This document discusses managing emergencies in a pediatric office setting. It emphasizes the importance of early recognition and stabilization of emergencies before timely transfer to a facility that can provide definitive care. Common office emergencies like anaphylaxis, croup, and seizures are reviewed. For anaphylaxis, early epinephrine administration is critical. Croup is treated with steroids and nebulized adrenaline as needed. Febrile seizures are commonly seen and status epilepticus requires lorazepam or midazolam to control seizures.
2. Office of paediatric primary care
provider often entry site to emergency
care system
Capabilities and limitations in office
practice
Early recognition and stabilisation of
emergencies in office
Timely transfer to appropriate facility for
definitive care
3. Common views
EMERGENCIES ARE NOT VERY
COMMON.
WILL INCREASE LIABILITY.
EXPENSIVE.
TIME CONSUMING.
REQUIRES TRAINING.
4. Standardised office based self assessment
What emergencies have you experienced?
How often?
Resources outside your office available
Emergency readiness training of OPD staff
How far is your office from nearest ED?
Do you practice children with special
health care needs?
5. Good Resuscitation Knowledge And Skills Are
Essential For Best Chances Of Survival
First Person To Assess Patient Is Often Least
Clinically Experienced Receptionist
Teach Them Symptoms And Signs Of Emergency
Periodically Check Waiting Area
Pediatric Office Based Protocols For 5-10 Top
Emergency Conditions
6. RECEPTION DESK EMERGENCY CARD
THE FOLLOWING SIGNS AND SYMPTOMS MAY SIGNAL
AN EMERGENCY:
Laboured Breathing
Blue Or Pale Colour (Cyanosis)
Noisy Breathing (Wheezing Or Stridor)
Altered Mental Status
Seizure
Agitation (In The Parent)
Vomiting After A Head Injury
Uncontrolled Bleeding
7. Aims of Assessment
LIFE THREATENING
Not Life
Threatening
Potentially Life
Threatening
8. Initial Assessment
Begins Before You
Touch The Patient
Form A General
Impression.
Determine A Chief
Complaint.
The Pediatric
Assessment Triangle
Can Help.
9. EQUIPMENT FOR ASSESSMENT
LOOK
Behaviour
Interactivity
Consolability
Tone
&Posture
LISTEN
Cry
Resp
sounds
Speech
mother
FEEL
Pulses
Skin
extremiti
es
MEASURE
Temp
Pulse
oximeter
Capillary
glucose
10. Key Question
What are the elements of
the assessment that are
most useful?
19. Triangle:
Brain Dysfunction
Abnormal
Appearance
Normal Work
of Breathing
Normal Circulation to Skin
MEANS BRAIN DYSFUNCTION
20. Key Points
1. The Triangle is a “quick look” of overall
severity and urgency of treatment.
2. primary survey in a rapid ordered,
stepwise evaluation of cardiopulmonary
and neurologic function to prioritize
treatment.
3. Begin resuscitation immediately when
you identify a life-threatening problem in
the primary survey.
21. Vital Signs by Age
Age Respirations
(breaths/mi)
Pulse
(beats/min)
Systolic
Blood
Pressure
(mm Hg)
Newborn: 0 to 1 mo 30 to 60 90 to 180 50 to 70
Infant: 1 mo to 1 yr 25 to 50 100 to 160 70 to 95
Toddler: 1 to 3 yr 20 to 30 90 to 150 80 to 100
Preschool age: 3 to 6 yr 20 to 25 80 to 140 80 to 100
School age: 6 to 12 yr 15 to 20 70 to 120 80 to 110
Adolescent: 12 to 18 yr 12 to 16 60 to 100 90 to 110
Older than 18 yr 12 to 20 60 to 100 90 to 140
22. Key values in practice
Pulse > 220/min consider SVT
Cap refill > 2 seconds is not normal
BP in kids > 1 year = 70 + (2 x age)
RR > 60/min NB, > 50/min till 1yr, > 40 /min till 5
yrs
PULSE OXIMETRY<92 In room air
CAPILLARY BLOOD SUGAR <60
24. ANAPHYLAXIS
An acute clinical syndrome caused by exposure
to a foreign substance to which patient has been
previously sensitised
Fatal food reactions cause respiratory arrest after
30-35 min
Insect stings cause collapse from shock in
10-15 min
Death after parenteral medication occur within
5 min
26. C R I T E R I A
1. Acute onset of an illness (minutes to several
hours) with involvement of the skin, mucosal
tissue, or both (eg, generalized hives, pruritus or
flushing, swollen lips-tongue-uvula)
AND AT LEAST ONE OF THE FOLLOWING
A. Respiratory compromise (eg, dyspnea, wheeze-bronchospasm,
stridor, hypoxemia)
B. Reduced BP* or associated symptoms of end-organ
dysfunction (eg, hypotonia, collapse,
syncope, incontinence)
27. ALLERGIC REACTIONS AND
ANAPHYLAXIS
Mild Moderate Severe
(anaphylaxis)
Hives,rash
No respiratory distress
Hives,rash
Abdominal cramping
Swelling of mucous
membrane
Normotensive
Mild bronchospasm
Altered mental status
Angioedema
Abdominal cramping
Hypoperfusion
Respiratory distress-grunting,
flaring,stridor,
bronchospasm
28. DIAGNOSING ANAPHYLAXIS
Diagnosis based on clinical presentation and
exposure history
Flushing and tachycardia invariably present other
cutaneous symptoms hives and itch may be absent
Very rarely may present only with profound
hypotension
Exposure to some inciting agent is one key to
diagnose in such rare cicumstances
29.
