Written June 1999, last updated July 12, 1999
Flores and Weinstock surveyed of Pediatric and Family Medicine practices in an affluent county in Connecticut without a Children’s Hospital and found:
Total: 2494 pediatric energencies presenting to clinic/ year amongst 51 practices
Median: 24 per clinic/year (range 1-250)
Monthly median: 2/month, range 0-22.5/month
The equipment available and level of preparedness and within this group varied tremendously, but very few were truly adequately prepared to handle even the level and number of emergencies they were seeing.
Have a plan.
Having a plan for what you are going to do, and making sure physicians, nurses and other staff in your practice are aware of your plan, will decrease the level of anxiety and confusion that is sure to present itself when an acutely ill child presents to clinic. Reviewing the plan periodically will keep everyone up-to-date, remind you to check your equipment and supplies, and again help things run smoothly should an emergency arise. Having a person at each level, physician, nurse and other staff involved in the planning will help in assigning responsibilities, and keep everyone involved.
The best thing to do in deciding what to prepare for is to look at your practice itself, and its history. Have you had critically or acutely ill kids present to your clinic? Most people have stories about those really sick kids who showed up in clinic and how the management went. Keeping a log of patients like this would prove helpful as well. If you see a pattern in the types of ill patients who come to clinic, those are the patients for which logically you should prepare.
In general, the more isolated, further from the hospital, less accessible your clinic is, the more you should be prepared to handle emergencies in your office. But just because you are right next to a hospital in a major metropolitan area doesn’t mean you can ignore the possiblity that acutely ill children may show up in your clinic. Realize that often time is a commodity that you can’t afford to waste
Four things to keep in mind
It doesn't matter how much equipment and medication you have, if people in your office don't know how to use the equipment or medications, you might as well not have them.
BLS - Basic Life Support (American Heart Association)
PALS - Pediatric Advanced Life Support (American Heart Association)
APLS - Advanced Pediatric Life Support (American Academy of Pediatrics/ACEP)
ACLS - Advanced Cardiac Life Support (American Heart Association)
BLS – consider training everyone who works in your clinic in Basic Life Support as a minimum. Think about who is going to see your patients first. Is it going to be the board certified pediatrician? Your highly experienced and trusted RN? Or your young but well meaning secretarial staff? Probably most likely it will be your receptionist and scheduling people. Training them, at least in BLS could prove very helpful.
PALS – think about whom would most likely be available if you had a critically ill child present to your clinic, and consider training them in PALS. The more people who are trained, the more likely trained people will be available should the situation arise.
Try running mock codes in your clinic. If your emergency plan involves the ambulance service to transport to the local hospital, try to schedule an occasional practice run with the ambulance service. Can they find your office, who long will it take them to get to your office, how long to pack the patient up, and how long to get to the hospital.? This information will prove very helpful in deciding how much you need to be prepared to do.
In the supplement at the end of this handout are suggestions for basic equipment and medication needs to handle emergencies related to airway issues, circulatory issues and seizures. They are broken up into basic needs which would be needed to initiate therapy, and advanced needs which involve a higher level of care, and may not be something you or your partners are comfortable with (such as intubation) or feel would be necessary in your practice because of proximity issues or otherwise.
Key in any supply of equipment and medications is that they are:
Transport is an important item to not overlook when planning for office emergencies. Your goal should be to assure that your patients continue to receive a high level of care when leaving your office and traveling to the ER or PICU. The first step would be to find out the level of training and Pediatric experience the ambulance service in your area has. Are they PALS or APLS certified, do they go on very many pediatric runs? If not you night want to encourage that they do get the training and more experience. There are also various transport services that provide advanced life support transport throughout the state and region. LifeLink III and North Aircare are two examples in this area. You should keep the numbers for transport services along with your other emergency equipment.
Commercial companies do manufacture products that can meet clinic preparation needs.
One example is a company that manufactures a functional Broselow tape, where not only are the doses of medications listed on the tape, the appropriate doses are contained in a compartment of the tape, as well as appropriately sized Endotracheal tubes and laryngoscope blades. There are other companies as well that provide services and kits with pre-packaged emergency medications.
Some examples: (this should not be assumed to be endorsements of either set of products)
Broselow/Hinkle Resuscitation system – Armstrong Medical
Banyan International - Statkits
1. Flores G, Weinstock DJ. The preparedness of pediatricians for emergencies in the office. What is broken, should
we care, and how can we fix it? [see comments] [published erratum appears in Arch Pediatr Adolesc Med 1996
Jun;150(6):592]. Arch Pediatr Adolesc Med. 1996;150:249-56.
2. Altemeier WA, 3rd. A pediatrician's view. Know your ABC's [editorial]. Pediatr Ann. 1996;25:312-3, 322.
3. Baker MD, Ludwig S. Pediatric emergency transport and the private practitioner. Pediatrics. 1991;88:691-5.
4. Baker RC, Schubert CJ, Kirwan KA, Lenkauskas SM, Spaeth JT. After-hours telephone triage and advice in
private and nonprivate pediatric populations. Arch Pediatr Adolesc Med. 1999;153:292-6.
5. Fuchs S, Jaffe DM, Christoffel KK. Pediatric emergencies in office practices: prevalence and office preparedness.
Pediatrics. 1989;83:931-9.
6. Kunstadter RH. Proposed guidelines for pediatric office emergency equipment. J Indiana State Med Assoc.
1975;68:42-3.
7. Martinot A, Fourier C, Hue V, Leclerc F. Family practitioner preparedness for pediatric emergencies [letter;
comment]. Arch Pediatr Adolesc Med. 1997;151:530-1.
8. Sapien R, Hodge Dd. Equipping and preparing the office for emergencies. Pediatr Ann. 1990;19:659-67.
9. Schexnayder SM, Schexnayder RE. 911 in your office: preparations to keep emergencies from becoming
catastrophes. Pediatr Ann. 1996;25:664-6, 668, 670, passim.
10. Schweich PJ, DeAngelis C, Duggan AK. Preparedness of practicing pediatricians to manage emergencies.
Pediatrics. 1991;88:223-9.
11. Shetty AK, Hutchinson SW, Mangat R, Peck GQ. Preparedness of practicing pediatricians in Louisiana to manage
emergencies. South Med J. 1998;91:745-8
Basic:
Advanced Needs:
(the use of muscle relaxants and or deep sedation should be avoided, as intubation in the office should be limited to patients who should not need medication)
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Basic Needs
Advanced needs
Unfortunately or fortunately, depending on how you look at it the next line drugs for treatment of seizures are not an option in your clinic. Traditionally IV Phenobarbital has been recommended as an agent to have available for treatment of seizures in the clinic. Currently though IV phenobarbital is not available (summer 1999) and most hospitals have exhausted their supplies. Hopefully phenobarbital will resume production in the next few months. Phenytoin and its prodrug Fosphenytoin have the potential to generate serious cardiac arrhythmias and should only be given in a monitored situation, and not in a clinic setting.
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Basic Needs
Advanced Level
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Basic Needs (Same as with Severe Dehydration/Shock plus)
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Comments or questions regarding this page should be directed to Dr. Ken Tegtmeyer at tegtm001@tc.umn.edu
Your feedback is strongly encouraged, to help make this a better resource.
This page generated on July 12, 1999
Last updated July 12, 1999 at 1320 CDT