Pediatric Office Emergencies. Presented by: John Graneto DO, FACOEP-dist, FACOP

Transcription

1 Pediatric Office Emergencies Presented by: John Graneto DO, FACOEP-dist, FACOP

2 Case #1 A four year old girl presents for wheezing symptoms Is she in respiratory distress?

3 Case #1 Respiratory Distress Recognition What is the Earliest Sign?

4 Earliest Sign Tachypnea > 60 neonate > 50 1 year old > 40 2 year old

5 Respiratory Distress Early Tachypnea Intermediate Grunting, flaring, retractions Late Cyanosis, apnea

6 Intermediate Signs Accessory muscle use Flaring of the nasal alae Grunting

7 Respiratory Distress Compensatory signs: tachypneic grunting, flaring, retractions Pathologic signs: wheezing, stridor, rales, rhonchi

8 Intermediate Signs They occur as compensatory result of respiratory distress... The body s innate ability to heal itself.

9 Later Signs Altered mental status Bradycardia Cyanosis

10 Case #1 Further information... 4 year old is wheezing Family Hx of asthma Tachypnea and retractions

11 Asthma 40,000 people miss school or work due to asthma. 30,000 people have an asthma attack. One in eight children

12 Asthma Heath care expenditures $6.2 billion 1 % of the total U.S. health care costs. Greater education and awareness could reduce health care costs by $500 million a year, and result in 50,000 fewer hospitalizations.

13 Asthma Triggers animals dust pollution stress viral exercise weather and......

14 Smoking in the Home 34% of children live in homes with smoking More Symptoms More E.D. visits More Admissions More Death

15 Case #1 Treat with albuterol

16 Albuterol Most widely used Dose mg / kg Every 1 hour up to 10mg MDI = 4-8 puffs q 20 min

17 MDI Easier and quicker Assess patient's skill Opportunity to educate Spacer < 10 years Mask < mg neb = 4-10 puffs MDI

18 Nebulizer Uncoordinated Agitated Patient / Parent expectation Can be given to drowsy

19 Continuous Moderate-severe asthma Plateau side-effects (do not increase)

20 Ipratropium 10% more airway dilatation After repeated doses No change in LOS, O 2 or algorithm progression J Pediatrics 2001 Jan;138(1):51-58

21 Corticosteroids Prednisolone 2 mg / kg PO

22 Pediatric Asthma Differences between adult and pediatric asthma care. Dis Month 2001 Jan ;47(1):34-44

23 Pediatric Asthma Most effective long term care begins as early as possible in life. J Allergy Clin Imm 2000;106:S1 53-7

24 Corticosteroids Parents of asthmatics have corticosteroid preferences Am J Emerg Med 2001 Jan;19(1):29-31

25 Powdered inhalations diskus fluticasone and salmeterol approved for > 4 y/o

26 Emergency Dept.. Factors associated with emergency department visits by children with asthma: implications for health education. Am J Public Health 1996;86:

27 Emergency Dept. ER for "routine" asthma care Lower income Inner city Majority of ER visits were "after hours" / weekends.

28 Emergency Dept. 64% outside of the ER have PCP Only 16% of the PCP's had discussed asthma care with them as far as developing a prospective treatment plan.

29 Asthma Admitted MDI use <11% had correct technique demonstrated. PCP had action plan in place Contact with PCP prior to admission failed to change treatment Higher rates of admission in rural areas

30 Pulse Oximetry Evaluation of pre and post treatment pulse oximetry in acute childhood asthma. Acad Emerg Med 1997;

31 Pulse Oximetry A single low pulse ox before treatment is NOT BEEN SHOWN to be a good indicator for admission.

32 Pulse Oximetry A post-treatment pulse ox that remains low or fails to improve --- maybe a better marker

33 Which of the following is true? a) Office Emergencies rarely seen b) Doctor / staff too busy to prepare c) Hospitals are close enough d) Kids aren t that sick e) None of the above Arch Pediatr Adolesc Med Mar;150(3):

34 Office Emergencies Surveys of staff find the actual occurrence of emergencies was greater than the perceived. Am Fam Physician Jun 1;61(11):