30.
31. Anaphylaxis:
Causes of Death
Upper and / or Lower Airway
Obstruction (70%)
Cardiac Dysfunction (24%)
32. Treatment
Mild Moderate
Consider benadryl
Oxygen
1mg/kg
Max 50mg
Benadryl
Epinephrine SC(1:1000) .,01ml/kg,
Max 0.3 ml
Resp symptoms salbutamol
nebulisation 2.5mg/3ml NS may repeat
if no improvement
33. GENERAL MANAGEMENT OF
ANAPHYLAXIS
Airway
Breathing
Circulation
But use epinephrine promptly
34. Prehospital care
Advise patient with airway obstruction or resp
distress position of airway comfort.
If feeling faint,unable to sit stand,make him in
trendelberg position.
Hypotensive pts could rapidly go into cardiac
arrest if they remain upright.
35. Epinephrine (adrenaline) is first line
treatment.
Epinephrine preferably given IM
Antihistamines & bronchodilators are not
first line treatment but may be given after
epinephrine.
Transportation to hospital should not be
delayed to administer these once
epinephrine has been given.
36. Management of anaphylaxis
Epinephrine 0.01ml/kg (1:1000)IM X3, every
5-20min as needed.
Subcutaneous or inhaled routes not recommended
If child is in shock administer IV adrenaline
0.1ml/kg(1:10000)
along with volume expansion
If there is significant wheezing nebulise with salbutamol
H1 antagonists eg Diphenhydramine (Benadryl) 25-100mg
Corticosteroids hydrocortisone (5-10mg/kg)
38. General approach
Do not separate child from mother
Avoid changing position of comfort which
child has adopted
Help mother to administer oxygen in a non
threatening manner
Perform rapidly cardiopulmonary cerebral
assessment
39. Triage Of These Children Will Depend
On -
The severity of obstruction
The cause of obstruction which will
give a clue to the rate of narrowing
40. Cause Of Obstruction
Where the rate of narrowing is likely to be
rapid or critical do not attempt to visualize the
throat
Rapid narrowing can be seen in anaphylaxis,
foreign body aspiration, burns involving the
airway, epiglottitis
Critical narrowing can be suspected when
there is extreme dyspnoea, diaphoresis or
significant retractions esp suprasternal
41. How do you Grade Severity of
Obstruction
Mild Moderate Severe
General
Appearan
ce
Happy
Feeds well
Interested in
surroundings
Fussy, but interactive
Comforted by parents
Restless
Agitated
Altered sensorium
Stridor Stridor on coughing &
crying
No stridor at rest
Stridor at rest
Worsening with agitation
Stridor at rest
Worsening with
agitation
Respirato
ry
Distress
No distress Tachypnea
Tachycardia & Chest
retractions
Marked tachypnea
Tachycardia with
retractions
Saturatio
n
> 92% in room air > 92% in room air < 92% in room air
MILD - No stridor at rest and able to maintain saturation
MODERATE -Stridor at rest, worsens on agitation but able to maintain
oxygenation
SEVERE - Severe stridor, altered mentation and failing to maintain
oxygenation
42. CROUP(ALTB)
Presents with history of prodromal URI followed by
barking cough,hoarse voice stridor and mild fever
Age 6-36 mths, commonly seen in early winter
Etiology parainfluenza type 1,3
RSV,adenovirus,influenza A
In all cases of stridor always rule out epiglottitis
where there is toxic appearance,high fever and
sudden onset of symptoms
46. Steroids in Croup
Best option is dexamethasone
0.6 mg/kg oral, iv, im
Oral prednisolone - 2 mg/kg
In children who cannot take oral
medications a single dose of budesonide
nebulised 2 mg
47. Adrenaline in Croup
Dose is 0.5 ml/kg upto a maximum of 5 ml
of a 1:1000 dilution
Can be repeated every 20-30 minutes for a
maximum of 3 nebulisations
Even if croup responds well, observe for
at least 2 hours
48. Treatment of Severe Croup
Oxygen
Rapid transfer
Steroids
Nebulize adrenaline as frequently as
needed
Intubate if airway obstruction / work of
breathing is worsening
Use a tube half size smaller than optimal
49. Foreign body
Sudden attack of respiratory symptoms
such as cough, choking gagging
,cyanosis in a previously normal child
Positive history must never be ignored
while a negative history may be
misleading
50. Removing a Foreign Body Airway Obstruction
DEPENDS ON AGE
OVER >1YR HEIMLICH MANEUVER
UNDER < 1YR BACK BLOWS
FOLLOWED BY CHEST THRUSTS
51. Removing a Foreign Body Airway Obstruction
In a conscious child:
Kneel behind the
child.
