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.

1. EMERGENCIES MANAGEMENT IN OFFICE
PRACTICE
Dr. Puja Dhupar
MD DNB
BALGOPAL CHILDREN HOSPITAL

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?

11. Pediatric Assessment Triangle
A P P E A R A N C E

12. Pediatric Assessment Triangle
B R E A T H I N G

13. 
Pediatric Assessment Triangle
A P P E A R A N C E W O R K O F
C I R C U L A T I O N
BREATHING

14. How
sick?
How
quick?

15. Triangle: Respiratory
Distress

Normal
Appearance
Increased
Work of Breathing
MEANS RESPIRATORY DISTRESS

16. Triangle:
Respiratory Failure
 Abnormal
Appearance
Increased or
Decreased Work
of Breathing
MEANS RESPIRATORY FAILURE

17. Triangle: Shock
Abnormal
Appearance
Poor Circulation to Skin
MEANS SHOCK

18. Triangle:
Poor Circulation to Skin
Normal
Appearance
M E A N S O B S E R V E

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

23. COMMON PEDIATRIC
OFFICE
EMERGENCIES

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

25. Causes of Anaphylaxis
 Food allergy eg peanuts,egg white,seafood,soya,food
additives
 Medications
(penicillin,NSAIDS,cephalosporins,quinolones,sreptom
ycin,iron dextran)
 Insect stings,tick bites
 Biological products( vaccines ,antisera,blood products)
 Contrast medias
 Idiopathic

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

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)

37. RESPIRATORY EMERGENCIES -
AIRWAY OBSTRUCTION MOST COMMON
FOLLOWED BY PARENCHYMAL AND PLEURAL

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

43. Croup Management
Mild
Moderate
Severe

44. Mild Croup
Symptomatic treatment +/- single
dose of oral steroids
 Parental education on symptoms
and signs of worsening even at
night

45. Moderate Croup
Steroids
Nebulised adrenaline
Close monitoring

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.

55. NEUROLOGICAL EMERGENCIES
FEBRILE SEIZURES AND STATUS
EPILEPTICUS

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

65. The most common mechanism
is a fall on an outstretched
hand.
On examination forearm is
held pronated,with partial
flexion at elbow

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.

72. Be Prepared Everyday With
MEDICATIONS
TRAINED STAFF EQUIPMENT
MET

73. Location of Equipment
All drugs
should be kept
in emergency
equipment
container and
expiry
checked
regularly

74. EMS

75. T
H
A
N
K
S