35 Office Emergencies The average FP practice sees 4 true PEDIATRIC emergencies in a year 3.8 (FP) 4.9 (Ped) J Fam Pract Sep; 50(9):757-61

36 Office Emergencies The average pediatric practice sees 24 emergency conditions a year. Arch Pediatr Adolesc Med Mar;150(3):249-56

37 Preparation Written protocols Recognition of distress Equipment purchases Scavenger hunts Unannounced Mock Codes Pediatrics 2003 Aug 112(2) 291-5

38 Which one is right for you? PEARS (AHA) Pediatric Emergency Assessment Recognition and Stabilization PALS (AAP and AHA) Pediatric Advanced Life Support APLS (AAP and ACEP) Advanced Pediatric Life Support ENPC (ENA) Emergency Nursing Pediatric Course NRP (AHA) Neonatal Resuscitation provider CME

39 Equipment Equipment lists vary for practice settings

40 Case #2 3 year old boy Seizing in your office! Don t Panic

41 Case #2 Oxygen Diazepam solution p.r. Diastat gel

42 Case #2 Generalized seizure Febrile No family history

43 Febrile Seizures - Serious?? In 7 pediatric ER s over 2 years. First time febrile seizures Low risk of having serious illness. In Fact % grew bacterial in CSF Academic Emergency Medicine August 2001 Vol 8 No

44 Who to Work-Up? Very young age Prolonged, Complex or Focal More than one in 24 hours Abnormal post ictal exam

45 After Immunization? Elevated risk of occurrence - - The day of DTP 8-14 days after MMR Not associated with any long-term, adverse consequences.

46 Case # 3 2 years old Tachypneic, tachycardic Coughing and sneezing on exam, choking or aspirated?? Is there a FB?

47 Or It was unwitnessed, mom thinks he swallowed something An 18 month old toddler is found by mom making a choking sound.

48 Nasal FB s Commonly seen in toddlers Decorative jewelry beads Clips, buttons, cotton Corn and peas Rocks, bugs, paper, etc

49 Button Batteries Watches, Toys, games, calculators Hearing aids (30% their own)

50 Button Batteries Lithium most voltage Mercuric easily broken

51 Button Batteries Tissue liquefaction necrosis at the local level Removed urgently if stuck in nasal airway or upper GI

52 Nasal FB s Traditional techniques bayonet or Noyse forceps suction on very high settings Amer J Emerg Med 1997 Jan;15(1):54-6

53 Nasal FB s

54 Nasal F.B.'s Finkelstein JA: Oral Ambu bag insufflation to remove unilateral nasal foreign bodies. Am J Emerg Med 1996; 14:57-58.

55 Nasal FBs Papoose 30 degree incline unaffected nares is closed bag mask over mouth FB forcefully expelled

56 Nasal FB s Alternatively parent administer positive pressure breaths into mouth occluded contra-lateral nostril

57 Nasal FB s

58 Swallowed F.B.'s What is the most likely FB swallowed and stuck in the esophagus?

59

60 Swallowed F.B.'s

61 Coin Sizes Cent Nickel Dime Quarter Dollar Half Dollar Copper Plated Zinc Presidential $1 Cupro-Nickel Cupro-Nickel Cupro-Nickel Cupro-Nickel Manganese- Brass Native American $1 Coin Manganese- Brass Composition 2.5% Cu 25% Ni 8.33% Ni 8.33% Ni 8.33% Ni 88.5% Cu 88.5% Cu Balance Zn Balance Cu Balance Cu Balance Cu Balance Cu 6% Zn 6% Zn 3.5% Mn 3.5% Mn 2% Ni 2% Ni Weight g g g g g 8.1 g 8.1 g in in in in in in in. Diameter mm mm mm mm mm mm mm Thickness 1.55 mm 1.95 mm 1.35 mm 1.75 mm 2.15 mm 2.00mm 2.00 mm

62 Swallowed F.B.'s Coins Most are stuck in proximal Esophagus Many present with upper airway signs and symptoms

63 Aspirated F.B.'s 250 deaths /year from aspirated FB s The most common cause of death, in the home, in toddler age 1 to 3 yr What FB is the most common cause of death from aspirated FB s?