Give the child five
abdominal thrusts.
Repeat the
technique until
object comes out.
52. Removing a Foreign Body Airway
Obstruction
If the child becomes unconscious,
inspect the airway.
Attempt rescue breathing.
If airway remains obstructed, begin
CPR.
53. Management of Airway
Obstruction in Infants
Hold the infant facedown.
Deliver five back slaps.
Bring infant upright on the
thigh.
Give five quick chest
thrusts.
Check airway.
Repeat cycle as often as
necessary.
56. Useful History for Child with Seizure
Does s/he have a fever?
Does s/he have a seizure disorder?
If yes, is s/he on anti-seizure medications?
If yes, is s/he taking them, or any recent
changes?
Any trauma?
Any medicines s/he had access to?
How was s/he before the seizure started?
Is s/he developmentally normal?
Family h/o epilepsy/febrile seizures
57. Treatment
Control Seizure
IV lorazepam 0.05mg/kg* or
IV midazolam 0.2mg/kg intranasal
(if immediate IV access is difficult)
4 puffs / 10 kg
* lorazepam loses potency at room temperature and needs to be refrigerated
Treat The Source Of Fever
58. If No IV Access…..
Lorazepam 0.1 mg/kg IM
Diazepam 0.5 mg/kg PR
Midazolam 0.5 mg/kg IM
0.2 mg/kg
Intranasal/buccal
0.15 mg/kg PR
59. Diagnosis of Status Epilepticus
Monitoring and control of vital
parameters:
Airway Breathing Circulation
Glucose,
Start O2, secure IV access
Lorazepam: 0.05- 0.1 mg/kg i.v.
Seizures Continuing?
Phenytoin (20 mg/kg i.v. at 1 mg/kg/min) or
Fosphenytoin (20 mg/kg at 3mg/kg/min)
Attention:
rhythm problems and falling blood pressure
If seizures continuing, treat as
refractory status
Make
arrangements
for early
transfer
ilae-epilepsy.org
60. ZIPPER ENTRAPMENT
INJURY
Most common genital injuries in
prepubertal boys.
Typically involve the foreskin or
redundant penile skin and may occur
during the zipping or unzipping process
61. Zipper Injury: Treatment
The procedure for entrapment release
depends upon the site of entrapment
within the zipper.
Entrapment of penile skin between the
zipper teeth (and not the zipper
mechanism)
Release by cutting across the zipper
62. ENTRAPMENT IN ZIPPER MECHANISM
Recommended technique:
The median bar may be cut with wire cutters, bone
cutters, or a mini hacksaw
Allows the mechanism to fall apart and leads to release
of the entrapped skin
Alternate technique:
Thin blade of a small flathead screwdriver
Placed between the faceplates on the side of the
mechanism in which the penile skin is not entrapped.
The blade is then rotated toward the median bar
This widens the gap between the faceplates, releasing
the skin
63.
64.
65. The most common mechanism
is a fall on an outstretched
hand.
On examination forearm is
held pronated,with partial
flexion at elbow
66.
67. PROCEDURE
DOESNOT REQUIRE SEDATION OR ANALGESIA
RADIOGRAPHY NOT NEEDED TO CONFIRM
DIAGNOSIS
GRASP CHILDS HAND IN HAND SHAKING
GESTURE AND RAPIDLY ROTATE EXTERNALLY
AND FLEXED SIMULTANEOUSLY
PALPABLE CLICK ,POP FOLLOWED BY CRY
RETURN TO NORMAL MOVEMENT IN 5-15 MIN
68. REMOVAL OF A NASAL FOREIGN
BODY
1. Nasal foreign bodies are most common
in 2-3-year-olds and common
foreign bodies include toy parts,
beads, insects, paper, and food items
.
2. Symptoms depend on how long the
object has been lodged in the nasal
passages.
69. B. PROCEDURE
1. Positive Pressure Techniques: with use of either
mouth-to-mouth by parent,
or with AMBU bag and
mask applied to mouth of
child, occlude the opposite
nostril and give a gentle,
positive-pressure breath to
expel the object.
70. 2 Instrumental Removal:
1.The child should be lying down and restrained.
2. Visualize the interior of the nose with a nasal
speculum.
3. Extract the object with suction, a hook, or
alligator forceps.
4. Do not push the foreign body into the
posterior nasopharynx
5. After the foreign body has been removed, ora
antimicrobial agents may be used in an effort
to
prevent an infection in the traumatized area.