GENERAL PEDIATRIC OFFICE EMERGENCIES

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ALEXANDRA WILSON MD

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TING CHANG MD

BACKGROUND

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• Survey of 52 suburban practices : average 1 emergency/month wide variation¹

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• Incidence varies between 0.9- 38 emergencies per year²

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• 75% are respiratory emergencies next dehydration, seizures, and anaphylaxis ²

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Pediatrics. 2003;12(2):291-295.

Arch Pediatr Adolesc Med. 1996;150(3):249-256.

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IMAGINE

You arrive early to the office to find your first patient has arrived early. She is a 3-week-old infant who is brought in with two-day h/o URI symptoms and a low-grade temp. While you are taking off your coat and reviewing emails the receptionist screams for help. You run out to the waiting room to find a limp apneic infant in her mother’s arms.

Suddenly you realize you are not at DCMC anymore

EMERGENCY PREPAREDNESS

• Protocols

https://www.ncems.org/protocols/allprotocols.pdf

• Staff training
• Equipment
• Medications
• Transport

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RECEPTIONIST: THE FIRST RESPONDER

• labored breathing
• cyanosis or pale lips
• stridor or audible wheezing
• decreased level of consciousness
• seizures
• vomiting after a head injury
• uncontrollable bleeding
• signs of anaphylaxis

PREPARATION: MAINTENANCE OF SKILLS

MOCK CODE ASSESSMENT

• Were the ABCs assessed rapidly?
• Were appropriate resuscitation methods used?
• Was EMS summoned quickly?
• Were the participants' roles clearly defined?
• Did someone record what happened during the mock code?

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EMERGENCY EQUIPMENT:�AIRWAY EQUIPMENT

• Face masks – Adult and Peds
• Oral airways
• Ambubags & masks
• Suction/suction catheters
• Pulse oximeter/Cardiac monitor
• Nebulizer

EMERGENCY EQUIPMENT:�CARDIOVASCULAR

• Automatic defibrillator
• IV, IO
• IV tubing/setup
• IV boards
• Normal Saline
• Syringes – multiple sizes

EMERGENCY MEDICATIONS

• Keep weight-based dosing chart handy
• Monitor expiration dates
• Route of administration
• IV vs. IM
• Broselow Pediatric�Emergency tape

EMERGENCY MEDICATIONS�

SOUCES FOR RESUSCITATION PACKS

• Banyan International – Statkits
• Broselow/Hinkle Resuscitation system – Armstrong Medical

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COMMON OFFICE EMERGENCIES

CASE 1

As you are heading into an exam room to see your next patient the receptionist calls out for help. You run to the waiting room to find a toddler with severe retractions and audible stridor

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ANY RED FLAGS?

ACUTE AIRWAY OBSTRUCTION

Call 911

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• Minimal agitation; allow parents to comfort
• Supplemental O₂
• Epinephrine

0.5 mL/kg per dose (maximum of 5 mL) of a 1:1000 dilution

• Steroids

IM form Decadron mixed with flavored Tylenol

IF YOU DON’T TRY THIS FIRST, YOU WILL BE SEEING THAT…..

ACUTE AIRWAY OBSTRUCTION

Intubate????

Decision to intubate is based on clinical grounds:

( Don’t try this in your office!)

• Marked progressive anxiety or air hunger
• Refractory Hypoxemia
• Refractory Hypercapnia
• Clinical evidence of resp muscle fatigue

ASTHMA

• 10-year-old with known asthma presents to our office with 2-day h/o URI symptoms and wheezing. He has been using his inhaler every hour for the last 6 hours. He arrives in your office in acute distress. You are out to lunch (literally) what are you going to instruct your office staff to do until you return?

ASTHMA

Management

• Pulse Oximeter
• Oxygen
• Albuterol – 0.5mg/kg
• Steroids
• Methylprednisolone IV 2mg/kg load
• Prednisone PO 2 mg/kg load (if no IV access)

CASE CONTINUED

ASTHMA

Intubate for the following:

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• Cardiac or respiratory arrest
• Severe hypoxia
• Rapid deterioration in mental state

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Remember high risk of cardiopulmonary deterioration with intubation- do with care

NEXT CASE

• 2-year-old girl brought to your office after developing hives after being stung by a bee. On her way to the office, she vomited once and now has swelling of her face and lips

ANAPHYLAXIS: TREATMENT

Call 911

• Monitor S_aO₂
• Secure airway – give oxygen
• B agonist aerosols (albuterol)
• Rapid volume expansion (if hypotensive) – NS or LR at 20 ml/kg
• Epinephrine
• IM – 0.1 mg/kg (0.01 ml/kg of 1mg/ml) Max child 0.3 ml adolescent 0.5ml
• IV/IO – 0.01 mg/kg (0.1 ml/kg of 0.1mg/ml )
• Repeat Q 5 to 15 min if necessary

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1 cc/10kg of 0.1mg/ml in a code

• From there you can figure out other doses fast

ANAPHYLAXIS: TREATMENT

Alternative: Epipen or Epipen Jr.

>30 mg – Epipen (0.3 mg per injection)

< 30 kg – Epipen jr. (0.15 mg per injection)

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Secondary management

• Methylprednisolone – 1 mg/kg IV/PO
• Diphenhydramine – 1mg/kg IV/PO Max 50mg

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AND YOUR NEXT PATIENT!

While sitting in his mother’s arms in the exam room waiting for you to finish your Starbucks Grande Latte a three-week-old infant begins to have a generalized T-C seizure. The RN calls for help

STATUS EPILEPTICUS

• Most common causes
• Fever
• Hypoglycemia
• Infection
• Head Trauma
• Hyponatremia
• Epilepsy

MANAGEMENT

ANTICONVULSANTS - RAPID ACTING

Benzodiazepines

• Lorazepam 0.1 mg/kg IV (Max dose 4 mg)
• Midazolam 0.2mg/kg IN/IM (Max 10 mg)
• Midazolam 0.5 mg/kg buccal ( Max 10mg)

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If seizure persists, repeat in 3-5 min

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A FINALLY ON YOUR WAY OUT

• The RN calls you after bringing back an 11-year-old who was carried in by his father after a 3-day history of fever, lethargy and myalgias. The boy is poorly responsive tachycardic and mottled what do you do now?

SHOCK�

Recognition

Signs of poor perfusion:

• Poor skin perfusion (pulses, delayed CRT)
• may see hyperperfusion, bounding pulses as well
• Irritability/lethargy (altered mental status)

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And compensatory mechanisms

• Effortless tachypnea with clear lungs
• Tachycardia

Remember BP fails last

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SHOCK –INITIAL TREATMENT

Provide supplemental oxygen.

Obtain vascular access

Provide isotonic fluid resuscitation –goal 60cc/kg NS in first 15min

( watch for CHF)

Check glucose and correct if needed

Obtain blood cultures if possible

Begin empiric antibiotic therapy

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and if things get bad… a little epi goes a long way!

DWINDLE DOSE EPI 1mcg/kg (or 0.1 ml/10kg)

TRANSPORT

IN SUMMARY…..

• Recognize emergencies do happen
• Consider your risk (office location, patient population) and plan accordingly
• Training
• Medications
• Equipment

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REFERENCES

• American Academy of Pediatrics Committee on Pediatric Emergency Medicine. Preparation for emergencies in the offices of pediatricians and pediatric primary care providers. Pediatrics. 2007;120;200-212.

http://pediatrics.aappublications.org/content/120/1/200.full