The Quarterly Consult is a quarterly supplement to the Bulletin highlighting pediatric clinical expertise. If you have an item of interest to include in the Quarterly Consult, contact Dr. Steve Dassel at 206-625-7373, mailbox 8588.
By Steve Dassel, MD
I spoke with Dr. Russ Migita, clinical director of the Emergency Department (ED) at Seattle Children's Hospital and assistant professor of pediatrics at the University of Washington (UW) School of Medicine. Russ received his undergraduate degree from Stanford University and his medical degree from the University of California San Diego. He did his pediatric residency at the UW and Seattle Children's, followed by a stint as a night float in the ED and a fellowship in emergency medicine at Children's and the UW.
Q: Let's start with respiratory emergencies. How can we detect impending respiratory failure early on?
A: You should be very aware of the possibility of respiratory failure in a patient with asthma, bronchiolitis or any other obstructive airway problem. In an infant with bronchiolitis, for example, look for a drop in respiratory rate from the 70s to the 30s. This is more reliable as an assessment tool than oxygen saturation, which has good sensitivity but poor specificity. In infants, watch for progressive apnea, both in duration of each apneic episode and shortening periods between episodes. Older asthmatics can decompensate relatively quickly. Red flags in these patients include a drop in respiratory rate or decreased alertness. Clinical progression is more useful than blood gases, in my opinion.
Q: What other signs should we follow?
A: Keep an eye on perfusion as assessed by a good capillary refill (less than two to three seconds) and the absence of a thready pulse.
Q: What can you share about management?
A: The mainstay is oxygen for all practical purposes. For the primary care provider (PCP), there is no contraindication to giving oxygen. When taking care of patients with respiratory failure, the most important airway management skill for PCPs is bag-mask ventilation.
Q: How would you judge sufficient stability for transport?
A: Make sure you have good control of oxygenation and ventilation by attending to the airway, breathing and cardiac output.
Q: What are our options for transport and how do we activate them?
A: In the more severe cases you should call 911. The fire department can help you stabilize your patient for transport and help you decide what kind of transport is indicated. Depending upon your distance from the receiving hospital, Airlift Northwest may be most appropriate. Obviously, using Airlift Northwest would necessitate coordination with the local fire department for transportation to your nearest landing site. Airlift Northwest's phone number is 800-426-2430.
Q: After the patient is ready for transport, who do we call at Children's?
A: Call 206-987-8899. It's a 24-hour number managed by senior Emergency Department nurses. They will ask you for the information we need to be ready for your incoming patient. If we need to coordinate with other services or departments at Children's, they can help with that as well.
Q: Let's move on to shock, starting with hypovolemic shock. How should we assess this situation?
A: I always come back to the ABCs of basic life support: airway, breathing, cardiac. Primary care physicians who deal with both adults and children should remember that children can be in shock without being hypotensive. Younger patients with good vascular tone and strong hearts are able to maintain their blood pressure in the face of hypovolemia. Recognition of the early stages of shock, such as delayed capillary refill, tachycardia, and weak peripheral pulses, is key to prevent progression to decompensated shock. Late signs of shock include signs of decreased end organ perfusion, such as altered mental status. Parents can be very helpful assessing mental status. Keep an eye out for tachycardia and possibly tachypnea. Overall, the most specific markers of dehydration include delayed capillary refill, dry mucous membranes, absence of tears, and general appearance.
Q: How should we manage the infant or child with fluid loss from the vomiting and diarrhea of acute gastroenteritis?
A: If vomiting can be controlled, oral rehydration is just as effective and timely as IV rehydration. We use volumes of 5 to 15 ml every five minutes and titrate up from there. Pedialyte or the World Health Organization's (WHO) oral hydration solution are preferred, but sport drinks are acceptable if children won't take electrolyte solutions with higher potassium and lower sugar content.
Q: And if the child is vomiting?
A: Our approach has changed over the past few years as studies have shown the efficacy and safety of some antiemetics. Promethazine (Phenergan) is contraindicated in young children, but the H3 blocker ondansetron (Zofran) has a very wide therapeutic window and the only contraindication is for children with migraines. We use a single 4 mg oral dissolving tablet for patients older than 12 months. For infants, the dosage of the liquid solution is 0.1 mg/kg. We restrict antiemetic use if a patient continues vomiting despite taking only small amounts of clear liquids. While antiemetics decrease the need for IV hydration, they don't eliminate the possibility of needing later follow-up.
