Orientation RPTCSource: Barton Schmitt, MD as presented at Reach for the Stars 2011 National Telehealth Conference

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:◦ Go To ED Now◦ See in office Tomorrow◦ Home Care

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?

Guideline: Crying-Before 3 months old Disposition: Go To ED Now Reason: Injury Suspected (r/o child abuse)

3 rib fractures Skeletal survey: negative for other fractures Head CT: no subdurals FOC (father of child) : Admitted squeezing

the baby hard when he was crying a few days ago

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.

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

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?

Eye-Allergy guideline Serious causes to consider: chemical in 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

Definition: severe 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 purchase special eyedrops. Ketotifen (OTC Zaditor) eyedrops can usually

eliminate chemosis.

Presenting Complaint: “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: otitis media once at 7 months Best Guideline?

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

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. Results (diagnostic groups): normal ear canal

and eardrum 69%, impacted earwax 12%, acute otitis media 12%, serous 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.

Presenting Complaint: “lip won’t 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?

Trauma- Mouth guideline

Caller denies serious symptoms:◦ Fall with object in mouth◦ Gaping cut of outer lip◦ Tooth damage

Best Disposition?

Disposition: Home Care Reason: Torn upper labial frenulum always

heals perfectly without sutures Reassurance: bleeding from the site always

stops. Caution: Don’t 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

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 hrs, alert, not in pain.

Best Guideline?

Colds guideline Disposition: See Tomorrow in Office Reason: ear infection suspected by triager Nurse discusses how to use saline with bulb

syringe.

Office next morning: RR 60, wheezing, mild retractions, o2 sat 86%

Admitted for bronchiolitis 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.

In office, can usually decide within 10 seconds whether or not a child is seriously ill.

On the phone, this may take 1 or 2 minutes Must actively disprove that patient has any

serious etiologies or complications for their main symptom (eg appendicitis for abdominal pain)

Don’t assume that caller knows If unsure, refer them in to be examined.

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

Normal breathing: effortless, quiet, slow Mild RD: tachypnea w/o dyspnea Moderate RD: working to breathe, 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

Presenting Complaint: “Wheezing for 2 hrs” Runny nose, cough and fever to 102 F

started 8 hours ago Difficulty breathing and wheezing. Mom

has Asthma since childhood. Best Guideline?

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

Lesson 1: Consider 911 option whenever you send child to ED

Apnea risk is high for infants < 6 months with respiratory infections

Recognize symptoms of severe respiratory distress: grunting, weak cry, inability to suck, groaning, moaning

Lesson 2: listen to child’s breathing

Presenting complaint: “swallowed a dime” When: 10 minutes ago No swallowing problems, drooling, spitting,

gagging, vomiting No breathing problems Best Guideline?

Swallowed Foreign Body guideline Disposition given: Home Care Care Advise: check stools for dime and

callback if FB has not passed w/in 3 days or develops symptoms

Result?

Parent called back in 4 hrs: Inconsolable crying and refusing to eat Referred to ED Diagnosis: button battery in esophagus Risk: saliva acts as electrolyte bath and

battery current can cause chemical burn, perforation or even vessel damage.

Presenting Complaint: “Stomach-ache” Onset: 3 hours ago, after playing BB Location: Lower left side Severity: moderate but constant, hurts to

walk Denies fever, vomiting, diarrhea Best Guideline?

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

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: Infarction and loss of

testicle if persists > 8 hrs

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?

Arm Trauma guideline Disposition: Go To ED Now Reason: Age < 4 years old AND cant move

elbow normally (r/o subluxed radial head)

Weather conditions: blizzard, 12 inches of snow so far today, family lives in foothills

Plan B?

Refer call to PCP or ED to manage 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

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 w/in 10 minutes

Presenting Complaint: “Constipation” Symptom: only 1 stool per day, dry and firm Urine: wet diaper every 3 hrs, pink Behavior: alert, acts hungry, sucks well,

breastfed Denies jaundice, fever, vomiting Best Guideline?

Breastfeeding guideline Disposition: See tomorrow in office Reason: Day 4 of life or later AND bowel

movements are < 3 per day Serious causes ruled out: sepsis, lethargy,

dehydration, high bilirubin Office DX: sore nipples and latching

problem Question: when are infrequent stools

normal in breastfed baby?

Between 4 and 8 weeks of age, some exclusively breastfed babies (20%) change ot normal infrequent stools.

Pass 1 large soft stool every 4 to 7 days Stool size relates to stool interval Passes easily, without pain or crying Most breastfed babies (80%), however,

continue to have several daily stools Resource for 20% prevalence: ABM List

Serve for breastfeeding experts

Infrequent stools during the first weeks of life: caused by inadequate breast milk production OR inadequate milk transfer until proven otherwise.

Main complication: dehydration of the newborn Rare complication: severe dehydration

progresses to DIC, renal failure or a stroke. Occurs day of life 7 to 14.

Prevention: all newborns with infrequent stools are referred to the office for a weight check, jaundice check, etc.

Admit for wgt loss > 10% Neifert M. Pediatr Clin North Am. 2001; 48(2):

1-23

Presenting Complaint: “Stomach is growling”

Last Feeding: 60 minutes ago Behavior: asleep Pain: none Hydration: wet diaper 40 minutes ago Denies all other symptoms Best Guideline?

Newborn Reflexes and Behavior guideline Disposition: Home Care Reason: Normal GI sounds and noises (All

triage questions negative) Care Advise: these noises are normal and

harmless, not a sign of illness

Learn from your calls Welcome any caller complaints Present best teaching cases at staff

meetings