ONE OF THE FOLLOWING

A. Respiratory compromise (eg, dyspnea, wheeze-bronchospasm, stridor, hypoxemia)

B. Reduced BP* or associated symptoms of end-organ dysfunction (eg, hypotonia, collapse, syncope, incontinence)  

ALLERGIC REACTIONS AND ANAPHYLAXISMild Moderate Severe

(anaphylaxis)

Hives,rash

No respiratory distress

Hives,rash

Abdominal cramping

Swelling of mucous membrane

Normotensive

Mild bronchospasm

Altered mental status

Angioedema

Abdominal cramping

Hypoperfusion

Respiratory distress-grunting,flaring,stridor,bronchospasm

DIAGNOSING ANAPHYLAXISDiagnosis based on clinical presentation and

exposure history

Flushing and tachycardia invariably present other cutaneous symptoms hives and itch may be absent

Very rarely may present only with profound hypotension

Exposure to some inciting agent is one key to diagnose in such rare cicumstances

Anaphylaxis: Causes of Death

Upper and / or Lower Airway Obstruction (70%)

Cardiac Dysfunction (24%)

Treatment Mild ModerateConsider benadryl 1mg/kgMax 50mg

Oxygen

Benadryl

Epinephrine SC(1:1000) .,01ml/kg,Max 0.3 ml

Resp symptoms salbutamol nebulisation 2.5mg/3ml NS may repeat if no improvement

GENERAL MANAGEMENT OF ANAPHYLAXISAirway

Breathing

Circulation

But use epinephrine promptly

Prehospital care Advise patient with airway obstruction or resp

distress position of airway comfort.

If feeling faint,unable to sit stand,make him in trendelberg position.

Hypotensive pts could rapidly go into cardiac arrest if they remain upright.

Epinephrine (adrenaline) is first line treatment.

Epinephrine preferably given IM

Antihistamines & bronchodilators are not first line treatment but may be given after epinephrine.

Transportation to hospital should not be

delayed to administer these once epinephrine has been given.

Management of anaphylaxis

Epinephrine 0.01ml/kg (1:1000)IM X3, every 5-20min as needed.

Subcutaneous or inhaled routes not recommended

If child is in shock administer IV adrenaline 0.1ml/kg(1:10000)

along with volume expansion

If there is significant wheezing nebulise with salbutamol

H1 antagonists eg Diphenhydramine (Benadryl) 25-100mg

Corticosteroids hydrocortisone (5-10mg/kg)

RESPIRATORY EMERGENCIES -

AIRWAY OBSTRUCTION MOST COMMON FOLLOWED BY PARENCHYMAL AND PLEURAL

General approach

Do not separate child from mother

Avoid changing position of comfort which child has adopted

Help mother to administer oxygen in a non threatening manner

Perform rapidly cardiopulmonary cerebral assessment

Triage Of These Children Will Depend On -

The severity of obstruction The cause of obstruction which

will give a clue to the rate of narrowing

Cause Of Obstruction

Where the rate of narrowing is likely to be rapid or critical do not attempt to visualize the throat

Rapid narrowing can be seen in anaphylaxis, foreign body aspiration, burns involving the airway, epiglottitis

Critical narrowing can be suspected when there is extreme dyspnoea, diaphoresis or significant retractions esp suprasternal

Mild Moderate Severe

GeneralAppearance

Happy Feeds well Interested in surroundings

Fussy, but interactiveComforted by parents

RestlessAgitatedAltered sensorium

Stridor Stridor on coughing & crying No stridor at rest

Stridor at restWorsening with agitation

Stridor at restWorsening with agitation

Respiratory Distress

No distress TachypneaTachycardia & Chest retractions

Marked tachypnea Tachycardia with retractions

Saturation

> 92% in room air > 92% in room air < 92% in room air

MILD - No stridor at rest and able to maintain saturation

MODERATE -Stridor at rest, worsens on agitation but able to maintain oxygenation

SEVERE - Severe stridor, altered mentation and failing to maintain oxygenation

How do you Grade Severity of Obstruction

CROUP(ALTB)

Presents with history of prodromal URI followed by barking cough,hoarse voice stridor and mild fever

Age 6-36 mths, commonly seen in early winter

Etiology parainfluenza type 1,3 RSV,adenovirus,influenza A

In all cases of stridor always rule out epiglottitis where there is toxic appearance,high fever and sudden onset of symptoms

Croup Management

Mild

Moderate

Severe

Mild Croup

Symptomatic treatment +/- single dose of oral steroids

Parental education on symptoms and signs of worsening even at night

Moderate Croup

Steroids

Nebulised adrenaline

Close monitoring

Steroids in Croup

Best option is dexamethasone 0.6 mg/kg oral, iv, im

Oral prednisolone - 2 mg/kg

In children who cannot take oral medications a single dose of budesonide nebulised 2 mg

Adrenaline in Croup

Dose is 0.5 ml/kg upto a maximum of 5 ml of a 1:1000 dilution

Can be repeated every 20-30 minutes for a maximum of 3 nebulisations

Even if croup responds well, observe for at least 2 hours

Treatment of Severe CroupOxygenRapid transferSteroids Nebulize adrenaline as frequently as needed

Intubate if airway obstruction / work of breathing is worsening

Use a tube half size smaller than optimal

Foreign body

Sudden attack of respiratory symptoms such as cough, choking gagging ,cyanosis in a previously normal child

Positive history must never be ignored while a negative history may be misleading

Removing a Foreign Body Airway Obstruction

DEPENDS ON AGE

OVER >1YR HEIMLICH MANEUVER

UNDER < 1YR BACK BLOWS FOLLOWED BY CHEST THRUSTS

Removing a Foreign Body Airway Obstruction

In a conscious child:Kneel behind the child.