64 Aspirated F.B.'s 250 deaths /year most common death in the home in toddler age 1 to 3 yr. most commonly by? X Latex Balloons JAMA 1995 Dec 13;274(22): No Helium Balloons at Parties Mylar instead

65 Aspirated F.B.'s What are the most common 4 food items aspirated by toddlers?

66 Aspirated FOODS 1) Hot dogs 2) Grapes 3) Peanuts / candies 4) Popcorn / vegetable pieces

67 Aspirated F.B.'s Why is this so common?

68 Aspirated F.B.'s Molar Eruption (A and B) Not until Age 2 Unable to sufficiently chew into small enough pieces to swallow effectively

69 6 mo. 1 year 2 years 3 years

70 A child is at birthday party and is eating a hot dog and grapes. She starts to cough and gag. Does she have a complete airway obstruction?

71 What are the signs of complete airway obstruction? Loss of sound Cyanosis Altered mental status

72 If witnessed and child is coughing What do you do?

73 If witnessed and child is coughing What do you do? Allow child to cough

74 BLS Child BLS = Infant BLS =

75 BLS Child BLS = Heimlich Infant BLS = back blows and chest thrusts How do you know if child or infant?

76 Infant BLS

77 Foreign Body s

78 Case #4 A 24 month old pulls hot coffee from the table Screaming & crying in pain

79 Case #4 Burns to her chest wall and arm Very erythematous and some blisters forming

80 Coffee Burn Coffee needs to be brewed at degrees to extract the most optimal flavor. 3 rd degree burns occur at that temp after 2-6 seconds exposure.

81 3 rd degree burns 110 = 6 hours 120 = 5 minutes > 180 = 3-6 seconds

82 Burn Management 1) Stop Offending Agent 2) Cool Skin 3) Treat Pain 4) Reduce Infection Risk

83 Coffee Burn Case Liebeck v. McDonald's Restaurants

84 Coffee Burn Case Shriner s Burn Institute in Cincinnati had published warnings to the franchise food industry that its members were unnecessarily causing serious scald burns by serving beverages above 130 degrees F Morgan, The Recorder, September 30, 1994.

85 Coffee Burn Case the day after the verdict, the news media documented that coffee at the McDonald's in Albuquerque [where Liebeck was burned] is now sold at 158 degrees.

86 Coffee Burn Case This temperature may cause third-degree burns in about 60 seconds, rather than in two to seven seconds [so that], The margin of safety has been increased as a direct consequence of this verdict.

87 Case # 4 Referral to Emerg Dept. > 5-10% BSA or circumferential burns burns of the face, perineum

88 BSA Assessment Adult BSA Child??? = palm Pediatr Emerg Care Aug;13(4):254-5

89 BSA Assessment Adult BSA Child 1% = palm Pediatr Emerg Care Aug;13(4):254-5

90 Case # 4 Stop offending agent Pain Control

91 Case # 4 Ibuprofen 10 mg / kg PO Ketorolac 0.5 mg / kg IM

92 Case # 4 Topical Antibiotic Twice Daily until epithelialization occurs

93 Case 5 A 3 year old girl has been eating strawberries for the first time What do you see? What worries you?

94 Case # 5 Tachycardic, SOB Hives, scratching Anxious

95 Medications Epinephrine 0.01 mg/kg SQ of 1:1000 solution; Can be repeated q 10 min

96 Case # 5 Epinephrine 0.01mg/kg Sub Q

97 Case # 5 Anti-histamine H 1 diphenhydramine 1 mg/kg/dose H 2 famotidine 0.5 mg/kg/dose

98 Case # 5 Corticosteroid Decadron 0.15 mg/kg/dose Methylprednisolone 1-2 mg/kg/dose

99 Case # 5 Do vaccines cause anaphylaxis?

100 Case # 5 Risk of anaphylaxis exceedingly rare. No one product type higher in incidence. Maybe multiple vaccines or combo s. Falsely elevated due to the increased use. Risk of Anaphylaxis after Vaccination. Peds Oct, 2003

101 Disposition RX s: EpiPen, Antihistamines, Steroids Dietary and lifestyle awareness teaching Avoidance of precipitating allergens

102 Phone Numbers 911 or your local FD Poison Control PICU s Transport Teams

103 Thank You!