Decision Making in Pediatric Emergency Medicine

1. Decision Making in Pediatric Emergency Medicine Ivan Steiner MD, MCFP-EM, FCFP University of Alberta, Edmonton, Canada

2. Goal for today To review a simple, personal, time tested tool for decision making in the ED.

3. Game plan • Look at the difference between ED, wards and clinics. • Review the components of decision making process in the ED. • Outline my template for decision making. • Answer questions. • Provide a summary.

4. Warm up 15 patients waiting in the waiting room when a 7 month old baby boy is brought by his parents into the E.D. of A peripheral hospital. He is unresponsive and is visibly covered by a rash. His BP = 60/?, P = 160, RR = 50, to = 40o, O2% = 96% on R.A. What is the problem? What are your priorities in this case?

5. The ED a distinct environment Question: In what way is the ED different than the wards and clinics?

6. The ED a distinct environment • Lack of control over volume of patients. • Variable acuity and availability of resources. • Triage. • Unknown patients. • Short intervention time. • Limited information. • “One shot” approach. • Uncertainty of dealing with unknown, or previously not encountered problems. So what does this mean to the clinician?

7. The ED a distinct environment Functioning in an environment with limited , variable resources AND dealing withfrightened, possibly hostile patients and families . Key skills and attitude/behaviours required to be successful in the ED: • Prioritized, organized approach to each situation. • Empathy, respect, tact. • On going, two - way communication.

8. Take home message for Part 1. • Decision making may have to start with the little or no information. • The “traditional” approach to patient management does not work in the ED. • A PEP is a “people person”. Rapport!

9. Decision making: key questions to ask oneself The three “Stop” signs: 1st “Stop” sign What are the first four key questions to ask oneself ?

10. Back to our case A 7 month old baby boy is brought into the E.D. of a peripheral hospital by his parents. He is unresponsive and is visibly covered by a rash. His BP = 60/?, P = 160, RR = 50, to = 40o, O2% = 96% on R.A. What are the first 4 key questions to ask ?

11. Decision Making: Key Questions to Ask Oneself • Is the patient in the right institution ? • Is the patient in the right part of the ED? • Is there a need for immediate resuscitation, or potential for resuscitation of LIFE, limb or salvage of function? • What immediate information/resources are required to start management of the patient? These questions lead to good triage and care!

12. How do we make decisions Presumption for PEP: the worst case scenario.

13. How do we make decisions • First step: trust your eyes, smell, hearing, touch. • Second step: check vital signs. • Third step: asses chief complaint.

14. How do we make decisions • Start with patient presentation and NOT diagnosis. • Anatomy and physiology are great guides!!!!

15. Back to our case Where do we start here based on the 4 key questions?

16. Take home message Part 2. • A good PEP anticipates problems. • In the ED, the clinician is first and foremost a clinical physiologist. • He/she is an expert at managing multiple, often limited resources.

17. Template to decision making The 7 step approach. How to get “Steinerized”

18. Template: the first 7 steps • Resuscitation. • Monitoring. • Symptomatic treatment. • Investigations. • Diagnosis/definitive treatment. • Disposition. • Social.

19. Template: step 1 • Does the patient need resuscitation or stabilization of physiological parameters ? The 1st “Stop” sign Life = resuscitate. Limb = reestablish circulation. Function = prevent further injury. (P.R.I.C.E.)

20. Back to our case. Does he need resuscitation?

21. Template: step 2 • Does the patient need monitoring? Life = VS=BP, P, RR, to, O2%, weight, sugar, (Co2). Limb = pulses, colour, sensation. Function = as above or specific (Visual Acuity)

22. Back to our case. Does he need monitoring?

23. Template: step 3 • Is there a need for symptomatic treatment? Provide symptomatic treatment based on need and using the most effective route! Offer it to the patient even though he/she may choose not to accept it.

24. Back to our case. Does he need symptomatic treatment?

25. Template: step 4 • Does the patient need prioritized investigations? The 2nd “Stop” sign Body fluids = blood & allother. Diagnostic imaging = simple & complex. Other = things that start with “E”.

26. Back to our case. Does he need prioritized investigations?

27. Template: step 5 • Do we know what is definitively wrong with the patient and what the definitive treatment options may be? Usually the answer is NO.

28. Back to our case. Do we know what is wrong and what the definitive treatment options are?

29. Template: step 6 • Do we know where this patient will end up? Too sick to go home = ward vs intensive care. Will go home = only obvious cases. Not sure = most patients fit in to this category. Remember: Starting presumption is that you are dealing with the worst case scenario.

30. Back to our case. Do we know where he will end up?

31. Template: step 7 • Are there any immediate social issues ? Consider these issues early and use the appropriate resources: social worker, etc.

32. Back to our case. Did you consider the parents here ?

33. Template: the first 7 steps • Resuscitation. • Monitoring. • Symptomatic treatment. • Investigations. • Diagnosis/definitive treatment. • Disposition. • Social.

34. Template: the first 7 steps How do I make it work? A = Asses. I = Intervene. R = Reassess. The sicker the patient, the more often one repeats A.I.R. and charts each intervention.

35. Template: the final 7 steps The 3rd “Stop” sign • Resuscitation. • Monitoring. • Symptomatic treatment. • Investigations. • Diagnosis/definitive treatment. • Disposition. • Social.

36. Template: the 3 “Stop” signs • Before triage & resuscitation • Before ordering all investigations • Before disposition of the patient

37. Take home message Part 3. • The 7 point template provides a simple and safe starting point. • The 7 point template provides a safe exit strategy. • The number of A.I.R. are dictated by the clinical status of the patient. • The 3 “STOP” signs help PEP slow down and make good decisions!

38. Questions

39. Distilled summary • Good PEP use a patient/family centered approach in decision making. • Early decisions are based on patient presentation and NOT diagnosis. • Physiology and anatomy never lie! • The 7 point template used on entry and exit + A.I.R. + the 3 STOP signs have been proven, useful and simple to use tools over time. • Teaching Pediatric EM to all medical students and residents who are treating children is essential.

40. The End