Presentation on ADHD at the TAPA Spring 2014 Meeting in San Antonio, TX, February 22, 2014

1. Robert L. Quillin, MD, FAAP

2. Disclosures
Speaker and consultant for VayaPharma, makers of
Vayarin
Previous research support provided by Pernix
Therapeutics

3. Presentation Outline
 Emergencies in the outpatient clinic setting
 Making “quick look” assessments
 Triage, treat or transfer approach to the sick
patient
 Office staff and practical management of patient
 Parent/caregiver in the treatment plan

4. This is an emergency . . .

5. This is sNOT!

6. Somewhere in between
 Fever
 Earaches
 Cough
 Sore throat
 Vomiting
 Injury, head, neck or face
 Stomach and abdominal
 Headache
pain
 Facial laceration
 Skin rash
National Hospital Ambulatory Medical Care Survey:
2010 Emergency Department Summary Tables

7. What are we talking about then?
Asthma
Fracture
Appendicitis
Seizure
Anaphylaxis
Concussion
Rash
Laceration
Cancer

9. Definitions
 What providers perceive
 “to become aware of, to know, or identify by means of the senses”
 What parents believe
 “to have confidence in the truth, the existence, or the reliability of
something, although without absolute proof that one is right in doing
so”
 What grandmothers know
 “to perceive or understand as fact or truth; to apprehend clearly and
with certainty”

10. Behind door number 1 . . .
 Check pulse
 Call 911
 Remember ABC’s
 Direct staff, reassure parents
 Make a decision

11. Triage, Treat, or Transfer
 Know limits of parents
 Know limitations of staff
 Know your own limitations
 Know your hospital/ER limitations

13. Case #1: Fever
 6mo fever to 104 over last two
days. No sick contacts, no
daycare, vaccines UTD
 VS: T 101.2
 PE: Feeding on bottle, PE wnl
 Labs: CBC with WBC 18.7,
57%G, UA not collected
 Triage, treat and/or transfer?
PEARL: DON’T FORGET
THE UA

14. Case #2: Fall
 4mo unrestrained rolls out of
carrier from counter to tile floor
 VS: T 98.2, P 120
 PE: Being held by father,
smiling, looking around
 Crepitus R parietal skull
 Labs/image: None, CT Head
PEARL: BUCKLE UP!
 Triage, treat and/or transfer?

15. Case #3: Wheezing
 7yo with known h/o wheezing,
fever 101. Had RSV as infant.
 VS: T 99, pulse ox 88%
 PE: Quiet, retrax present, no
wheezing?
 Labs: None, CXR?
 Triage, treat and/or transfer?
PEARL: SAY YOUR ABC’s?

16. ICD-10 FOLLIES
W61.92
Z63.1
W45.8XXA
V52.2XXA
V00.32
X92.0
W00.1
V97.33XD
Struck by other birds
Problems in relationship with in-laws
Other foreign body or object entering though
skin, initial encounter
Person on outside of pick-up truck or van
injured in collision with two or three-wheeled
motor vehicle in nontraffic accident
Snow-ski accident
Assault by drowning and submersion while in
bathtub
Fall from stairs and steps due to ice and snow
Sucked into jet engine, subsequent encounter
David Pittman, Med Page Today

17. Case #4: Foreign body
 18 mo swallowed a nickel, no
vomiting, no cough
 VS: T 98.7
 PE: waddling around exam
room, NAD
 Labs/image: CXR/KUB
 Triage, treat and/or transfer?
PEARL: NICKELS ARE
GOOD, BATTERIES AND
MAGNETS ARE BAD

18. Case #5: Crush injury
 2 yo smashed finger in car door
 VS: T 99
 PE: crying in room,
apprehensive, finger tip and nail
partially avulsed, not actively
bleeding
 Labs/image: Xray
 Triage, treat and/or transfer?
PEARL: PLASTIC SURGEON
IS YOUR BEST FRIEND

19. Case #6: Nodes
 5yo with recurrent fever to 102,
swollen glands, recent dx of
mono after 5 days of fever
 VS: T 101.8, P 100
 PE: pale, diffuse cervical LAD,
guarding RUQ, bruising
 Labs/image: WBC 52K, H/H wnl,
plts 30,000
 Triage, treat and/or transfer?
PEARL: BEWARE OF NODES

20. Don’t forget the patient
comes first!

21. Thank you TAPA
and
safe travels!