General Information:
General Information:Phone triage, not emergency services.You are deciding whether the parents should call 911, bring the child to the emergency department immediately, or schedule a clinic appointment first thing the next day.If you do not send them to a provider immediately, you should also give some advice regarding home treatments, expected course of the illness, and red flags to watch for that would warrant a return call or trip to the ED.Remember, you can always have them call back later to check the child’s progress. Remember, the moms and dads calling are?concerned parents?with sick child at home (either in reality or in their perception). They were worried enough to call. In the end, we’d rather have parents call too often, than not call when there is a critical issue.You are basing advice on?what they tell you. You cannot see or examine the child yourself.Document the pertinent aspects of the call in EPIC as a communication tool for your colleagues in clinic.If you don’t know what to do, call your back-up clinic attending (not the hospitalists).If you are concerned about the patient, send them in to the ED to be evaluated.Ask questions; it gives you time to think.Do not prescribe medications over the phone. Although if a clinic prescribed medicine needs modification such as change tablets to suspension, wrong dose, then that can be changed. Break things down in easy-to-understand language for the parents?Ask name, age, brief past medical history (i.e., any major medical problems), medications, what have parents tried so far for every patientCheck in EPIC to make sure they are our clinic patients only, If their PCP is a doctor not working in our clinic then ask them to call their answering service. But before that just make sure that the child is ok and not in any crisis. Our patient is anybody who is followed at South campus, 3OPC or Dr. Wahl.In case it is from Casa De Los Ninos then ask the operator to connect them to the on call attending. If it is regarding a medicine prescribed by the inpatient resident then ask the operator to connect to the on call hospitalistAlways document, If it wasn’t documented it did not happen.Take notes so that when you document it say the next day, you don’t forget the important things, especially if it was a middle of the night call.Constipation?QuestionsName? Age?What do stools look like?Hard, dry, rabbit pellets = constipationHow often does the child stool? When was the last stool?Normal stool timing: 3 times daily to every 2-3 days. Varies. Timing / duration: when did this episode start? Is this a long-term problem? Has the child had this problem before?If chronic: schedule outpatient appointmentWhat other symptoms is the child experiencing?Straining (>10 min), pain, large stool, streaks of blood in stool.Does the child have any soiling (encopresis)?If encopresis is present: schedule outpatient appointment (severe, chronic constipation; rule out Hirschprung, cystic fibrosis)What have you tried so far??PMH? Meds? Diet?Antihistamines, opioids, tricyclic antidepressants?Red flags: go to Emergency Department or have child seen in clinicVomitingimpaction / obstruction>4-5 days duration for older children; infants can stool every 4-5 days if softimpaction / obstructionSevere rectal painProlapse, fissure, abscess, surgical abdominal processDehydrated newbornAdequate breastfeeding (Q3-4h, >10 min)Wet diapers (1 diaper for ea. day of life until age 6 days)?AdviceEducation about constipation v. normal stooling behavior.Normal stool habits in babies: straining, grunting, turning red in the face. Explain that these behaviors are normal; it is difficult to poop when all you eat is milk and you’re lying flat on your back.Constipating foods: dairy, cereal, bread, rice, bananaIf <1 year old:sorbitol-containing juice (prune > pear, white grape > apple (no citrus <1y)One oz per age in months (up to 6) BID. Can mix in formula.Glycerin suppository: rarely neededIf >1 year old:Diet: raw fruit and vegetables at least TID. Figs, prunes, dates, raisins, peaches, pears, apricots, apples, beans, peas, cauliflower, broccoli, cabbage.Bran (can buy bran and mix ? - 1 teaspoon in food), popcornIncrease fluid intakeDecrease milk and dairyMiralax (polyethlylene glycol) 0.8 g/kg (children >18 mo). If child really needs Miralax, he should be seen in clinic.Behavior: sit on toilet for 10 min after a mealTake advantage of gastrocolic reflex; make sure feet touch the floor. Avoid laxatives and cathartics. Do not recommend enemas over the phone.Cough?QuestionsName? Age?How long has child been coughing?If >3 days, schedule appointment in 24h.If chronic or recurrent, especially at night, schedule appointment. May be uncontrolled asthma.How bad is the cough? Is it getting better or worse??How is the child breathing?Respiratory distress: call 911: retractions, cyanosis, struggling, grunting, inability to speak, head bobbing, belly breathing, decreased alertnessWhat does the cough sound like?--Pertussis: whoop (>1 year old), coughing paroxysms (<1 year old)--“Barky” or “brassy” in croup. Advise cool mist humidifier, cold air, steam from shower, allowing position of comfort. 911 or ED if?respiratory distress, drooling, or stridor at restDoes the child have a fever? Runny nose / congestion??Is the child?coughing up blood?If yes: ED immediatelyMost common cause is vessel in throat or tonsilsPMH? Meds??Allergies, asthma, exposure to TBWhat have you tried? How is it working???AdviceMost common diagnosis: viral upper respiratory infection (common cold).DDX: asthma, bronchiolitis, pneumonia, croup, pertussis, foreign body aspiration, post-nasal drip, allergic rhinitis?No cough medicine?in patients <6 years old (associated with increased risk of death). No benefit of mucolytics, antihistamines, or decongestants.Warm fluids (tea with lemon and honey if >1 year old), humidity (steam from shower, cool mist humidifier).Scrupulous hand hygiene to reduce spread.Child can continue to drink milk or formula. If post-tussive emesis occurs, continue feeding.If?respiratory distress?develops, seek medical attention immediately.VomitingPoison Control: 222-1222Differentiate from spitting up (effortless regurgitation, relatively small volume) and post-tussive emesis?QuestionsName? Age?How many times has the child vomited today??When did it start??Any?blood?or?bile?(bright green)?Blood: ulcer, esophagitis, Mallory-Weiss tear, varies, although usually from the tonsils or stomachBile: biliary obstructionGo to EDDoes it occur after coughing?Post-tussive emesisDoes vomiting?wake the child from sleep?or only occur in the?morning?Possible increase intracranial pressure.Vomiting during the middle of the night is not associated with increased ICP in most cases, however wakening in early am (just before sunrise) is.Decreased number of wet diapers or decreased urine output? Unable to keep fluids down? Lips dry?Dehydration?(go to ED).Clear vomit 3-4 times +/- frequent watery diarrhea: risk of dehydration, go to EDDoes the child have diarrhea? How many times? Is there blood? Is there mucus??Sick contacts? Recent travel??PMH? Meds?Meds associated with vomiting: erythromycin iron.Ingestion/overdose: go to ED?Red flagsIngestionCall 911 if altered mental statusHead injury in last 3 days (subdural hematoma with increased intracranial pressure)If altered mental status: call 911 If vomiting only: go to EDAltered mental statusMeningitis, encephalitis, increased ICPRecent abdominal traumaDuodenal hematoma causing obstructionAbdominal pain not relieved by vomitingAppendicitis, ileus, intussusceptionDecreased urine output, vomiting >24h especially without diarrhea, frequent watery diarrheaRisk of dehydration?AdviceRule out causes that require immediate attention. Most likely cause is viral gastroenteritis.Oral rehydration: basically, roughly calculate maintenance fluid requirement and give orally.Almost all children will tolerate frequent sips of clear fluids. Do not give ad lib or large amounts at once (will exacerbate vomiting).No anti-emetics (vomiting can be protective).?Serious or life-threatening causes of vomiting?to keep in the back of your worried mind:Pyloric stenosis (2 months to 2 years, projectile) IntussusceptionObstructionAppendicitisAbdominal injury with duodenal hematomaIncreased intracranial pressureToxicityAlcoholInborn error of metabolismFeverFever = temp >100.4 F or >38 C. Hypothermia = temp < 96.8 or <36 (emergency in infants)Your job: rule out serious disease, then counsel on rational fever management.Parental assessment of fever (child “feels warm”) is 84% sensitive and 76% specific (Graneto 1996?Ped Emerg Care?12(3):183-184).Recommend Diamond Children’s ED (especially babies)Acetaminophen 15 mg/kg Q4-6h????????????Ibuprofen 10 mg/kg Q6-8h?????????No aspirin (Reye syndrome)160 mg/5ml 100 mg/5mlQuestionsAge?