Pediatric Office EmergenciesPediatric Office Emergencies

Mark E. Siegel, MDMark E. Siegel, MD

Division of Pediatric Critical CareDivision of Pediatric Critical Care

Hackensack University Medical CenterHackensack University Medical Center

BackgroundBackground

Pediatrics, August 1991, Vol. 88:2Pediatrics, August 1991, Vol. 88:2• 427/1000 office based Pediatricians surveyed427/1000 office based Pediatricians surveyed• >90% within 5 miles of ER>90% within 5 miles of ER• 58% PALS/APLS certified58% PALS/APLS certified• 77% had ever seen ‘severe asthma’, 66% in 77% had ever seen ‘severe asthma’, 66% in

past yearpast year• 67% had ever seen ongoing seizure, 45% in 67% had ever seen ongoing seizure, 45% in

past yearpast year• 22% had an arrest in office, 6% in past year22% had an arrest in office, 6% in past year

BackgroundBackground• Arch Ped Adolesc Med, March 1996, Vol 150Arch Ped Adolesc Med, March 1996, Vol 150

• Fairfield County, ConnecticutFairfield County, Connecticut• 51/52 practices surveyed by phone: 114 MDs, 127 51/52 practices surveyed by phone: 114 MDs, 127

RNsRNs• 2400 ‘lfe threatening emergencies’/year2400 ‘lfe threatening emergencies’/year• 24 emergency visits/practice/year – wide variation24 emergency visits/practice/year – wide variation

• Status asthmaticus, trauma, shock most commonStatus asthmaticus, trauma, shock most common

• 16% had cardiac arrest16% had cardiac arrest• 17% RN/MD PALS certified17% RN/MD PALS certified• 86% had Epi, only 2% had pulse oximeter86% had Epi, only 2% had pulse oximeter

BackgroundBackground• Prehospital Emerg Care, April/June 1999, Prehospital Emerg Care, April/June 1999,

Vol 3:2Vol 3:2– Rochester, NYRochester, NY– Mail survey: 119/199 practices (Peds Mail survey: 119/199 practices (Peds (70%)(70%)/FP/IM-/FP/IM-

Peds)Peds)– 16% initiated resuscitation in office16% initiated resuscitation in office– 27% PALS certified27% PALS certified– 269 ‘recalled’ events269 ‘recalled’ events

• r/o epiglottitis, foreign body, severe asthma, severe r/o epiglottitis, foreign body, severe asthma, severe dehydration, meningococcal disease, active seizuresdehydration, meningococcal disease, active seizures

– Mean Distance to ER: 10-12 minutesMean Distance to ER: 10-12 minutes– 48% sent via EMS, 38% family car, 9% MD car, 48% sent via EMS, 38% family car, 9% MD car,

4% taxi 4% taxi

Preparation: Preparation: TrainingTraining• TrainingTraining

• MD vs. RN vs. Ancillary staffMD vs. RN vs. Ancillary staff

• OptionsOptions• BLSBLS• NRP NRP (NALS)(NALS)

• PALSPALS• APLSAPLS • ACLS ACLS (kids come with parents!)(kids come with parents!)

• RenewalsRenewals

Preparation: Preparation: Response PlanResponse Plan

• Triage protocolsTriage protocols• ReceptionistReceptionist

• Office EmptyOffice Empty

• Assign RolesAssign Roles• PrimaryPrimary• AssistantAssistant• MedicationsMedications• DocumentationDocumentation

• Call 911Call 911• Information givenInformation given

• Call ERCall ER

Preparation: Preparation: Maintenance of SkillsMaintenance of Skills

• Mock scenariosMock scenarios• ReviewReview

• SkillsSkills• equipment locationequipment location• equipment useequipment use

• Monitor expiration datesMonitor expiration dates

Preparation:Preparation:FamiliesFamilies

• Prepare parentsPrepare parents• Handouts for EmergenciesHandouts for Emergencies• Instructions on handling during/after Instructions on handling during/after

office hoursoffice hours• Phone Numbers to callPhone Numbers to call

• EMS, Poison Control, HospitalEMS, Poison Control, Hospital

• Avoiding emergencies- Prevention!Avoiding emergencies- Prevention!

