OMG Its An Emergency Rapid triage and treatment

OMG It’s An Emergency! Rapid triage and treatment in the school setting Zander Brown RN, BSN, CPEN

Emergencies in Schools § Injuries are the leading cause of death among children 5 -19 years old. § 10 -25% of injuries to children occur at school. § Average child spends 28% of their day and 14% of total annual hours in school. § 25% of pediatric emergency visits are children with chronic heath problems or special needs. American Academy of Pediatrics, Council on School Health. Medical Emergencies Occurring at School, Policy Statement; 2004

Responding to Emergencies § Recognition and Assessment § Triage § Intervention

Recognition and Assessment Appearance Activity Work of Breathing Circulation Color

Activity § Assesses neurological status > > > Alert and Aware “Out of it” Crying Drowsy Abnormally calm Panic § What is the normal activity for the situation? For instance crying immediately after injury. § Deviations suggest neurological insult > > Head injury Seizure Intoxication Shock

Work of Breathing § Rate > Increased rate is an early indication impending shock § Effort > > > Retractions Accessory muscles, Abdominal breathing Nasal flaring Posture § Quality > Stridor, Wheezing > Inspiratory vs. expiratory ratio > Clipped verbalizations, panic Age Normal Respiratory Rate Pre-School 22 -34 School-Age 18 -30 Adolescent 12 -20

Work of Breathing § Respiratory compromise is a much more common cause of death in pediatrics vs. adults. § Children compensate through increased rate but can only do so for a limited time. § Small airways mean decreased ability to handle inflammation and edema.

Color § Assess color at mucous membranes § Capillary refill, assess at nail beds or thenar eminence § Deviations include > Flushing > Mottling > Pallor is a late sign of shock. Children will compensate through increased HR and vasoconstriction until cardiovascular collapse is imminent.

Triage will guide interventions § Back to class § Call Parents > Home > PCP, Urgent Care, Emergency Care § Call Paramedics

Interventions Back to Class § The child has no significant injury or illness § Assess and Stabilize § Palliative > Bandaids, ice packs § PRN Rx > Clear care plan essential > Refer to AAP website for links to treatment plans

Interventions Call Parents § The child has a potentially significant illness or injury which requires further attention § Home vs. Primary Care/Urgent Care § Primary Care/Urgent Care vs. Emergency Care § When can child return?

Interventions Call the Paramedics § The child requires urgent treatment or may rapidly worsen § Supportive care until arrival, ABCs § Care plan for chronic health care needs § Communicate with EMS and receiving facility

Injuries § Head > Deformities, step-offs, tenderness, mandibular injury > Signs and symptoms of concussion § Loss of consciousness § Vomiting § Cognitive deficits § Neck and back > If injury suspected, immobilize until EMS arrives > Assess for point tenderness over spine. Spinal vs. muscular pain § Teeth > Traumatic loss or displacement of tooth = emergency dental care > Keep avulsed teeth in toothsaver, mouth or milk. Handle by crown. > Goal is re-implantation within 60 minutes

Injuries § Torso > Blunt trauma to abdomen with resulting tenderness = ED > Trauma Criteria for EMS § Falls >10 feet § Auto vs. ped. /bike, thrown, run over, or >20 mph § Bike crash > 20 mph § Extremities > Suspected fractures § Direct to PCP, Urgent Care, or ED based on severity § Assess perfusion, angulation, pain, open vs. closed § Lacerations – Triage to PCP, Urgent Care, or ED based on difficulty » Compliance of child, degree and location of laceration should be considered. Will the child need sedation for repair?

Respiratory Emergencies § Stridor = Upper airway > Foreign Body > Croup, epiglottitis, tracheitis > Anaphylaxis § Care Plan? PRN Epi-pen? § Wheezing = Lower airway > Asthma § Care Plan? PRN Albuterol? > Bronchiolitis, pneumonia

Chest Pain § Concerning Signs > Trouble breathing > Worse with exertion § Reassuring Signs > Reproducible with palpation, movement § Causes > > > Reflux Injury Costrochondritis Pneumonia MI, PE (extremely unlikely in healthy children)

Abdominal Pain § Accompanying Symptoms? § Wide Differential > > > Vomiting? Diarrhea? Fever? Tenderness? Dysuria Constipation § Context > Duration > Location > Situation > > > Constipation Gastroenteritis UTI Appendicitis Pneumonia Strep Throat Injury Pregnancy, ectopic Mittelshmerz Cholecystitis Pancreatitis

Altered Mental Status § Seizure > Generalized vs. focal > Diastat, Intranasal Versed, Vagal Nerve Stimulators, care plans > Pseudoseizure § Ingestion > Intentional vs. accidental > Recreational vs. Self-harm § Stroke > Traumatic vs. spontaneous § Hypoglycemia > Care plans for DM 1 students

Lets play the Triage Game You get to choose. § Back to Class? § Call the Parents? § Call the Paramedics?

