Which protocol would you choose?
- 1. What Protocol Would You Choose? Orientation RPTC- Source: Barton Scmitt, MD, as presented at Reach for the Stars 2011 National Telehealth Conference
- 2. How to Choose • You are the triage nurse for PhoneRN. It is 8pm on a weekday evening. • Triage: Sort the patient into one of the following 3 levels of care: • God to ED Now • See in office tomorrow • Home care
- 3. Call 1: Tucker, 6 Week Old Male • Presenting Complaint: “crying more than usual” • Fussier than normal for 2 days • Difficult to console; cries more when held • Popping sound of right rib cage with movement • Alert, feeding well, normal urine output, breathing well • Choose the best guideline and disposition
- 4. Tucker, 6 Week Old • Guideline: Crying- before 3 months old • Disposition: Go to ED Now • Reason: Injury suspected (r/o child abuse)
- 5. ED Findings • 3 rib fractures • Skeletal survey: negative for other fractures • Head CT: no subdurals • FOC (father of child): Admitted squeezing baby hard when he was crying a few days ago
- 6. Child Abuse and Crying • Inconsolable crying is the #1 trigger for lethal-outcome child abuse. • Usual mechanism: Shaken baby syndrome • SBS main symptoms: extreme irritability, vomiting, seizure, apnea, bulging AF • Goal: Detect minor inflicted injuries before SBS occurs
- 7. Clues to High Risk for SBS • Inconsolable crying • Angry comments about baby • Admits fear of hurting baby • Has spanked baby • Unexplained bruise, swelling, or mark • Paradoxical response to being held or moved • Bruises before 4 months old • Pierce MC, Pediatrics 2010; 125: 67-74
- 8. Call 2: Greg, 12 Year Old Boy • Presenting complaint: “Blisters on eyeball” • Present x 1 hour, Started during a bike ride • Eyes very itchy, bloodshot and watery, blisters on sclera • Nasal symptoms also present. Has hay fever and didn’t take anything today • Best guideline?
- 9. Greg, 12 Year Old Boy • Eye allergy guideline • Serious causes to consider: Chemical eye, FB • Disposition: See tomorrow in office • Reason: Sacs of clear fluid (blisters) on whites of eyes or inner lids • R/O: chemosis or allergic cysts
- 10. Chemosis and Allergic Conjunctivitis • Definition: sever reaction of the eye to allergen, manifested by edema of the bulbar conjunctiva • Cause: high pollen count or pollen load • CC: whites of eyes look swollen or have clear blisters. Cyst size: 4 to 10 mm • Treatment: cold wet cloth, oral antihistamines, and purchased special eyedrops • Ketotifen (OTC Zaditor) eyedrops can usually eliminate chemosis
- 11. Call 2: Jada, 2 year old girl • Presenting Complain: “Pokes at her right ear. Could she have an ear infection?” • Onset: 3 days ago • No fever, cold, cough, runny nose, ear discharge • No pain, crying, or night awakenings • PMH: otisis media once at 7 months • Best Guideline?
- 12. Jada, 2 Year Old Girl • Ear: Pulling at or itching guideline • Disposition: Home care • Reason: Ear pulling without other symptoms is not a sign of an ear infection • Additional history: Uses Q-tips • Risk: perforated eardrum
- 13. Ear Pulling in Young Children • 1992 study: 100 children with ear pulling as the chief complaint where examined. • Age: 11 months median (SD 8 months) • Challenge: most children under age 2 unable to confirm or deny presence of an earache. • Challenge: most children under age 2 unable to confirm or deny presence of an earache. • Results (diagnostic groups): normal ear canal and eardrum 69%, impacted earwax 12%, acute otitis media 12%, serious OM 7%, FB none. • Conclusion: simple ear pulling without other symptoms of an illness or infection was never associated with an ear infection. • Baker RB Pediatrics. 1992: 1006-1007
- 14. Call 4: Sandy, 3 Year Old Girl • Presenting complaint: “lip wont stop bleeding” • Fell 20 minutes ago at her BD party • Location: Inside the upper lip • Amount: small, but hasn’t stopped • Also small scrape on outer lip. Denies head trauma • Best guideline?
- 15. Sandy, 3 Year Old Girl • Trauma- Mouth Guideline • Caller denies serious symptoms: • Fall with object in mouth • Gaping cut of outer lip • Tooth damage • Best disposition?
- 16. Cut of Upper Labial Frenulum • Disposition: Home Care • Reason: Torn upper labial frenulum always heals perfectly without sutures • Reassurance: bleeding from the site always stops • Caution: Do not pull the lip out again to look at it (Reason: the bleeding will start again) • It’s safe to look at it after 3 days
- 17. Call 5: Zack, 4 Month Old • Presenting complaint: “Hard to clean out his nose.” • First cold started 8 days ago • Mild cough, no fever, cloudy nasal discharge, nose seems blocked, cries when uses bulb syringe • Drinking less but wet diapers every 4 hours, alert, not in pain • Best guideline?