• Medically complex childrenMedically complex children• Medical Information SheetMedical Information Sheet

Preparation:Preparation:EquipmentEquipment

• Multiple sizesMultiple sizes• High costs?High costs?• Storage spaceStorage space

• Periodic checksPeriodic checks• WorkingWorking• ExpirationExpiration• BatteriesBatteries

Emergency EquipmentEmergency EquipmentAirway EquipmentAirway Equipment

• Face masks – various sizesFace masks – various sizes• Oral/Nasopharyngeal airwayOral/Nasopharyngeal airway• AmbubagsAmbubags• Intubation equipmentIntubation equipment

• Laryngoscope, blades & Endotracheal tubesLaryngoscope, blades & Endotracheal tubes• EZ capEZ cap• tapetape

• Suction/suction cathetersSuction/suction catheters• Magill Forceps – remove foreign bodiesMagill Forceps – remove foreign bodies• Pulse oximeter/Cardiac monitorPulse oximeter/Cardiac monitor• Nebulizer – single or ‘continuous’Nebulizer – single or ‘continuous’

Emergency EquipmentEmergency EquipmentCardiovascularCardiovascular

• Automatic defibrillatorAutomatic defibrillator• IV, IOIV, IO• IV tubing/setupIV tubing/setup• IV boardsIV boards• Normal SalineNormal Saline• Syringes – multiple sizesSyringes – multiple sizes

Emergency MedicationsEmergency Medications

• Keep weight based dosing chart Keep weight based dosing chart handyhandy

• Monitor expiration datesMonitor expiration dates• Route of administrationRoute of administration

• IV vs. IMIV vs. IM

• Broselow PediatricBroselow PediatricEmergency tapeEmergency tape

Emergency Medications Emergency Medications RespiratoryRespiratory

• Portable Oxygen tankPortable Oxygen tank• Flow metersFlow meters• Masks/tubingMasks/tubing

• Albuterol – inhaledAlbuterol – inhaled• Racemic Epinephrine – inhaledRacemic Epinephrine – inhaled• Terbutaline – SQ or IVTerbutaline – SQ or IV• Decadron – PO, IM or IVDecadron – PO, IM or IV

Emergency MedicationsEmergency MedicationsCardiac & OtherCardiac & Other

• EpinephrineEpinephrine• Diphenhydramine IVDiphenhydramine IV• Glucose 50%Glucose 50%• Diazepam/LorazepamDiazepam/Lorazepam• NarcanNarcan• Corticosteroids IV/IMCorticosteroids IV/IM• CeftriaxoneCeftriaxone

Commercial ProductsCommercial Products

• Broselow/Broselow/Hinkle Hinkle Resuscitation Resuscitation System System (Armstrong Medical)(Armstrong Medical)

• Statkits (Statkits (Banyan Banyan

International)International)

Emergency Universal RulesEmergency Universal Rules

• Airway• Breathing• Circulation• Initiate stabilizationInitiate stabilization• Call 911Call 911• NPONPO

Office EmergenciesOffice Emergencies

• AnaphylaxisAnaphylaxis• Respiratory DistressRespiratory Distress

• AsthmaAsthma• Foreign BodyForeign Body

• SeizuresSeizures• Sepsis/ShockSepsis/Shock

AnaphylaxisAnaphylaxis

• Multi-systemic allergic reactionMulti-systemic allergic reaction• medications, foods, insect bites, latex, medications, foods, insect bites, latex,

cryptogeniccryptogenic• Range of reactionsRange of reactions

• UrticariaUrticaria• Upper Airway: laryngeal edema, stridorUpper Airway: laryngeal edema, stridor• Lower Airway: coughing, wheezingLower Airway: coughing, wheezing• Cardiovascular collapseCardiovascular collapse

AnaphylaxisAnaphylaxisManagementManagement

• 911 early if airway involvement911 early if airway involvement• OxygenOxygen• Consider Securing airwayConsider Securing airway• Epinephrine 0.01 ml/kg 1:1,000 SQ Epinephrine 0.01 ml/kg 1:1,000 SQ (max: (max:

