Alix Casler, M.D., F.A.A.P. Orlando, FL

Alix Casler, M.D., F.A.A.P. Orlando, FL

Emergencies in the School Setting Initial triage Basics of History and Exam Specific Scenarios

Initial Assessment and Triage First steps in evaluating a potential emergency: Assess situation safety Assess ABC s Assess vitals Obtain complete history including medications Perform physical assessment Triage to determine urgency of situation Emergent Urgent Non-Urgent http://www.luhs.org/depts/emsc/schl_man.pdf

Emergent situations An emergent situation is one posing an imminent threat requiring immediate medical attention Examples: Cardiopulmonary arrest Shock (hypovolemic, anaphylactic, cardiogenic) Severe respiratory distress or failure Severe burns Status epilepticus or first time seizure Altered mental status Severe trauma Limb trauma with loss of distal pulse Spinal cord injury Severe pain in significant area of the body (chest, abdomen) http://www.luhs.org/depts/emsc/schl_man.pdf

Emergent course of Action Support ABCs Activate EMS Initiate appropriate interventions as per specific protocol Contact parent/guardian and school administrator Follow up http://www.luhs.org/depts/emsc/schl_man.pdf

Urgent Situations An urgent situation is an acute condition that, although not severe or life-threatening, requires medical attention within a few hours Examples: Wheezing, unresponsive to medication but not associated with shortness of breath Seizure, not status or first time Laceration which may require repair, without large blood loss Head trauma with temporary loss of consciousness Fracture of a long bone without large blood loss or circulatory compromise Gastroenteritis with evidence of mild dehydration http://www.luhs.org/depts/emsc/schl_man.pdf

Urgent course of Action Determine need for EMS versus parent transport Continuously observe and monitor student for change Initiate appropriate treatment/intervention based upon medical problem at hand Follow up http://www.luhs.org/depts/emsc/schl_man.pdf

Nonurgent situations A nonurgent situation involves a condition which is not severe and requires only routine medical care Examples: Minor abrasions, bruises or sprains Ear ache Sore throat Wheezing responsive to medication and without any shortness of breath Mild pains such as stomach ache, headache, without fever or other severe or abnormal findings http://www.luhs.org/depts/emsc/schl_man.pdf

Nonurgent course of action Initiate appropriate course of treatment as per protocols Observe student Notify parent/guardian Return student to class or send home as indicated Follow up if needed http://www.luhs.org/depts/emsc/schl_man.pdf

Emergent/Urgent Medical Situations at School: Tools for Evaluation Across the room assessment Scene safety assessment Brief health history CIAMPEDS Physical Assessment ABCDEFGHI http://www.luhs.org/depts/emsc/schl_man.pdf

Patient History: CIAMPEDS Chief Complaint Immunization Status Allergies to medications or other agents Medications Past medical history Events preceding the problem Diet/elimination Symptoms associated with presentation http://www.luhs.org/depts/emsc/schl_man.pdf

Problem-Oriented Exam: ABCFEGFHI Airway Breathing Circulation Disability Expose/Examine Farenheit (temperature) Get vital signs Head-to-toe examination Isolate if indicated http://www.luhs.org/depts/emsc/schl_man.pdf

Some specific scenarios: Abdominal Pain Head Injury Allergic Reaction/Anaphyllaxis Fever/Communicable Diseases Heat-Related Injuries Lacerations/Avulsions/Amputations Fractures

Abdominal Pain Emergent Diminished perfusion/shock Diminished sensorium Decreased or absent bowel sounds Abdominal or GU trauma with abdominal distension or rigidity Urgent Moderate to severe pain Vomiting Mild vital sign changes Non-Urgent Mild or intermittent pain or cramps Mild diarrhea Vital signs must be normal and stable

Abdominal Pain: Clinical Example Case: 10 year old male presents with temperature of 100.9 and complaint of increasing abdominal pain since the morning before school. History Physical Triage

Head Injury Emergent Ongoing change in level of consciousness Seizure Peripheral neurologic symptoms Blood/csf leak Significant mechanism of injury Urgent Brief disorientation/amnesia/dizziness Laceration requiring medical attention Neck pain Nausea/vomiting Non-Urgent Alert Normal and stable vital signs Minor abrasions or swelling (goose-egg)

