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COVER ARTICLE/CME Urgent Care 2(7):16, 2007 Urgent care clinics don’t handle many pediatric emergencies, but you never know when one will come through your door. Will you be ready? This article will help you prepare for the unexpected. Which patient would you rather treat: a 62-year-old with acute coronary symptoms or a two-year-old with severe respiratory distress? If you chose the 62-year-old, you’ve got plenty of company. Most urgent care practitioners and their staffs feel anxious about treating pediatric emergencies because they aren’t that common in urgent care settings. Studies show that the typical pediatric or family practice office sees between 1 and 30 pediatric emergencies a year. The incidence is probably similar in urgent care clinics, although no data are available. The wide variation no doubt stems from different definitions of “emergency” being used in each report, as well as recall and selection bias. We can’t predict when a parent will rush through our door with an acutely ill or injured child, but we can prepare for the unexpected and give the best care possible. This article covers common types of pediatric emergencies, medications and equipment used to treat them, preparation for such emergencies in an urgent care setting, and current guidelines on pediatric emergency preparedness. KEY QUESTIONS In 2005, the American Academy of Pediatrics (AAP) published a policy statement, “Pediatric Care Recommendations for Freestanding Urgent Care Facilities,” that outlined a list of general recommendations regarding pediatric emergency preparedness (see table below). Most of the suggestions are practical and easy to carry out in a busy urgent care center. Others require more planning but are still excellent goals to strive for.
The AAP has also published a detailed list of medications and equipment to have on hand for pediatric emergencies (see table below). Acquiring these supplies is essential, but before ordering them, ask yourself these key questions: What pediatric emergencies do you expect to see? How available and skilled are the local emergency medical services (EMS)? How far from the office is the nearest hospital emergency How skilled are your urgent care practitioners and office staff in handling pediatric emergencies? Let’s consider each of these questions in turn. Expected pediatric emergencies. The most common pediatric emergencies seen in the primary care setting are listed in the box below. As you might expect, most of these conditions are respiratory in nature, followed by problems of the upper airway and circulatory system. Keep these conditions in mind when choosing medications, equipment, and additional emergency supplies.
EMS availability. Base your choice of medications and equipment on the availability and skill level of EMS providers in your area. In rural settings, urgent care practitioners may have to do more than stabilize a critically ill child before transfer; they may have to conduct prolonged resuscitation until the paramedics arrive and then give them advice on how to care for the patient en route to the emergency department. In addition to the medications and equipment listed in the table below, rural facilities should at the very least consider purchasing a cardiac monitor and should have sodium bicarbonate, intravenous fluids, and other resuscitation equipment that are useful during prolonged emergency care. The AAP guidelines recommended additional equipment for any clinic whose EMS arrival time is longer than 10 minutes.
Distance to the emergency department. The distance between the urgent care facility and the nearest hospital emergency department is another major concern for rural clinics. Due to increased transport time, urgent care physicians may need to provide additional treatment before the patient departs with the paramedics. The AAP suggests a more extensive equipment and medication list for clinics located more than 20 minutes from an emergency department. On the other hand, the proximity of a clinic to a hospital shouldn’t be an excuse for complacency when it comes to purchasing emergency equipment. It’s well established that early treatment of pediatric cardiopulmonary distress greatly increases the chance of a more favorable outcome. Skill level of practitioners and other staff. Most important, the decision on how to equip your urgent care clinic should depend on your practitioners’ skills. For medical and legal reasons, no facility should stock equipment that can’t be used safely by office personnel. Practitioners who do not feel confident in their ability to perform pediatric endotracheal intubation may elect not to store a laryngoscope in their facility. However, they should still make an effort to remain proficient in bag-valve-mask (BVM) ventilation. Although recommendations for pediatric emergency equipment and medications vary in the medical literature, the current standard for urgent care centers is the recommendations published by the AAP. Expanded recommendations for clinics with more than a 10-minute EMS response time or those located more than 20 minutes from an emergency department can be found in a joint publication from the AAP and the American College of Emergency Physicians, which is included in the Suggested Reading list at the end of this article. EMERGENCY MEDICATIONS As noted above, when stocking emergency medications, you have to consider the skill level of your staff. For example, if no one on your staff has the ability to place an intravenous catheter in a child, you can elect not to purchase intravenous medications. However, you should strongly consider other medications such as intramuscular corticosteroids, epinephrine, and rectal diazepam. If your staff has limited