§ 5 year old with sudden onset of inspiratory stridor and drooling in Kindergarten today.

§ 5 year old with sudden onset of inspiratory stridor and drooling in Kindergarten today. § Call the Paramedics. Possible foreign body aspiration. 12/7/2020 RANDALL CHILDREN'S HOSPITAL 21

§ 10 year old with nosebleed that started while taking history test.

§ 10 year old with nosebleed that started while taking history test. § Hold pressure x 2 minutes. If it stops, back to class. If not, reassess. 12/7/2020 RANDALL CHILDREN'S HOSPITAL 23

§ 12 year old with sudden onset of chest pain following lunch. No dyspnea, not reproducible. Admits to eating bag of “Takis. ” 12/7/2020 RANDALL CHILDREN'S HOSPITAL 24

§ 12 year old with sudden onset of chest pain following lunch. No dyspnea, not reproducible. Admits to eating bag of “Takis. ” § Call the Parents. Likely reflux. Possible return to class.

§ 13 year old, standing with back to soccer goal, took blindside soccer ball to head. Dizzy and slightly nauseated but otherwise fine. 12/7/2020 RANDALL CHILDREN'S HOSPITAL 26

§ 13 year old, standing with back to soccer goal, took blindside soccer ball to head. Dizzy and slightly nauseated but otherwise fine. § Call the Parents. Likely concussion. Should go to PCP, UC or ED. Assess for neck pain. If neck injury suspected call paramedics.

§ 6 year old, bumped heads in PE. 1 cm laceration to inner lower lip. 12/7/2020 RANDALL CHILDREN'S HOSPITAL 28

§ 6 year old, bumped heads in PE. 1 cm laceration to inner lower lip. § Call parents. Assess for dental injury. Minor mucosal lacerations (not crossing the vermillion border) are not typically repaired. PCP or UC could easily handle.

§ 14 year old with abdominal pain and limping gait. Started last night but got worse today. Temperature of 100 F, RLQ tenderness. 12/7/2020 RANDALL CHILDREN'S HOSPITAL 30

§ 14 year old with abdominal pain and limping gait. Started last night but got worse today. Temperature of 100 F, RLQ tenderness. § Call the parents. Likely appendicitis. While PCP or UC could begin care, ED at a children’s hospital is recommended.

§ 8 year old, basketball vs. face in PE today. Lost loose deciduous incisor. Scant bleeding. 12/7/2020 RANDALL CHILDREN'S HOSPITAL 32

§ 8 year old, basketball vs. face in PE today. Lost loose deciduous incisor. Scant bleeding. § Call parents to notify and verify that tooth was deciduous. If adult tooth emergent dental care is indicated. Assess for symptoms of neck injury or concussion. If no other symptoms appropriate for back to class.

§ 15 year old with history of peanut allergy developed vomiting and generalized uriticarial rash. 12/7/2020 RANDALL CHILDREN'S HOSPITAL 34

§ 15 year old with history of peanut allergy developed vomiting and generalized uriticarial rash. § Care Plan? § Call the Paramedics. Symptoms of allergic reaction in multiple body systems (GI tract and skin) suggests evolving anaphylactic reaction. If directed in care plan, administer benadryl. Be prepared to administer epi-pen.

§ 7 year old fell off of monkey bars at recess. Tenderness at right wrist. No apparent deformity. Pain rates at 5/10. 12/7/2020 RANDALL CHILDREN'S HOSPITAL 36

§ 7 year old fell off of monkey bars at recess. Tenderness at right wrist. No apparent deformity. Pain rates at 5/10. § Call Parents. Possible stable fracture. PCP, UC or ED visit indicated.