0.35ml)0.35ml)

• AlbuterolAlbuterol• Diphendydramine IV or PODiphendydramine IV or PO• SteroidsSteroids• IVF, inotropic infusion for hypotensionIVF, inotropic infusion for hypotension• PICU admission for any airway symptomsPICU admission for any airway symptoms• EpiPen for future use, depending on etiologyEpiPen for future use, depending on etiology

AsthmaAsthma• Very commonVery common• BronchoconstrictionBronchoconstriction• Subacute or acuteSubacute or acute• Signs & SymptomsSigns & Symptoms

• CoughCough• WheezingWheezing• RetractionsRetractions• Nasal FlaringNasal Flaring• Peak FlowPeak Flow• Mental Status changesMental Status changes

AsthmaAsthmaManagementManagement

• Pulse oximetryPulse oximetry• OxygenOxygen• Albuterol – ‘unit’ dose for all agesAlbuterol – ‘unit’ dose for all ages

• Continuous albuterolContinuous albuterol

• Steroids – Prednisone 2mg/kgSteroids – Prednisone 2mg/kg• Terbutaline 0.01mg/kg SQ Terbutaline 0.01mg/kg SQ (max 0.4mg)(max 0.4mg)

• infusioninfusion

• IVF FluidsIVF Fluids• R/O foreign body, anaphylaxis…R/O foreign body, anaphylaxis…

Respiratory FailureRespiratory Failure

• TachypneaTachypnea• TachycardiaTachycardia• BradypneaBradypnea• Accessory muscle useAccessory muscle use• DiaphoresisDiaphoresis• GruntingGrunting• Hypoxemia/CyanosisHypoxemia/Cyanosis• IrritabilityIrritability• SomnolenceSomnolence

Foreign BodyForeign Body• Presentation varies with locationPresentation varies with location• Ball valveBall valve• Distal foreign bodies may present Distal foreign bodies may present

latelate• Signs & SymptomsSigns & Symptoms

• Acute Respiratory FailureAcute Respiratory Failure• CyanosisCyanosis• Cough, gaggingCough, gagging• StridorStridor• Focal wheezingFocal wheezing

Foreign BodyForeign BodyManagementManagement

• 911911• FB may change position – esp. during FB may change position – esp. during

transporttransport• OxygenOxygen• BLS – back blows/HeimlichBLS – back blows/Heimlich• Avoid blind probing oropharynxAvoid blind probing oropharynx• Airway positioningAirway positioning• Layngoscopy/Magill forcepsLayngoscopy/Magill forceps• IntubationIntubation

ShockShock

• Decreased delivery of ODecreased delivery of O22 and nutrients to and nutrients to tissuestissues

• Infectious commonInfectious common• HypovolemicHypovolemic

• Vomiting/DiarrheaVomiting/Diarrhea• DKADKA

• Progression may be rapidProgression may be rapid• CompensatedCompensatedUncompensatedUncompensatedIrreversibleIrreversible

ShockShock

• Signs and SymptomsSigns and Symptoms• TachypneaTachypnea• Respiratory DistressRespiratory Distress• TachycardiaTachycardia• Cool or warm extremitiesCool or warm extremities• Decreased perfusionDecreased perfusion• Bounding pulsesBounding pulses• Altered mental statusAltered mental status• Blood pressureBlood pressure

ShockShockManagementManagement

• OxygenOxygen• Airway controlAirway control• IV AccessIV Access• Rapid fluid resuscitationRapid fluid resuscitation

• 20 ml/kg NS or LR rapidly20 ml/kg NS or LR rapidly• RepeatRepeat• RepeatRepeat

• AntibioticsAntibiotics

SeizuresSeizures• Status epilepticusStatus epilepticus

• Time: > 10 minutes (if Afebrile)Time: > 10 minutes (if Afebrile)• No recovery between repeated episodesNo recovery between repeated episodes

