Pediatric Office Emergencies

Michael Ushay, M.D., Ph.D.

(presented at the CAMS 2002 Annual Scientific Meeting)

 Any emergency you’ve anticipated is not as bad as one you haven’t!

             Some pediatric practices average at least one emergency per month (1).  In a study of 52 pediatric offices, 24 emergencies occurred per practice per year (2). A 1995 AAP survey found pediatricians see an average of 2.1 patients per week who required emergency treatment or hospitalization (3).  From an intensivist’s perspective, pediatric patients with severe illness progressively destabilize until an intervention, even if not the definitive one, is made.  A small intervention at the right time may prevent further destabilization and make dealing with the patient easier.

             Questions an office-based pediatrician should ask with respect to potential emergencies include: Do I have a plan? Are I and my staff trained? Do I have the necessary equipment? Do I have emergency medications? Do I know how to activate the EMS/ transport system and what capabilities do they have? Where do I want my patient to go to get a definitive intervention?  Illnesses to prepare for include respiratory distress, seizures, sepsis, meningitis, shock from severe dehydration, anaphylaxis, croup, airway obstruction and trauma.  Sources of information include Pediatric Advanced Life Support (PALS) and Advanced Pediatric Life Support (APLS). The APLS course includes a module on office emergencies. Information specific to office emergencies includes the AAP Committee on Pediatric Emergency Medicine report “Childhood emergencies in the office, hospital, and community” (4).  WWW based resources include the Office preparedness for pediatric emergencies provider manual published on the WWW by the North Carolina Office of EMS and “Preparing your office for pediatric emergencies” by K. Tegtmeyer, M.D. found at www.peds.umn.edu/divisions/pccm/teaching/acp/officeprep.html.  Recent articles on office preparedness for pediatric emergencies (5) and equipping your office for medical emergencies (6) have been published.  Lists of appropriate emergency equipment can be found in the latter article. The expense of purchasing equipment, the necessity for checking it regularly, familiarity with infrequently used equipment and skills, and expiration of emergency drugs are all relevant issues.

             Bronchiolitis, asthma, and pneumonia are common causes for respiratory distress and, consequently, office emergencies. Basic equipment and supplies to consider for respiratory emergencies include oxygen, flow meter, tubing, facemasks or nasal cannulae in various sizes, auto inflating bag-valve-mask with different size masks, and a portable or oxygen powered nebulizer with albuterol solution. More advanced equipment to consider would be a suction device, suction tubing with catheters including Yankauer tips, pulse oximeter, and if skills and interest so indicate, equipment for intubation including a laryngoscope with multiple blade sizes and various sized endotracheal tubes ranging from 3.5 to 6.0 sizes with stylets. Anatomic and physiologic aspects of infants and children that make them especially prone to respiratory distress include a large, easily posteriorally displaced tongue, a compliant trachea which is narrowest in the subglottic space, a compliant rib cage which makes a child’s breathing more diaphragm dependent, collapse of small airways at functional residual capacity of the lung, and a relatively high oxygen consumption. Tachypnea, retractions, flaring, grunting, stridor and lack of auscultatable air movement may foreshadow respiratory failure. Oxygen should be the first intervention in a child with respiratory distress. Nasal cannula oxygen at 2 LPM can yield a FiO2 > 0.5. Oral and nasal pharyngeal airways can be extremely helpful in a patient with airway obstruction related to obtundation such as one might see in a head injured or post ictal child. Bag-valve-mask ventilation is an important skill for all physicians and requires hands-on practice with regular review and reinforcement of skills. The Pediatric Advanced Life Support curriculum places a heavy emphasis on this skill and the current manual provides good instructional material. Proper positioning to maximize airway patency includes placing the patient in a sniffing position with a roll under the shoulders of an infant and beneath the head of an older child.

             Skill in managing tracheostomy emergencies could be lifesaving in the growing numbers of special needs patients that are being seen in pediatric practices. Familiarity with types and sizes of tracheostomy tubes as well as knowing how to suction and change tubes is important. Removing an obstructed tube is preferable to leaving the patient with a blocked airway.

             As well as the judicious management of seizures in the office, one must be prepared for apnea and airway obstruction in the post ictal patient treated with lorazepam or diazepam in this extremely common childhood emergency.  Obtunded post ictal patient or similarly, head injured patients at the scene of an accident, are at extremely high risk of secondary hypoxic insult related to upper airway obstruction. Relieving airway obstruction by means of jaw thrust or head tilt with chin lift can be instrumental in preventing a significant secondary insult to the patient’s brain.

             In the patient with shock due to hypovolemia or sepsis or a combination of these, early volume repletion with parenteral fluids given by the intraosseous (IO) route if necessary can make the definitive management in the hospital easier. In possible sepsis or meningitis, early administration of an antibiotic such as ceftriaxone at 100 mg/kg by the IV/IO/IM routes can be extremely helpful. Early antibiotic, volume and appropriate support of airway will make the PICU course and ultimate outcome better.

             The office-based practitioner should be familiar with the resources and capabilities of their local EMS system.  In NYC, the combined response of FDNY and FDNY EMS to a severe emergency is both rapid and robust. Pediatric capability in the EMS system is not yet on par with that for adults but is increasing rapidly.

             Finally, the recent widespread implementation of automatic external defibrillators (AED) in public places as well as in schools and at athletic competitions demands that we as health care providers gain some knowledge into this technology. The FDA has approved the Phillips Heartstream FR2 AED with pediatric pads for use in children < 8 years old.  The widespread prevalence of AEDS coincides with a recent change in AHA PALS philosophy stating that potentially lethal arrhythmias such as ventricular fibrillation may not be as rare in children as once commonly believed.

 References cited:

1.  Heath BW, Coffey JS, Malone P, et al. Pediatric office emergencies and emergency preparedness in a small rural state. Pediatrics 2000;106:1391.

2.  Flores G, Weinstock D. The preparedness of pediatricians for emergencies in the office. Arch Pediatr Adolesc Med 1996;150:249.

 3.  American Academy of Pediatrics. Periodic Survey 27. Elk Grove Village, IL, American Academy of Pediatrics, 1995.

 4.  Seidel JS, Knapp JF (eds). Childhood emergencies in the office, hospital, and community: Organizing systems of care. Elk Grove Village, IL, American Academy of Pediatrics, 2000.

 5.  Toback S. Prepare your office for a medical emergency. Contemporary Pediatrics 2002;19:107-121.

6.      Schuman AJ. Be prepared: equipping your office for medical emergencies. Contemporary Pediatrics 1996;13:27.

 Dr. Ushay is Associate Professor of Clinical Pediatrics, Weill Medical College of Cornell University