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Indian Pediatr 2016;53: 465-467 |
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Survival of Sickest
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Pramod P Jog
National President, Indian Academy of Pediatrics,
2016.
Email:
[email protected]
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W hen a general pediatrician faces a critically ill
child in outpatient department (OPD), he/she somehow wants to get rid of
the patient. This attitude develops either out of lack of confidence
(which is either due to lack of knowledge or skills), lack of
infrastructure (due to non-availability of equipment or lack of trained
staff), fear of patient’s death and consequent impact on reputation, or
fear of getting involved medicolegally in the event of an adverse
outcome. A sick child is rarely taken to pediatric intensive care unit
(PICU) directly; most of the times a family physician or a pediatrician
is the first contact with the sick child. He/she needs to recognize the
sick child, stabilize the child, and shift to a higher center at
appropriate time, so that chances of survival are high, and
justification is done to the respect we command in our noble profession.
For recognizing and stabilizing a sick child, one requires knowledge,
skills, manpower and equipments.
Most of the pediatricians practicing in periphery
have small nursing homes, and do not have back-up of big multispecialty
hospitals like in cities. Hence they have to manage various pediatric
emergencies and critically ill children on their own. It is necessary to
have the knowledge about Triage, ABC, Vitals, Emergency medications,
Equipments, Emergency procedures and Transport of sick child. It is
equally important to have skills related to airway and breathing
management, vascular access, and some procedures like needle thoracotomy
and intercostal tube insertion.
Survival of Sickest (SOS), which will be achieved
through HOPE – (Handling Office Pediatric Emergencies), an IAP action
plan 2016, is a part of our sincere efforts to empower a peripheral
pediatrician to provide emergency services at the site of emergency.
Early management of emergencies in the first golden
hour increases the chances of survival of criticall ill children. For
example, if an infection is suspected or etiology of shock is not clear,
current guidelines recommend obtaining cultures (blood, urine and others
as indicated), and administering empiric broad-spectrum antibiotics
within one hour of presentation [1]. Antibiotic therapy should not be
delayed beyond one hour in order to obtain cultures if there is a
concern for severe sepsis or septic shock. One never gets a second
chance to make the first impression! Similarly, early institution of
oral glucocorticoids reduces the duration of exacerbation of asthma, and
can prevent hospitalization and relapse [2,3]. Time is essence and every
minute counts. Rapid clinical assessment should be simultaneous with
stabilization. The widely used definition of sepsis, which was based on
the SIRS scoring, has recently ben replaced by the SOFA scoring
(Sequential Organ Failure Assessment). A simpler version of the 7
variable SOFA score has been proposed for prompt bedside identification
of patients suspected of infections who are more likely to have a poor
outcome. This has been named as the qSOFA score (quick SOFA) and uses 3
clinical parameters, assigning 1 point for low blood pressure (SBP <100
mmHg), high respiratory rate (RR >22/min) and altered mentation (GCS <
15). A qSOFA of ³2
is an indication for prompt management on the lines of sepsis.
Validation of a similar bedside scoring for the pediatric population
will be beneficial. For stabilization of a critically ill child (before
transporting), a pediatrician can do some bare minimum things. Once
airway and breathing have been stabilized, he/she can at least secure
intravenous (IV) or intraosseous access, and administer appropriate IV
fluids or anticonvulsant medication, as per need. No child should die
due to a lack of vascular access.
First dose of broad spectrum antibiotic (such as IV
ceftriaxone) should be given in correct dose prior to transfer. In
septic shock, one hour of delayed appropriate antibiotic administration
increases mortality by 10%. Blood sugar level should be checked before
transfer. If it is < 50 mg/dL, bolus of IV10% dextrose should be given.
Normothermia should be maintained. If the child is hypothermic, warm
blankets should be used; and if hyperpyrexic, per rectal paracetamol
suppository be used. Oxygen should be started in any patient with
respiratory distress (tachypnea, retractions, cyanosis) and shock.
Nebulization is to be given if wheezing is noticed. In case of croup,
one dose of IV or intramuscular dexamethasone (0.25 mg/kg) should be
given.
Pediatrician should not panic, and must observe the
child till transport arrives, inform the respective PICU (or neonatal
intensive care unit), be in touch with the respective intensivist, and
inform him/her condition of the child so that he/she can arrange for
further care till patient reaches. It is important to inform all
possibilities to the relatives in writing till the ICU care becomes
available so that legal complications are avoided. Only shifting to ICU
does not ensure the survival; proper pre-transfer care and safe
transport increase the chances of survival. Effective communication with
emergency medical services and assurance of safe transport to a higher
level of pediatric care is important in management of sick child.
Pediatric Office Preparedness
Children with life-threatening illnesses are taken to
primary care pediatricians’ office by parents or caregivers because they
are familiar and have trust in him/her. When this occurs, the office and
staff need to be prepared to provide initial stabilization and
life-saving care. The consequences of being not prepared are serious.
The steps to prepare an office for handling a pediatric emergency
includes development of a written response plan, training of all office
staff, effective surveillance and triage for critically ill or injured
children who come to the office, and immediate availability of
appropriate pediatric resuscitation equipment and medications.
Nonclinical personnel (e.g. the receptionist)
are often the first office staff to assess the patient. They should
receive basic training regarding signs and symptoms of common pediatric
emergencies, including those associated with respiratory distress,
shock, seizures and altered mental status. Respiratory emergencies,
seizures, infections (especially in young infants), shock/dehydration,
traumatic injuries are the most common causes of emergency visits [4,5].