§ 17 year old male. Sudden onset of chest pain after a fit of coughing. Increased respiratory rate and shortness of breath at rest. Anxious. 12/7/2020 RANDALL CHILDREN'S HOSPITAL 38

§ 17 year old male. Sudden onset of chest pain after a fit of coughing. Increased respiratory rate and shortness of breath at rest. Anxious. § Call the paramedics. Chest pain with SOB is concerning. Possible pneumothorax. December 7, 2020 RANDALL CHILDREN'S HOSPITAL 39

§ 16 year old. Stung by bee with area of localized pain and redness. History of bee sting allergy. Epi -pen on hand in office. 12/7/2020 RANDALL CHILDREN'S HOSPITAL 40

§ 16 year old. Stung by bee with area of localized pain and redness. History of bee sting allergy. Epi -pen on hand in office. § Assess for signs of systemic reaction. If no systemic response call the parents and consider benadryl. If systemic response, call the paramedics and consider Epi-pen. 12/7/2020 RANDALL CHILDREN'S HOSPITAL 41

§ 11 year old with history of Asperger’s and ADHD. Jumped up into door jamb and sustained 3 cm laceration to forehead. 12/7/2020 RANDALL CHILDREN'S HOSPITAL 42

§ 11 year old with history of Asperger’s and ADHD. Jumped up into door jamb and sustained 3 cm laceration to forehead. § Call the parents. Child needs laceration repair which will likely be complicated by behavioral compliance and facial location. Consider referral to children’s hospital emergency department. 12/7/2020 RANDALL CHILDREN'S HOSPITAL 43

§ 7 year old, helmeted bike crash en route to school this morning. Sustained abrasion to knee and elbow. Now pale with dizziness and abdominal pain one hour later. 12/7/2020 RANDALL CHILDREN'S HOSPITAL 44

§ 7 year old, helmeted bike crash en route to school this morning. Sustained abrasion to knee and elbow. Now pale with dizziness and abdominal pain one hour later. § Assessment reveals tenderness and 3 cm diameter bruise on abdomen. Call the paramedics. Recommend trauma activation. 12/7/2020 RANDALL CHILDREN'S HOSPITAL 45

§ 8 year old with intermittent abdominal pain for one week. No fever, nausea, vomiting, or diarrhea. Generalized pain without specific tenderness. 12/7/2020 RANDALL CHILDREN'S HOSPITAL 46

§ 8 year old with intermittent abdominal pain for one week. No fever, nausea, vomiting, or diarrhea. Generalized pain without specific tenderness. § Call the parents. Consider constipation. Recommend visit to PCP, UC, or ED. December 7, 2020 RANDALL CHILDREN'S HOSPITAL 47

§ 11 year old with altered mental status. Confused, nauseated, not making sense in class. History of type 1 DM. 12/7/2020 RANDALL CHILDREN'S HOSPITAL 48

§ 11 year old with altered mental status. Confused, nauseated, not making sense in class. History of type 1 DM. § Care Plan? Glucometer? If mild hypoglycemia with directions in care plan, correct as directed and call parents. If not, call the paramedics. 12/7/2020 RANDALL CHILDREN'S HOSPITAL 49

§ 8 year old fell while running in hall with pen in mouth. 0. 5 cm laceration to posterior oropharynx. Minor bleeding. 12/7/2020 RANDALL CHILDREN'S HOSPITAL 50

§ 8 year old fell while running in hall with pen in mouth. 0. 5 cm laceration to posterior oropharynx. Minor bleeding. § Call the parents. Monitor closely. Recommend immediate ED visit. Penetrating injuries to the posterior opropharynx are essentially penetrating injuries to the neck. CT scan likely. 12/7/2020 RANDALL CHILDREN'S HOSPITAL 51

§ 10 year old swallowed penny. No difficulty talking or swallowing. No respiratory distress or abnormality. 12/7/2020 RANDALL CHILDREN'S HOSPITAL 52

§ 10 year old swallowed penny. No difficulty talking or swallowing. No respiratory distress or abnormality. § Call the parents. Visit to PCP, UC, or ED appropriate. Swallowed objects that have passed to the stomach typically do not require intervention. Notable exceptions include magnets, batteries, and sharp objects which may perforate the GI tract. 12/7/2020 RANDALL CHILDREN'S HOSPITAL 53

Thank you!