Give the child five abdominal thrusts.

Repeat the technique until object comes out.

Removing a Foreign Body Airway Obstruction

If the child becomes unconscious, inspect the airway.

Attempt rescue breathing.

If airway remains obstructed, begin CPR.

Management of AirwayObstruction in InfantsHold the infant facedown.Deliver five back slaps.Bring infant upright on

the thigh.Give five quick chest

thrusts.Check airway.Repeat cycle as often as

necessary.

Workstation Videos1.mp4

NEUROLOGICAL EMERGENCIES

FEBRILE SEIZURES AND STATUS EPILEPTICUS

Useful History for Child with Seizure

Does s/he have a fever?Does s/he have a seizure disorder?

If yes, is s/he on anti-seizure medications?

If yes, is s/he taking them, or any recent changes?

Any trauma?Any medicines s/he had access to?How was s/he before the seizure started?Is s/he developmentally normal?Family h/o epilepsy/febrile seizures

TreatmentControl Seizure

IV lorazepam 0.05mg/kg* orIV midazolam 0.2mg/kg intranasal (if immediate IV access is difficult)

4 puffs / 10 kg

* lorazepam loses potency at room temperature and needs to be refrigerated

Treat The Source Of Fever

If No IV Access…..Lorazepam 0.1 mg/kg IM

Diazepam 0.5 mg/kg PR Midazolam 0.5 mg/kg IM

0.2 mg/kg Intranasal/buccal

0.15 mg/kg PR

Diagnosis of Status Epilepticus

Monitoring and control of vital parameters:

Airway Breathing CirculationGlucose,

Start O2, secure IV accessLorazepam: 0.05- 0.1 mg/kg i.v.

Phenytoin (20 mg/kg i.v. at 1 mg/kg/min) orFosphenytoin (20 mg/kg at 3mg/kg/min)

Attention:rhythm problems and falling blood pressure

Seizures Continuing?

If seizures continuing, treat as refractory status

Make arrangements

for early transfer

ilae-epilepsy.org

ZIPPER ENTRAPMENT INJURY

Most common genital injuries in prepubertal boys.

Typically involve the foreskin or redundant penile skin and may occur during the zipping or unzipping process

Zipper Injury: Treatment

 The procedure for entrapment release depends upon the site of entrapment within the zipper.

Entrapment of penile skin between the zipper teeth (and not the zipper mechanism)

Release by cutting across the zipper

ENTRAPMENT IN ZIPPER MECHANISM

Recommended technique:The median bar may be cut with wire cutters,

bone cutters, or a mini hacksaw Allows the mechanism to fall apart and leads to

release of the entrapped skin Alternate technique:

Thin blade of a small flathead screwdriver Placed between the faceplates on the side of

the mechanism in which the penile skin is not entrapped.

The blade is then rotated toward the median bar This widens the gap between the faceplates,

releasing the skin

The most common

mechanism is a fall on an outstretched hand.

On examination forearm is held pronated,with partial flexion at elbow

PROCEDUREDOESNOT REQUIRE SEDATION OR ANALGESIA

RADIOGRAPHY NOT NEEDED TO CONFIRM DIAGNOSIS

GRASP CHILDS HAND IN HAND SHAKING GESTURE AND RAPIDLY ROTATE EXTERNALLY AND FLEXED SIMULTANEOUSLY

PALPABLE CLICK ,POP FOLLOWED BY CRY

RETURN TO NORMAL MOVEMENT IN 5-15 MIN

REMOVAL OF A NASAL FOREIGN BODY

1.Nasal foreign bodies are most common in 2-3-year-olds and

common foreign bodies include toy parts, beads, insects, paper, and

food items.

2. Symptoms depend on how long the

object has been lodged in the nasal

passages.

B. PROCEDURE 1. Positive Pressure Techniques: with use of either

mouth-to-mouth by parent, or with AMBU bag and mask applied to mouth of child, occlude the opposite nostril and give a gentle, positive-pressure breath to expel the object.

2 Instrumental Removal:

1.The child should be lying down and restrained.

2. Visualize the interior of the nose with a nasal speculum.

3. Extract the object with suction, a hook, or alligator forceps.

4. Do not push the foreign body into the posterior nasopharynx

5. After the foreign body has been removed, ora antimicrobial agents may be used in an effort to prevent an infection in the traumatized area.

Be Prepared Everyday With

MEDICATIONS

TRAINED STAFF EQUIPMENT

MET

Location of Equipment

All drugs should be kept in emergency equipment container and expiry checked regularly

EMS

T H A N K S