<2 months:?ED.Most recent temp? Highest temp? How did you measure?>105 F (>40.6 C): EDHow long has the child had a fever?>3 days in an infant: schedule appointment with PCP.>5 days: Evaluate for Kawasaki diseaseHas the child had recent immunizations?Usually low-grade fever. High fever after immunizations is reportable. High fever and toxic appearance: must think of other causes. Does she have other symptoms?--Limp, asymmetric movements, pain with movement of a joint:?septic arthritis--Vomiting and diarrhea: acute gastroenteritis--URI symptomsHow is the child acting (both when she has the fever and when the fever goes down)?Lethargic / toxic: go to EDMost children feel/act better when fever abatesSick contacts? Travel? PMH? Meds?--Congenital heart disease: risk of?subacute bacterial endocarditis--Immunocompromised patient (transplant patients, sickle cell disease, malignancy, HIV): Direct admit (call attending).What have you tried? Does it work?Make sure parents are using correct doses of antipyretics?Red FlagsLimp, lethargic, unresponsive, inconsolable, irritable, bulging fontanel, stiff neckMeningitis, sepsis, encephalitis: DO NOT MISSPurple, non-blanching spots on skinRocky Mountain spotted fever (most common on the reservations; also associated with headache, chills, myalgia), meningococcemiaAge <2 mo?Temperature >105 F (40.6 C)Duration >5 daysKawasaki diseaseDroolingEpiglottitis (rare), retropharyngeal abscessSeizures?Dysuria, foul odor to urine, cloudy urineUrinary tract infectionPersistent fever despite antipyreticsMore likely to be bacterial infectionAdviceMost common cause: viral URI. Fever is often first symptom.Reassurance: Fever itself will not hurt child unless >107 F (41.7 C) – 108 F (42.2 C). (Think about going outside in the summer in Tucson—it can be 105 outside and your brain does not melt.)Fever is the body’s immune response to fight infection.How the child looks is more important than the value of the temperature (exception: <2 months old).Fevers will not continue to increase without fort measures: Cool fluids, minimal clothing, light blanket if chills/shivering, spongingRespiratory distress and congestionQuestionsName? Age?Describe the child’s breathing?--Struggling for each breath--Grunting--Inability to speak or cry--Severe retractions--Head Bobbing--Belly breathingFast or slow?--Tachypnea: go to ED--Shallow, slow, weak: may be impending apnea (sepsis, toxic ingestion, increased ICP, DKA)What is the child doing?--Playing v.?just lying there (depressed mental status)What sounds is the child making?Wheezing, stridor (stridor at rest, stridor during both inspiration and expiration:?go to ED)How bad is it??When did this problem start? Is it intermittent or constant??Does the child have URI symptoms? Cough? If he is an infant, does he get better when his nose is suctioned?Clues for bronchiolitis: winter, age 0-2 years, congestion, cough, fever.Can still have severe distress requiring medical attention.PMH? Meds? Cardiac history?Have parents been giving albuterol?Asthma, recurrent respiratory distressHeart failure?if history of cardiac lesions?Does the child have asthma?How often is she taking albuterol? If <Q4: go to ED If Q2 and in distress: call 911How does the child look after a treatment?If minimal improvement: Call 911How far do you live from the hospital?Is it Friday and the patient can tolerate Q4?Rx prednisone 1 mg/kg/day, call attendingRed FlagsApnea--Initiate CPR, call 911--Apnea may recur. Call 911 if apneic episode resolved.RSV, pertussis, Chlamydia pneumoniaShallow, slow, weakImpending apneasepsis, toxic ingestion, increased ICP, DKAStridorGo to ED if