Thus, it is essential that pediatric offices are equipped with devices,
medications, communication systems and trained personnel to manage these
emergencies. Initial treatment provided in the office may mean the
difference between life and death. Appropriate stabilization of
pediatric emergencies and timely transfer to an appropriate facility for
definitive care are important responsibilities of every medical provider
who cares for children.
If the pediatrician’s clinic is near to the facility
where pediatric emergency care can be provided, the focus should be on
brief stabilization of life-threatening condi-tions and rapid transfer.
If the facility is remote, the office staff need to be able to provide
extended care. The responsibility of medical care rests on the referring
doctor till the sick child is handed over to a critical care center. The
child should be accompanied by a trained doctor in a well equipped
ambulance. Delay in transfer of a sick child increases the mortality. If
the referring pediatrician has an idea about availability of beds prior
to referral, the parents of a sick child will not have to run from one
hospital to other. Indian Academy of Pediatrics (IAP) is developing a
mobile App to provide data about availability of the beds, blood/blood
products etc., to help the pediatricians, neonatologists,
intensivists, parents and even ambulance drivers in that area.
The program SOS-HOPE (Survival Of Sickest through
Handling Office Pediatric Emergencies) has taken a big leap forward in
an attempt to reach maximum number of pediatricians, and innovative
methods are being implemented to make it more useful in day-to-day
practice for all pediatricians. The SOS-HOPE module was recorded in a
film studio in Bangalore, and the presentations were given by the
scientific committee which had prepared the module. A website (www.pedhope.com)
has been created, and all modules of SOS-HOPE are available there. This
would be an interactive website and every pediatrician can interact with
the scientific team of SOS-HOPE to give suggestions and get involved. We
have also created Whatsapp groups for facilitating interaction.
SOS-HOPE App, released in Pedicon 2016, is a very useful mobile
application to guide a pediatrician in handling emergencies in
day-to-day practice, and follow evidence-based medicine. It has been
developed to guide a pediatrician in Triage, ABC, vitals, emergency
medications, dosages, equipments, emergency procedures, transport of a
sick child, and several clinical conditions. Lectures and procedures
related to the emergency (like suturing, inhaler demonstration, foreign
body removal, cardiopulmonary resuscitation, laryngeal mask airway
insertion, intraosseous insertion) can be viewed through the App. Most
of these features can be used offline. Please download the App on your
smart phone as soon as you finish reading this article!
IAP is planning to gift a kit containing basic
equipments like bag and mask, endotracheal tubes, laryngeal mask airway,
emergency medicines and contact reference for oxygen (giving information
as to where oxygen is available in that area). We are also planning to
involve Indian Medical Association for training of family physicians.
Friends, every activity starts with Akriti
(planning) with Navanirmiti (innovation). Then starts real
Kriti (action). The action requires Yuti (team) and Gati
(speed), and ultimately it leads to a Kalakruti (masterpiece)
which is the Falashruti (achievement).
The program SOS-HOPE under 2016 IAP Action plan has
taken a positive step to train 10000 pediatricians in recognition,
stabilization and transport of sick children presenting to pediatric
office. The program is reaching to the grass root level, and has
definitely brought about some changes in the way our pediatricians
practice. Pediatricians are adopting the features of the module into
their day-to-day office practice. lt has transformed pediatricians to
have Triage system where sickest child gets preference. Most notable
changes are that many pediatricians have started keeping oxygen in their
office. Pediatricians are giving first dose of antibiotic in sepsis and
septic shock, and are giving nebulizations through oxygen in acute
severe wheeze. Pulse oximetry is regularly used. Pediatricians are
prepared to handle emergencies by preparing their staff members and
keeping emergency equipments in their office. They are referring the
sick child in 108 or other ambulance, and not in their private vehicle.
These changes, when practiced all over the nation, will result in
improved chances of survival of the sickest, and will lift the standard
of care in our office practice.
We always discuss about the infant mortality rate and
the under-five mortality rate in India being far behind the developed
countries. As pediatricians, we can make a remarkable difference by
reducing the mortality rate by appropriate handling of office pediatric
emergencies. I hope that the program helps our colleagues to
sharpen their ‘higher centers’ before they refer children to higher
centers. Let us help the sickest of the children in times of crisis, and
enable them to survive like the fittest.
References
1. Dellinger RP, Levy MM, Rhodes A, Annane D, Gerlach
H, Opal SM, et al. Surviving sepsis campaign: International
guidelines for management of severe sepsis and septic shock: 2012. Crit
Care Med. 2013;41:580-637.
2. Rachelefsky G. Treating exacerbations of asthma in
children: the role of systemic corticosteroids. Pediatrics.
2003;112:382-97.
3. Rowe BH, Spooner C, Ducharme FM, Bretzlaff JA,
Bota GW. Early emergency department treatment of acute asthma with
systemic corticosteroids. Cochrane Database Syst Rev. 2001;CD002178.
4. Fuchs S, Jaffe DM, Christoffel KK. Pediatric
emergencies in office practices: prevalence and office preparedness.
Pediatrics. 1989;83:931-9.
5. Schweich PJ, DeAngelis C, Duggan AK. Preparedness
of practicing pediatricians to manage emergencies. Pediatrics.
1991;88:223-9.
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