Head Injury: Example Case: A three year old child is running and collides with a concrete pillar at the school History Physical Triage Case 2: A 16 year old female is brought to the nurse s office. Her friends say that she was drunk and that she fell while walking and hit her head. You smell alcohol on her. She is very sleepy. History Physical Triage

Allergic Reactions/Anaphyllaxis Emergent: Loss of consciousness Severe respiratory distress Shock Any allergic reaction with a history of severe allergy or prior anaphyllaxis Urgent: Mild systemic symptoms such as generalized hives, abdominal cramps or nausea, mild respiratory symptoms, facial or oral swelling Unresponsive to antihistamines or epinephrine if prescribed Non-Urgent: Localized allergic reaction Responsiveness to antihistamines

Allergic Reactions: Example Case: A 5 year old kindergartener with a history of peanut allergy is given a peanut butter cookie by a friend History Physical Triage

Fever/Communicable Diseases Emergent Signs/symptoms of infectious disease accompanied by any abnormalities of ABC s Purpuric rash or petechiae Altered mental status which persists with fever reduction Fever with meningismus Hyperthermia produced by external factors Urgent Fever Malaise Gastrointestinal symptoms Any sign of infectious illness in an immunocompromised or unvaccinated child Non-Urgent Sore throat without fever Minor URI symptoms GI symptoms without fever Mild cough without fever

Examples of Purpura and Petechiae

Heat-Related Injuries Emergent: (bullets 1-4 are consistent with HEAT STROKE) Hyperthermia (>104 F) Altered level of consciousness Hot/dry/red skin Altered vitals: fast thin pulse, fast shallow respirations Seizures Severe heat exhaustion Urgent Mild symptoms of heat exhaustion: no alteration of level of consciousness Mild fever if any Mild headache, weakness, dizziness Mild tachycardia, normal BP Signs of mild dehydration Non-Urgent Awake and alert Mild muscle cramping Mild fatigue Thirst Heat Exhaustion skin cool, moist, pale or red dilated pupils headache nausea/vomiting fatigue muscle cramps normal or low-grade fever

Lacerations and Tissue Avulsions Emergent: Absent distal pulse Crush wound Penetrating wound Significant blood loss Shock/diminished perfusion or cap refill Altered mental status Respiratory distress Amputation Urgent: Significantly dirty lacerations Facial lacerations Puncture wounds, especially of the shod foot Wounds which may require sutures Ongoing but controllable bleeding No emergent findings Non-Urgent: Superficial contusions or scrapes Small foreign bodies such as splinters

Amputation First-Aid Tend to the patient first remember the ABC s and stabilization of the victim Control bleeding Check for other injuries Activate EMS Preservation of the amputated body part is important: Gently cleanse with clean cool water Wrap in a damp cloth and seal in a plastic bag Store in cold water (ice water if possible); not on ice directly A room-temperature body part will not be useful after 4-6 hours

Avulsed Teeth Routine History/Physical/Triage is necessary Check for other trauma/wounds Handling Avulsed Teeth Avulsed primary teeth are never replaced Administer routine first aid such as cleansing and compression, pain control Avulsed permanent teeth should be treated as an emergency Handle the tooth by the crown only Rinse dirt or debris off the tooth, but do not scrub/rub it Attempt to replace the tooth in the socket gently and hold it there If unable to replace tooth, place it in milk or saline for transport. Do not wrap the tooth or allow it to dry The child should be taken to the ER or to the dentist s office immediately

Fractures Emergent: Open fracture Femoral fracture Any distal vascular compromise Shortness of breath or chest pain Amputation Severe deformity or angulation Urgent: Visible angulation Significant pain No emergent issues Non-urgent: Fracture clinically not apparent May be mild swelling Controllable pain Some use of limb/digit preserved No urgent or emergent characteristics

Fracture stabilization Treat for shock if present. If the person feels faint or is breathing in short, rapid breaths, lay the person down with the head slightly lower than the trunk and, if possible, elevate the legs. Activate 911. Clean open wounds gently and stop any bleeding. Apply pressure to the wound with a sterile bandage, a clean cloth or a clean piece of clothing. Immobilize the injured area. Don't try to realign the bone. Support and immobilize the area. Apply a splint if you know how. Do not tightly wrap as the area will swell. Apply ice packs to limit swelling and help relieve pain until emergency personnel arrive. Don't apply ice directly to the skin wrap the ice in a towel,

Thank You