stridor at rest or if stridor occurs during inspiration and expirationForeign body, croup, epiglottitis (rare, ask about drooling), anaphylaxis (ask about exposure, rash, angioedema), croupChild on home O2Increase O2 concentration and go to ED?Chest pain?Pneumothorax, pulmonary embolism?AdviceRule out more serious causes and determine that child has mild distress.Most common cause is viral upper respiratory infection.Suction nose after applying few drops on normal saline (Little Noses brand or generic), humidifier.Diarrhea / dehydrationQuestionsHow many stools has the child had today?Best indicator of severity is frequency. >8 in last 8 h: go to EDMild: loose, mushy bowel movements.Severe: copious and watery.What do the stools look like?Blood or mucus?Blood or mucus: Shigella, Salmonella, Campylobacter, E. coli (STEC), intussusception How long has diarrhea been present?>2 weeks: schedule outpatient appointment (Giardia, subacute bacterial gastroenteritis, malabsorption, milk-protein allergy)Vomiting?If vomiting, treat as vomiting (not diarrhea)Is the child taking fluids normally?Is the child dehydrated?--Decreased urine output?--Not making tears when she cries?--Dry lips/mouth?--General ill appearance?--Alert, happy, playful child is not dehydrated--No UOP >6h (<1 year old), >12h (>1 year old): go to EDAbdominal pain?Usually gas, but consider appendicitis, intussusception Other household members with similar symptoms?Consider infectious etiologyPMH? Meds? Recent travel? New foods?Red flagsSevere watery diarrheaED or 911Limp, weak, unresponsive, cool/pale skinPossible hypovolemic shock, call 911<1 mo old with blood, mucus, foul odorED (rule out NEC, sepsis)FeverED or clinic (Rule out bacterial enterocolitis)If it is difficult to differentiate between stool and urine, have parents place cotton ball near urethral opening, check and call back later.Advice: viral gastroenteritis or colitis, well hydrated or mildly dehydratedDO: Offer unlimited fluids (note that this is different from the management of vomiting). DO: Offer starchy foodsDO: give probioticsDON’T: rest the gut (risk of dehydration) or give liquids onlyDON’T: give juice, water (<4-6 months old), diluted or concentrated formulaDON’T: give Imodium (loperamide): slows the gut, does not allow egress of stool, risk of toxic megacolon with shigellosis.Children younger than 1 year:--Formula-fed: Regular diet, full-strength formula--Breast-fed: continue breast-feeding at more frequent intervals. --Oral glucose-electrolyte solution (i.e. Pedialyte). Transition back to formula over 24h.Children older than 1 year:--Offer unlimited fluids. Give water and starchy foods. Offer yogurt (active culture, restores healthful bacteria to gut).Expected course: about 1 week despite treatment. Come to clinic if longer. Scrupulous hand hygieneCall back or go to clinic/ED if signs of dehydration, no improvement in 48hHead injuryQuestionsName?Age?< 6 months: have child evaluated (difficult to assess neurologic status over phone)What happened?--What height did he fall from--What surface did he land on?--What part of the head did he hit?High speed (i.e. motor vehicle collision)Fall from > twice child’s heightStairwayGreat force (baseball bat)Suspicious mechanism (not consistent with age)When did it happen?Does the child have loss of consciousness? What did the child do immediately afterwards?Loss of consciousness, brief confusion, amnesia: concussion. Go to ED.Crying >30 min: have the child evaluatedHow is the child acting now? See Red Flags belowIs there any injury to the scalp?Laceration: large with profuse bleeding (may require sutures)Hematoma >2 inches (5 cm) (increased risk of TBI or fracture)Is the child vomiting?