Pediatricians in outpatient settings can better prepare for psychiatric emergencies in the office and carry naloxone as an essential medication, according to an updated policy statement from the American Academy of Pediatrics (AAP).

Clinicians should envision what types of emergencies may occur to ensure the right equipment and resources are available. Respiratory distress, seizures, and allergic reactions are the most common in-office pediatric emergencies, according to the AAP.

The updated recommendations reflect the latest available evidence on office protocols, staff preparedness, and management of emergencies when they arise, since the first policy was released in 2007.

“Offices have expanded their capabilities. With close attention and good follow-up, pediatricians are able to keep a lot of kids from needing hospitalization,” said Jenna Wheeler, MD, pediatric critical care physician at Orlando Health Arnold Palmer Hospital for Children in Orlando, Florida, who was not involved with the report.

The Nuts and Bolts

Pediatricians should create protocols for situations in which staff are absent and develop a documentation system for handoff to emergency medical services (EMS) personnel and for office records, according to the authors of the report from the AAP Committee on Practice and Ambulatory Medicine, Committee on Pediatric Emergency Medicine, and Section on Urgent Care Medicine.

The report lists many medications to store in case of emergency, including epinephrine, which is also now available in intranasal form. Activated charcoal has been removed from the medication list, whereas naloxone and dexamethasone were added. Offices should also keep albuterol in stock.

Glucometers were also added to the essential equipment list, whereas automated external defibrillators should also be kept on hand.

The report highlights that simply having equipment is insufficient if the staff is not practiced in using it. Pediatricians should move beyond checking expiration dates and implement annual, emergency simulation drills. Team roles, such as leader, airway management, and scribe, can also be defined.

Clinicians should use pre-calculated tools instead of manual calculations because the latter are a major source of medical error during crises. The AAP recommends that every exam room or resuscitation cart should have a preprinted, kilogram-based drug dose manual or preprinted tape.

Other steps pediatric offices can take include training medical staff in basic life support at a minimum. More advanced training can include pediatric emergency assessment, recognition, and stabilization.

Newly added to the report are psychiatric emergencies. If a child is at imminent risk for suicide or self-harm, clinicians have a few options for further evaluation, including teleconsultation with a psychiatrist or specialized psychiatric emergency departments or urgent care.

If these are not available or the child’s acuity is too severe, transfer to an emergency department should be made. While awaiting transfer, the patient should be observed, and unsafe objects such as cords should be removed. Using EMS instead of a caregiver’s car can prevent self-harm during transportation, the report states.

The report addresses acute aggression or agitation, such as biting or head banging. Clinicians should use de-escalation strategies, which might include minimizing stimulation by dimming lights or decreasing the number of staff present. If a child is exhibiting destructive or dangerous behavior that is putting staff or themselves at harm, an antipsychotic medication such as olanzapine can be administered orally or intravenously.

Clinicians should also evaluate the typical time for local EMS to respond to their specific location to determine the level of care needed while waiting. EMS arrival times can reach up to 14 minutes in rural settings compared with 7 minutes in nonrural settings. If located in a rural area, staff must stock supplies for more prolonged stabilization, such as intraosseous needles and additional intravenous fluids.

The study received no external funding. Various study authors reported receiving financial disclosures related to AstraZeneca Pharmaceuticals, Ironshore Pharmaceuticals, and Tris Pharma, among others. Wheeler reported having no disclosures.