Transcript 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
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year
AAP survey in 2003-73% of offices had one
patient/week requiring emergency treatment or
hospitalization
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
PCP’s
Office
Hospital or
Tertiary
Center
Pediatric
Emergency
Emergency
Department
EMS
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
arise?
 Where are the nearest emergency facilities?
 What local EMS services are available? How are they
accessed?
 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
procedures.
 “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
emergency.
 Document plans to enhance emergency preparedness.
Office Preparation: EMS
 Can assist in office emergency care and transport
 EMS levels
 First responders, BLS
 ALS
 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
Anaphylaxis
 Acute, immediate hypersenitivity reaction involving
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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
intravenous.
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
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True medical emergency
A,B,Cs
Positioning
Epinephrine (1:1,000) 0.1 ml/kg up to 0.3 ml SQ or IM
Albuterol
Antihistamines-H1 and H2
Steroids
IV fluids
Special considerations:
 Beta blockers
 Injection or sting
Dehydration
 Remains a cause of significant pediatric morbidity and
mortality
 Not a disease in itself but a symptom of another
process
 Is on the hypovolemic shock spectrum
 Infants at risk due to large water content, increased
metabolism, renal immaturity and dependence on
caregivers
Dehydration: Etiology
 Diarrhea
 Hemorrhage-internal and external
 Vomiting
 Inadequate fluid intake
 Osmotic shifts-DKA
 Third space losses
 Burns
Dehydration: Signs &
Symptoms
 “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
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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)
Seizures
 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
process
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
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A,B,Cs
Protect the patient
C collar if trauma suspected
Identify and treat known causes
Anticonvulsant therapy for seizures lasting longer than 5-10
minutes
 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
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Posture/mental status
Nasal flaring
Retractions
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
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Metered dose inhaler
Nebulization
 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:
Bronchiolitis
 Acute viral infection of the lower respiratory tract most
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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
concern
Feeding is important consideration in disposition
Respiratory Emergencies:
Bronchiolitis
 Treatment
 Oxygen
 Nasal suction
 Albuterol if a family history of asthma
 Nebulized epinephrine if no family history of asthma
 Observation
Fever/Sepsis
 Complete clinical picture
 Know what is “out there”
 “Fever phobia”
 Occult infections, Serious Bacterial Infection (SBI) are
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concerns with fever especially with no obvious source
Think of shock and respiratory failure
Give antibiotics sooner rather than later
Oxygen
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 =
fever
 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”.