Q: How should we manage anaphylactic shock in the primary care office?
A: Fluid and epinephrine are the mainstays. The dose of epinephrine is 0.01 mg/kg, either subcutaneously or intramuscularly. Intramuscular would be preferred, especially in the kid with poor perfusion.
Q: And septic shock?
A: Here, the key is early recognition. First of all, the setting, i.e., the febrile child, and then, the state - altered perfusion. There are two keystones of management: early and aggressive IV hydration using as much as 60 to 100 ml fluid per kg and early administration of antibiotics. We suggest ceftriaxone 75 mg/kg IM or IV. In a septic child, I would rather deal with the inconvenience of compromised cultures when the child gets to the ED than have a PCP delay antibiotics.
Q: So, this would be the reason for keeping our IV access skills sharp?
A: Perhaps, but in a code situation, don't forget the intraosseous route. This is an excellent route for administering fluid and medications and is certainly easier, especially in the patient with vascular collapse. Also, if you are really worried about a child, don't forget your local emergency medical services (EMS).
Q: How can we attain and keep these skills?
A: Pediatric Advanced Life Support (PALS) courses at Children's Hospital teach access.
Q: Let's move on to central nervous system (CNS) emergencies and start with altered mental status.
A: In children, the most likely etiologies are respiratory failure and decreased CNS perfusion from hypovolemia. Also, don't forget to consider hypoglycemia, ingestion or CNS infections. As many primary care physicians know, lethargy is a pretty common presenting complaint. I think that most PCPs are very good at distinguishing kids who are depressed in a worrisome way from those who just don't feel well.
Q: What about management of emergencies associated with coma?
A: In addition to the ABCs, I would add glucose. In the office, it's important to have the ability to both test for and treat hypoglycemia. I also think it's reasonable to have ceftriaxone on hand, in case you're dealing with sepsis or a CNS emergency. When you're taking your history, always ask about the possibility of ingestion. Sometimes, with caregivers, you have to be specific and remember to consider any pills that might belong to another family member. In coma, the most lethal drugs are tricyclic antidepressants and calcium channel blockers.
Q: What are your thoughts on seizure management in the primary care office?
A: Again, I'd say oxygen and assessment of the ABCs. Perhaps suction, but that is not as important. You should not put anything in the child's mouth. Before I begin seizure medications, I watch for a few minutes.
Q: As Dr. Robby Robertson says, sometimes it is best if you "don't just do something, stand there."
A: Right. Watch for a pattern, see whether it is localized, and then, whether it is progressive. See whether it is tonic, or tonic and then clonic, and take note of eye deviation - although I don't consider that to be as helpful. In most cases the seizure will stop on its own and you will not have to use antiseizure medications.
Q: What antiseizure medication do you prefer?
A: In a primary care clinic, I prefer rectal diazepam. It has a very complex dosing schedule based upon patient's age and weight. I think it can be simplified: The smallest infants should receive 2.5 mg; toddlers 5 mg; school-age kids should receive 10 mg. It takes 10 to 15 minutes to work, so I would administer it and then send the patient off to the ED by ambulance.
Q: Let's construct a drug and equipment list for primary care providers. Drugs: oxygen, oral rehydrating solutions such as Pedialyte, WHO's oral hydrating solution and perhaps sports drinks, ondansetron, epinephrine, ceftriaxone, glucose and finally rectal diazepam. Equipment: self-filling bag and mask, IV/intraosseous fluid and administration set (if possible) and suction. Do we need anything else?
A: Although it is fairly expensive, you might consider an automated external defibrillator (AED).
Q: How often should primary care physicians' offices have drills on using our "crash carts," and what kind of drills should we have?
A: The important thing is for staff to get comfortable in a code situation. Ideally, office staff should be practiced enough that they don't have to think too much when faced with a code. Most importantly, staff should know where drugs and equipment are and how to use them. Frequent drills will lead to a smoother operation; the more the better. If I were to have staff trained in any one thing, it would be providing good basic life support - chest compressions and bag-mask ventilation.
Q: What common mistakes do you see primary care doctors make when handling office emergencies or transport?
A: The biggest potential mistake is sending the patient away too soon. I think primary care doctors underestimate their own capabilities to provide stabilizing care. A patient who may be critically ill is much safer in your office than in the back of a parent's car. Don't forget to utilize your EMS resources. Finally, remind caregivers to keep their children NPO (nothing by mouth) if seriously ill or if you anticipate that they may require sedation, surgery, or contrast CT scans.