experience calculating medication doses, consider pre-filled emergency medications, such as autoinjectable epinephrine, which comes in adult and junior doses. You should also purchase and store intraosseous needles, which can be used for both fluid resuscitation and to administer most resuscitation medications (epinephrine, atropine, lidocaine, and naloxone). Finally, don’t stock any medication if your practitioners aren’t capable of managing the most common side effects. For example, don’t have benzodiazepine in your clinic if you can’t manage the respiratory depression that may result from its use. Although I believe the AAP’s recommendations are an excellent starting point, I feel they deserve some commentary from an urgent care doctor who worked in the trenches. In my opinion, activated charcoal is too messy and time-consuming to administer to children. I prefer that pediatric patients who have ingested toxic substances or medications be treated in the emergency department after being seen in our clinic. However, if your clinic is located far from an emergency department, you may want to administer activated charcoal before transfer. I think the cardiac medication atropine deserves some commentary. Atropine is currently recommended in pediatric advanced life support (PALS) protocols for bradycardia that is resistant to epinephrine. In many instances, pediatric bradycardia resolves with adequate positive pressure ventilation alone, and atropine should only be used after several doses of epinephrine have failed to increase the heart rate. I do not foresee much use of this medication in pediatric emergencies, but because it’s a first-line drug for adult bradycardia, it is a necessary addition to the list of emergency medications. Much the same can be said about sodium bicarbonate. This medication may be used in infants and children for cases of known acidosis or presumed acidosis due to prolonged resuscitation. Again, this medication is more commonly used in adults but it is relatively inexpensive, so it too may be added to your list of emergency supplies. In my experience, ceftriaxone is a good antibiotic to have available for pediatric use because it can be administered both intravenously and intramuscularly. I would also suggest that any clinic prepared to administer a benzodiazepine to children stock its reversal agent, flumazenil, as well. In addition, I would move dextrose from the “strongly suggested” category to the “essential” list of medications because it’s inexpensive and hypoglycemia is seen in so many pediatric emergency conditions. Finally, I would suggest having dexamethasone available for intramuscular injection (although it’s successfully used as an oral medication for croup), as well as prednisolone for its superior palatability. EMERGENCY EQUIPMENT I feel the AAP list of pediatric emergency equipment is very complete and requires only limited commentary. Personally, I would not stock pediatric intubation equipment due to the high risk of airway complications and the fact that equivalent patient outcomes have been seen with BVM ventilation. The medical literature is beginning to support the use of BVM ventilation over the laryngoscope in pediatric emergencies, and this is reflected in the teaching of current PALS classes. I feel strongly about the importance of intraosseous needles for emergency fluid/medication access despite the squeamishness that can accompany inserting one. Placing this type of needle can be a lifesaving skill. Several pediatric CME venues offer emergency skills workshops where this technique can be practiced. In addition to the intraosseous needle itself, I find it helpful to have a 60-ml syringe, three-way stopcock, and extension tubing available for the rapid delivery of bolus fluids. This set-up will allow you to draw a fluid bolus from the intravenous bag through the stopcock. Then, by turning the stopcock, you can push the fluid directly into the patient through an intravenous or intraosseous needle. This “push and pull” technique facilitates the rapid delivery of fluid boluses. I would also like to highlight the usefulness of length-based emergency tape (Broselow tape) in estimating pediatric medication doses. If this tape isn’t used, another way to rapidly calculate medication doses should be available. Last, if you’re purchasing an automatic external defibrillator (AED), I would recommend a model that was specifically tested on pediatric arrhythmias and includes pediatric chest leads. These defibrillators have been approved for use in children as young as 12 months old, but only certain models have been studied in the setting of pediatric arrhythmias. Typically, these models will have properly-sized pediatric pads or an adapter that will reduce the voltage by one third to one half. As with any AED, I would recommend that a physician be placed in charge of overseeing its use. Also, a schedule should be created for checking the equipment regularly and ensuring that the AED is incorporated into the clinic’s emergency protocol and planning. This list of suggested equipment, including a moderately priced AED, can be purchased for under $2,000. Apart from the AED, a large portion of this cost is for equipment that would frequently be used on many nonurgent and somewhat urgent patients—for example, a pulse oximeter, oxygen tank, glucose meter, and nebulizer. Resuscitation drugs such as epinephrine are fairly inexpensive, whereas specialty products, such as pre-filled rectal diazepam and autoinjectable epinephrine, are more costly. The right equipment for dealing with pediatric emergencies is only useful in experienced hands. Ideally, all employees should be trained and routinely retrained in basic life support (BLS), regardless of their normal responsibilities