>3 times: go to EDRed flags: the following behaviors indicate risk of traumatic brain injuryLoss of consciousnessConfusion, abnormal behaviorSlurred speechDifficulty awakeningChanges in visionChanges in gait (unsteadiness)Weakness of upper extremitiesNeck pain (Rule out spinal injury)AdviceWash laceration with soap and water. Apply wrapped ice or ice pack.Rest. Allow patient to sleep but check on him periodically (about every 2 hours). Make sure he can walk/talk normally.Close observation for 48 hours. Awaken twice at night and make sure he can walk and talk.Consider sleeping in same room to monitor respirations.Reassurance than lumps, scrapes, and lacerations are common.PECARN study looked at prediction rule for clinically-important TBI’s after head injury. Younger than 2 years: normal mental status, no scalp hematoma except frontal, no loss of consciousness or loss of consciousness for less than 5 s, non-severe injury mechanism, no palpable skull fracture, and acting normally according to the parents Negative predictive value of 100%, sensitivity of 100%. Older than 2 years: normal mental status, no loss of consciousness, no vomiting, non-severe injury mechanism, no signs of basilar skull fracture, and no severe headacheNegative predictive value 99.95%, sensitivity 96.8%(Kupperman et al. Identification of children at very low risk of clinically-important brain injuries after head trauma: a prospective cohort study. Lancet 2009; 374: 1160–70) Epidural hematoma: injury to side of head (middle meningeal artery), lucid interval. More common in teens.Subdural hematoma: venous. 10x more common than epidural. Gradual neuro changes.Basilar skull fracture: CSF leak, raccoon eyes, Battle signs (posterior auricular eccymosis)RashesRule out anaphylaxisQuestionsName? Age? Local, widespread, or associated with medications?What does it look like?Purple, blood-colored, non-blanching; ask about other signs of bleeding (gums, stool, nose, urine) petechiae/purpura, risk of meningococcemia, sepsis, bleeding disorder: ED or 911Bright red, tender, possible streaksCellulitis: EDLike a burn, very tender, sloughingStaphylococcal scalded skin syndrome: ED<1 month old with blisters or pimplesHSV: EDerythema toxicum (benign)Crusty, yellowImpetigo: go to clinicHivesED; ask other symptoms (see below) Round with central clearingTinea, Lyme (rare in AZ)Anaphylaxis?History of anaphylaxis?Hives respiratory distress Vomiting dysphagia diarrhea lip swellingabdominal pain slurred speech 911URI symtoms?URI symptomsViral exanthemLocation?Hands, feet, mouthHand foot mouth diseaseFlexural surfaces (older), extensor surfaces and face (younger)Eczema, usually chronicDiaperFeetAthlete’s footContact distribution (clothes, socks, jewelry; difficult to assess over phone)Number/size of spots?When did it start?Exposure history, bites, burn, stingMedications?See belowPruritis?Local: most common cause is contact with irritant.What have you tried? Avoid irritants, soap and detergents with fragrance/dye. Avoid scratching. Apply cold compress, calamine lotion, OTC hydrocortisone 1% cream/ointment (caution around face/eyes). Usually resolves in 2-3 days.Widespread: usually viral exanthem. Rule out serious causes (above). If pruritic: apply cool compress or bath then calamine lotion. Avoid scratching. Can try antihistamine.Usually self-resolves in 48 hours.Associated with medications: clarify timing of med administration, when med was started, when symptoms started.Rule out anaphylaxis, endotoxin reaction from GNR’s after antibiotic.If rash in 2h after giving med: risk anaphylaxis. Stop med. Ask about respiratory distress, dysphagia, slurred speech, vomiting, diarrhea, lip swelling. If present, call 911.If hives, itching, or any systemic symptoms: stop med and see PCP (may need to change med). See physician immediately: Petechiae, Fever >3 days with rash, angioedemaCall 911: anaphylaxis symptoms develop (Hives with respiratory distress, vomiting, dysphagia, diarrhea, lip swelling, abdominal pain, slurred speech)Eye dischargeIf chemical exposure or foreign body: flush, flush, flush, then go to the EDLukewarm water, hold eye openRed eye without pus: allergic, chemical, foreign body, viral, uveitis, cellulitis, corneal ulcer, keratitisQuestionsName?Age?