• DifferentialDifferential• Low levelsLow levels

• Non-complianceNon-compliance• GrowthGrowth• New MedicationsNew Medications

• InfectiousInfectious• ToxinsToxins• MetabolicMetabolic

• Glucose, Calcium, Sodium, MagnesiumGlucose, Calcium, Sodium, Magnesium

SeizuresSeizuresManagementManagement

• Airway controlAirway control• Oxygen (ABCs)Oxygen (ABCs)• Bedside glucoseBedside glucose

• DD2525W 2-4 ml/kg IVP for hypoglycemiaW 2-4 ml/kg IVP for hypoglycemia

• IV access if possibleIV access if possible• MedicationsMedications

• Diazepam: 0.2-0.5 mg/kg IVDiazepam: 0.2-0.5 mg/kg IV• Rectal 0.5mg/kgRectal 0.5mg/kg

• Lorazepam: 0.1 mg/kg IVLorazepam: 0.1 mg/kg IV• Midazolam: 0.1mg/kg IV/IMMidazolam: 0.1mg/kg IV/IM• Dilantin/FosphenytoinDilantin/Fosphenytoin• PhenobarbitalPhenobarbital

TransportTransport• Ambulance if:Ambulance if:

• Airway issueAirway issue• Oxygen requirementOxygen requirement• ShockShock• Risk of rapid deteriorationRisk of rapid deterioration• Need for monitoring en routeNeed for monitoring en route• Rapid transportRapid transport

• Call ahead to Emergency Room to give Call ahead to Emergency Room to give historyhistory

• Consider riding along, depending on severityConsider riding along, depending on severity• NPONPO

References & ResourcesReferences & ResourcesOffice Emergencies – Mark E. Siegel, MDOffice Emergencies – Mark E. Siegel, MD

• Pediatric Advanced Life Support (PALS)Pediatric Advanced Life Support (PALS) - -American Heart AssociationAmerican Heart Association• Hackensack Life Support Training: 201-996-2401Hackensack Life Support Training: 201-996-2401

• Advanced Pediatric Life Support (APLS)Advanced Pediatric Life Support (APLS) - - The Pediatric Emergency Medicine CourseThe Pediatric Emergency Medicine Course• American Academy of Pediatrics, American College of Emergency PhysiciansAmerican Academy of Pediatrics, American College of Emergency Physicians

• Childhood Emergencies in the Office, Hospital, & CommunityChildhood Emergencies in the Office, Hospital, & Community - - American Academy of American Academy of PediatricsPediatrics

• Emergency Pediatrics: A Guide to Ambulatory CareEmergency Pediatrics: A Guide to Ambulatory Care - - Roger Barkin & Peter RosenRoger Barkin & Peter Rosen• Handbook of Pediatric Mock CodesHandbook of Pediatric Mock Codes - - Mark G. RobackMark G. Roback• PedInfo: An Index of the Pediatric InternetPedInfo: An Index of the Pediatric Internet – http://www.pedinfo.org/ – http://www.pedinfo.org/• Pediatric Critical CarePediatric Critical Care – http://pedsccm.org – http://pedsccm.org• New Jersey Poison ControlNew Jersey Poison Control – http://www.njpies.org/ or – http://www.njpies.org/ or National: National: http://www.aapcc.org/http://www.aapcc.org/

• NATIONAL Phone Number: 800-222-1222NATIONAL Phone Number: 800-222-1222• Emergency Medical Services for ChildrenEmergency Medical Services for Children - http://www.ems-c.org/ - http://www.ems-c.org/

• Office Preparedness for Pediatric Emergencies - http://www.ems-c.org/PIE/media/b2.pdfOffice Preparedness for Pediatric Emergencies - http://www.ems-c.org/PIE/media/b2.pdf • Emergency Preparedness for Children with Special Health Care NeedsEmergency Preparedness for Children with Special Health Care Needs

• http://www.aap.org/advocacy/emergprep.htmhttp://www.aap.org/advocacy/emergprep.htm• http://www.acep.org/1,374,0.htmlhttp://www.acep.org/1,374,0.html

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