within the clinic. Medical staff should be strongly encouraged to maintain certain skills, depending on their level of training. Nurses and medical assistants should be trained in BLS, and physicians, physician assistants, and nurse practitioners should have advanced life support (ALS) training. The need for regular re-education in lifesaving skills despite adequate initial training has been well documented. PLANNING FOR PEDIATRIC EMERGENCIES Planning is one of the most important steps in preparing for pediatric emergencies. Urgent care facilities should create a written emergency protocol that outlines the steps to follow in the event of such an emergency. The protocol should take into account each employee’s emergency skills and assign specific responsibilities if resuscitation is necessary. The front office staff should also be trained to recognize and respond to acutely ill children, as they are often the first ones in the clinic to see the patient. Observation of a child’s level of consciousness, work of breathing, and skin color can alert them to an impending emergency and allow for earlier initiation of lifesaving care. Front office staff should also be trained in how and when to contact EMS. If possible, designate a room for administering pediatric emergency care and for storing all emergency equipment. If the clinic layout makes this difficult, emergency equipment should be portable—for example, stored on a rolling cart or in carrying cases—and kept in a specific location. Many clinics find that algorithms describing the treatment sequence for specific medical conditions are very helpful. These protocols typically follow the “airway, breathing, circulation” model of emergency care taught in formal life support classes. Excellent algorithms for pediatric cardiac emergencies are available in the PALS provider manual and may also be purchased on the American Heart Association Web site (www.americanheart.org). CONDUCTING MOCK CODES Finally, nothing does more to maintain your clinic’s level of preparedness than practicing for emergencies. A mock code is an emergency drill in which a mannequin is used to simulate a critically ill patient. When properly conducted, these drills allow you to practice all the steps in an emergency protocol as well as individual lifesaving skills. Unanticipated problems with either the protocol or medical equipment can be discovered and corrected. Starting a mock code program may elicit some anxiety in your clinic. In an effort to minimize this, I suggest starting slowly. Ideally, one would like to start by having the staff attend either a BLS or PALS program. Next, review your pediatric emergency protocol to ensure that staff members are clear on their roles in a true emergency situation. This may also be a good time to review the location and use of emergency equipment. The discussion may include a demonstration of techniques as simple as connecting the oxygen tank to the facemask and starting the flow of oxygen. A mock code can be completed in about an hour. The staff member acting as the mock code director (MCD) is responsible for preparing the mannequin and setting up all the equipment. I would recommend a simple infant mannequin that can be ventilated (but not intubated), which is relatively inexpensive. The MCD may write the scenarios used in the mock code or follow those in the handbook recommended in the Suggested Reading list. Once the set-up is complete, the MCD should briefly discuss how the mock code team should interact, stressing that the mannequin should be approached as a real patient. Code team members are required to auscultate the chest to assess the quality of breath sounds and to slip on a blood pressure cuff of the proper size. The MCD will be familiar with the patient’s history and can describe all the physical findings, but he should only provide this information if the appropriate questions are asked and the required examination steps are completed. It is also the MCD’s job to describe the patient’s response to each procedure or medication; the patient may become critically ill if certain steps are neglected or improve if treated appropriately. The MCD may end the mock code when the key teaching points have been covered, regardless of the patient’s outcome. After each mock code, time should be set aside for review, which should focus on how the participants acted as a team and how they fulfilled the objectives of each scenario. Since the ultimate goal is to increase your staff’s confidence in pediatric emergency situations, the MCD should stress the positive aspects of each mock code before detailing the areas that need improvement. CHANGING ATTITUDES, BETTER CARE Improving the way your urgent care facility prepares for pediatric emergencies may require a change in the attitude of your entire staff. In the past, practitioners have often neglected pediatric preparedness because of the rarity of pediatric emergencies, the time and financial constraints involved, and their proximity to an emergency department. But the children we serve can’t afford for us to be unprepared. Only by properly equipping clinics, educating staff, and practicing lifesaving skills can pediatric emergencies be kept from becoming pediatric catastrophes. l
Suggested Reading
To go to the test page where you can earn your credits online, click here. CONTINUING MEDICAL EDUCATION CME Mission Statement The American Academy of Urgent Care Medicine (AAUCM) is committed to bringing change in health care provider behavior through innovative educational programs that improve patient care. CME Needs
Target Audience
Accreditation Credit Designation Disclosure Policy Evidence-Based Content Statement
August 2007 CME Learning Objectives: |
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