Pediatric Office Emergencies

Pediatric Pathways

Pediatric Office Emergencies

After reading this article and answering the review questions the reader will be able to:

  1. Identify the most common pediatric emergencies seen in the outpatient setting.
  2. List the supplies necessary for common pediatric emergencies in this setting.
  3. Recognize the importance of written emergency protocols and regular mock codes in clinics.
  4. Identify the additional steps necessary for emergency preparedness for children with special needs

Case

You are working in your clinic one sunny summer afternoon when a 2-year-old girl, Madelyn, is brought in by her mother. Madelyn was playing at the park and stung by a bee and experienced an abrupt onset of hives. The mother tells the receptionist that en route to the office, the girl also developed swelling of her lips and face. She vomited once, and her breathing is somewhat labored.

The receptionist notifies the nurse of the girl’s condition and escorts the child and her mother to the office procedure room. The nurse recognizes that the child is experiencing an anaphylactic reaction, instructs the receptionist to call 911 immediately, and then retrieves you from another patient’s room for help.

When you arrive, you see a toddler who is clearly distressed. She is covered in hives, has significant angioedema of the lips, and is tachypneic with wheezing and deep retractions. The nurse goes in search of a pulse oximeter while you scramble to find an appropriately sized face mask and an oxygen canister. The medical assistant informs you that her vital signs are as follows: pulse 130, respiratory rate 55, temperature 99.0, blood pressure 85/62. Once the pulse oximeter is obtained, the oxygen saturation is noted to be 81% on room air. You place the child on oxygen and administer 1:1000 epinephrine IM. You also order an albuterol nebulizer treatment and a dose of IM benadryl, and ask the nurse to place an IV. At this point, the patient is starting to look better, and her oxygen saturation has increased to 92%. EMS arrives and you provide a brief summary of the patient’s course while in the office, including the interventions performed and vital signs. The receptionist provides the EMS team with a printed patient summary from the patient’s electronic medical record, and the patient is transported to the nearest hospital.

If this child had been brought to your office, would she have received the prompt medical attention she needed? Would the staff have noted her ill appearance and notified you immediately? Would your office have had the necessary emergency medications and equipment organized, up-to-date, and readily available? Would there have been a written protocol for pediatric anaphylaxis on-hand?

Overview

Children requiring urgent or emergent treatment often initially present to their primary care physician. According to the 2012 Periodic Survey #27 from the American Academy of Pediatrics (AAP), pediatricians see an average of about 2 patients per week who require emergency treatment.1

The most frequently encountered emergencies are respiratory in nature, most commonly severe asthma. Most pediatricians in the AAP study saw an average of eight patients with severe asthma and four patients with other causes of respiratory distress in the past year.1 Dehydration, seizures, and anaphylaxis are the next most commonly encountered emergencies. Rarer emergencies include respiratory failure, severe trauma, foreign body/obstructed airway, shock, meningitis, sepsis, and apnea.2

Given the high prevalence of outpatient pediatric emergencies, it is critical that offices are well-prepared. Adequate preparation requires stocking necessary equipment and medications, developing written emergency protocols, and ensuring that staff are properly trained.

Office Self-assessment

Outpatient offices should consider the kinds of emergencies that are most likely to occur in their patients, the response time of local EMS, and the distance to the nearest emergency department when deciding how best to prepare the office for medical emergencies. There are a number of medications and supplies that are listed as essential or strongly suggested to stock in outpatient offices in the 2007 AAP policy statement titled “Preparation for Emergencies in the Offices of Pediatricians and Pediatric Primary Care Providers.”3 As the majority of outpatient pediatric emergencies are respiratory in nature, it stands to reason that the bulk of the essential equipment listed is used to maintain the airway and to facilitate breathing. Some examples include: an oxygen-delivery system, bag-valve-masks, oxygen masks of various sizes, a suction device, a nebulizer, oral airways, and a pulse oximeter. There are also suggested items for use in obtaining vascular access as well as miscellaneous items, such as a Broselow tape, backboard, blood pressure machine, and a defibrillator. Equipment should be checked regularly to ensure that all items are present and functional. Essential medications include oxygen, albuterol, and 1:1000 epinephrine. Additional suggested medications include antibiotics, anticonvulsants, corticosteroids, and fluids. Medications should be checked on a regular basis to ensure that they have not expired.3

Office Training and Mock Codes

Each member of the office staff should be trained in basic life support, including cardiopulmonary resuscitation and defibrillator use. Worrisome signs and symptoms that are noted during telephone calls or at patient check-in should be quickly recognized by reception staff and immediately reported to a nurse or physician. Office staff should also keep a list of important information to be communicated to EMS by the phone, including age and condition of the child, current vital signs, type of emergency, interventions already performed, and specific driving directions to the office. Written protocols for the most common pediatric emergencies should be available, and roles on the response team should be clearly defined in advance (ie., which team member will call 911, record information, obtain vital signs, maintain the airway/provide oxygen, perform chest compressions, operate the AED, obtain vascular access, draw and administer medications, etc).4

Additionally, offices should practice working through scenarios of the most common outpatient pediatric emergencies. The AAP policy statement provides a list of sample scenarios for use in office-based mock codes, including diabetic ketoacidosis, sepsis, asthma, head trauma, seizures, stridor, and anaphylaxis.3

Children with Special Needs

Additional emergency preparation should be undertaken for children who have special healthcare needs. These children are more likely to have exacerbations of their underlying medical issues requiring emergency care, and clear and timely communication of their medical issues to health care providers is critical. The AAP has created a standardized form for primary care providers to maintain for each child in the practice with special needs. The form provides demographic information, names and contact information of each physician involved in the patient’s care, a listing of diagnoses and baseline physical exam findings, allergies, immunizations, and common presenting problems with corresponding suggested management plans for each. These forms should be reviewed with the child’s parents, and copies should be available at home, at school, in the car, and anywhere the child spends considerable time. Parents should be instructed to give the form to EMS providers, emergency room staff, and each provider involved in the child’s care. The form should be kept on file at the primary care provider’s office and updated on a regular basis.5

Conclusion

There are many demands placed on physicians and staff in outpatient offices, and these seem to be increasing every day. It can be difficult to prioritize preparation for office emergencies. However, basic preparation is fairly easy to implement and is worth the effort if it leads to a better outcome for just one young patient in your practice. Think back to the little 2-year-old girl with anaphylaxis—if she comes into your office tomorrow, are you ready for her?

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CME Questions

References and Resources

  1. American Academy of Pediatrics Committee on Pediatric Emergency Medicine. Periodic survey #27 emergency readiness of pediatric offices. Available at http://www.aap.org/en-us/professional-resources/Research/Pages/PS27_Executive_Summary_EmergencyReadinessofPediatricOffices.aspx. Accessed February 17, 2014.
  2. Santillanes G, Gausche-Hill M, Sosa B. Preparedness of selected pediatric offices to respond to critical emergencies in children. Pediatr Emerg Care. 2006;22:694-698.
  3. 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.
  4. Fuchs, S. Pediatric office emergencies. Pediatr Clin N Am. 2013;60;1153-1161.
  5. American Academy of Pediatrics Committee on Pediatric Emergency Medicine. Emergency preparedness for children with special health care needs. Pediatrics. 1999;104;4;e53.

Additional Resources

American Academy of Pediatrics, Committee on Pediatric Emergency Medicine. 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.