<1 month with purulent discharge: gonorrhea (first few days), Chlamydia (>5 days); ED or clinic immediately One eye? Both eyes?Discharge? Color? Amount? What is it like?Parents will probably call any eye discharge “pus”, ask specifically about qualities of dischargeWhen did it start?Eyelids red or swollen?If swollen shut, or entire lid is red, go to ED or clinic immediately to rule out periorbital cellulitisAre there changes in vision?Difficult or impossible to assess in young childrenIs there pain with eye movement? Is there photophobia?Cellulitis, glaucoma, uveitis, severe conjunctivitisAre there associated URI symptoms or recent illness?Suggestive of viral conjunctivitisDoes the child wear contact lenses?Evaluate in clinic or ED, rule out PseudomonasAdviceBring child to clinic if: parents have to wipe away discharge more frequently (multiple times per hour), increasing redness, swelling of eyelidsInfant with clear discharge: may be dacrostenosisGently massage tear duct, wipe away discharge. Significant increase in frequency or amount may indicate infection Older child:Allergic conjunctivitis: Bilateral, watery discharge, other allergic symptomsOver the counter artificial tears for symptom relief; cool compresses; avoid rubbing (as much as possible) Viral conjunctivitis: Highly contagious. Usually affects other eye in 24-48h. Gets worse over 3-5 days, may last 2 weeks.Adenopathy, fever, pharyngitis, URI. Ocular manifestation of systemic infection. SpreadInjection; watery, stringy, mucoserous discharge (no true pus); burning, sandy, or gritty sensation.Adenovirus. No specific treatment. Self-limited. Can use non-antibiotic eye drops to wash eye for symptom relief, remove virus from eye. Bacterial conjunctivitis: (needs to be seen in clinic)More common in children than in adults (may be because bacterial conjunctivitis is brought to medical attention more frequently). Highly contagious.Unilateral, purulent discharge, crusty, dried/matted, red/pink sclera, puffy eyelidsS. aureus (more common in adults), S. pneumoniae, H. influenzae, M. catarrhalisTreatment is erythromycin?ophthalmic ointment or polymyxin/trimethoprim?drops; need to be seen in clinic for prescriptionNeonatal jaundiceQuestions:Age? Gestational age?>7 days with worsening jaundice (not physiologic)Premature: needs to be evaluated (higher risk)When did jaundice start?<24h of lifeDescribe the jaundice: how much of the body is involved? Are the eyes yellow?Face only: increase frequency of feeds.Lower abdomen or legs: needs to be evaluatedHow is the baby acting? Does the baby appear sick? Is there a fever?If sick: go to ED, consider 911. (Sepsis workup)How did the baby do after birth? Any complications during the nursery/post-natal period?What is the baby’s blood type? Mother’s blood type?ABO incompatibility (more common, Mom O, baby A or B)Rh incompatibility (Rh- mom, Rh+ baby)Are there any bruises or lumps on the head?CephalohematomaAny siblings requiring phototherapy for jaundice?Risk factorFamily history?G6PD deficiency, hemoglobinopathiesHow is the baby feeding? How often? How much?Feed Q2-3h, not more than 4h apart at night, at least 10 min (breastfeeding), baby appears satisfiedHow many wet diapers?Should have had a wet diaper within 6 h.1 wet diaper for each day of life until day 6 (i.e. 1 diaper on day 1, 2 diapers on day 2, etc.)How many stools is the baby having?Should have 3 stools/day. (This is variable; may have fewer in breastfed infants before mom’s milk comes in at day 4-5).Consider having the parents take a picture and email itRed flags: immediate evaluation Not waking to feed LethargicDecreased urine outputage <24h or >7 daysIf baby appears sick: EDIf baby is not waking up at all: call 911.Advice (once red flags have been ruled out)Physiologic jaundice is normal in the majority of babies. Peaks day 4-5, dissipates over 1-2 weeks.Increase frequency of feedings (Q1?-2? hours). Continue breastfeeding. Can supplement with formula after breastfeeding if baby appears hungry.Do not let the baby sleep more than 4 hours at night before waking to feed.Call back, take baby to clinic, or go to ED (night/weekend) if:Jaundice worsensPoor feeding or poor weight gain developBaby acts sick (ED)References in case you are stuckHarriet –Lane- For medications and dosing. For normal ranges of BP, sugars, EKG changes. EtcYellow bookUptodateRedbookGoogle search Pediatric Telephone advice by Barton Schmitt.On call Attending ................
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