- 18. Zack, 4 Month Old Boy • Colds guideline • Disposition: See Tomorrow in Office • Reason: ear infection suspected by triage nurse • Nurse discusses how to use saline with a bulb syringe
- 19. Office Findings • Office next morning: RR 60, wheezing, mild retractions, o2 sat 86% • Admitted for bronchitis • During the night: frequent awakenings, unable to sleep laying down, parents took turns holding upright all night • Nurse Error: Did not ask about breathing or respiratory distress
- 20. Lesson: Child is Unsafe Until Proven Otherwise • In office, can usually decide within 10 seconds whether or not a child is seriously ill • On the phone, this may take 1 to 2 minutes • Must actively disprove that the patient has any serious etiologies or complications for their main symptom (eg. Appendicitis for abdominal pain) • Don’t assume the caller knows • If unsure, refer them in to be examined
- 21. Respiratory Distress • Respiratory arrest: the primary cause of death in young children • Recognizing Respiratory distress: an essential skill for telephone triagers • Always assess Respiratory Distress in any respiratory guidelines: cough, croup, flu, wheezing, even colds • For cold symptoms with fever, do NOT use fever guideline
- 22. Respiratory Distress Defined • Normal breathing: effortless, quiet, slow • Mild RD: Tachypnea w/o dyspnea • Moderate RD: working to breath, some retractions, some wheezing or stridor may be present, but not tight • Severe RD: Struggling to breathe, severe retractions, difficulty eating or speaking, worse with walking, grunting to push air out, too hypoxic to sleep
- 23. Call 6: Morgan, 8 month old girl • Presenting complaint: “Wheezing for 2 hours” • Runny nose, cough and fever to 102F started 8 hours ago • Difficulty breathing and wheezing. Mom has asthma since childhood • Best guideline?
- 24. Morgan, 8 month old girl • Wheezing Guideline • Disposition given: Go to ED now • Result: Child stops breathing in car while driving in • Father starts driving through stop signs and hits another car
- 25. Bronchiolitis • Lesson 1: Consider 911 option whenever you send a child to ED • Apnea risk is high for infants <6 months with respiratory infections • Recognize symptoms of sever respiratory distress: grunting, weak cry, inability to suck, groaning, moaning • Lesson 2: Listen to child’s breathing
- 26. Call 7: Boris, 2 year old boy • Presenting complaint: “swallowed a dime” • When: 10 minutes ago • No swallowing problems, drooling, spitting, gagging, vomiting • No breathing problems • Best guideline?
- 27. Boris- 2 Year old boy • Swallowed foreign body guideline • Disposition given: Home Care • Care Advise: Check stools for dime and call back if FB as not passed within 3 days or develops symptoms • Result?
- 28. Coin or button battery? • Parent called back in 4 hours • Inconsolable crying and refusing to eat • Referred to ED • Diagnosis: button battery in esophagus • Risk: Saliva asks as electrolyte bath and battery current can cause chemical burn, perforation, or even vessel damage
- 29. Jack, 14 year old boy • Presenting complain- Stomach ache • Onset: 3 hours ago, after playing basketball • Location: Lower left side • Severity: moderate but constant; hurts to walk • Denies fever, vomiting, diarrhea • Best guideline?
- 30. Jack, 14 year old boy • Abdominal pain guideline • Disposition given: Go to ED now • Reason: Moderate pain (interferes with activities) AND constant AND present >2 hours R/O appendicitis, other acute abdomen • ED Diagnosis: Left testicular torsion • Lesson: males may not give their mom correct location of pain
- 31. Testicular Torsion • Definition: testicle twists and cuts off its blood supply • Peak age: 16 (70% between 12 and 18) • Symptoms: abrupt onset of scrotal pain and swelling • Exam: testicle elevated and cremasteric reflex absent • Surgical Emergency: Infraction and loss of testicle if persists > 8 hours
- 32. Call 9- Gabby, 3 year old girl • Presenting complaint: “won’t use right arm” • Onset: 30 minutes ago while dad was swinging her • Symptoms: Holds right arm partially flexed at elbow with palm down. Cries and resists any movement. • Best Guideline?
- 33. Gabby, 3 year old girl • Arm Trauma Guideline • Disposition: Go to ED now • Reason: Age<4 and cannot move elbow normally (r/o subluxed raial head) • Weather conditions: blizzard, 12 inches of snow so far today, family lives in foothills • Plan B?
- 34. Reducing a Subluxed Radius • Refer call to PCP or ED managed by telephone • Last resort: triage nurse gives instructions on how to reduce radius • Either technique is effective • Confirmation of success: Click is felt and child uses arm within 10 minutes • Kaplan, RE, Pediatrics 2002: 110: 171-174
- 35. Hyperpronation Script • Support your child’s elbow with one hand • Grip your child’s wrist with the other hand • Turn your child’s wrist and forearm until the palm faces entirely downward • You should feel a click as the elbow is reduced • Your child should start using the arm normally within 10 minutes