ED - Acute Asthma Exacerbation (18 mo - 30 years)
Last Updated: 5/15/2017 5:33:15 PM
Order Set
  Associated Pathway(s)
 Acute Asthma Exacerbation (18 mo - 30 years) - http://www.curbsideup.com/link/4
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  Inclusion Criteria
Inclusion Criteria ( Any one criteria present )
  • Clinical symptoms consistent with asthma exacerbation
Exclusion Criteria
  • Toxic appearance
  • Chronic lung disease
  • History of airway anatomical or functional abnormality
  • Complex cardiac disease
  • Complex neurologic disease, hypotonia or neuromuscular disorder
  • Immunodeficency
  • Sickle Cell Anemia
  Respiratory Score
  Variable 0 points 1 point 2 points 3 points
1 RR        
  1-2 years   ≤ 40 41 - 44 ≥ 45
  2-3 years   ≤ 34 35 - 39 ≥ 40
  4-5 years   ≤ 30 31 - 35 ≥ 36
  6-12 years   ≤ 26 27 - 30 ≥ 31
  > 12 years   ≤ 23 24 - 27 ≥ 28
2 Retractions None Subcostal or intercostal 2 of the following: subcostal, intercostal, substernal OR nasal flaring (infant) 3 of the following: subcostal, intercostal, substernal, suprasternal, supraclavicular OR nsasal flaring / head bobbing (infant)
3 Dyspnea        
  0-2 years Normal feeding, vocalizations and activity 1 of the following: difficulty feeding, decreased vocalization or agitated 2 of the following: difficulty feeding, decreased vocalization or agitated Stops feeding, no vocalization or drowsy and confused
  2-4 years Normal feeding, vocalizations and play 1 of the following: decreased appetite, increased coughing after play, hyperactivity 2 of the following: decreased appetite, increased coughing after play, hyperactivity Stops eating or drinking, stops playing, OR drowsy and confused
  > 4 years Counts to ≥ 10 in one breath Counts to 7 - 9 in one breath Counts to 4 - 6 in one breath Counts to ≤ 3 in one breath
4 Auscultation Normal breathing, no wheezing present End-expiratory wheeze only Expiratory wheeze only (greater than end expiratory wheeze) Inspiratory and expiratory wheeze OR diminished breath sounds OR both

To calculat the respiratory score add each variable's points: RR + Retractions + Dyspnea + Auscultation

  PATHWAY QUESTIONS
  Calculated Respiratory score less than 5
Albuterol MDI
8 puffs, Inhaled, ONCE
Albuterol nebulization
5 mg, Inhaled, ONCE
  Calculated Respiratory score equal to or greater than 5
Albuterol nebulized
20 mg, Inhaled, CONTINIOUS, Alert MD 1 hour after medication initiated
Ipatroprium bromide nebulized
0.75 mg, Inhaled, ONCE
  MEDICATIONS
  Glucocorticoids
      All patients with acute asthma exacerbations should receive systemic or nebulized glucocorticoids.
Dexamethasone (DECADRON) IV - Given orally
0.6 mg/kg Oral, ONCE, Max: 10 mg, Route: OK to give IV formulation orally.
Dexamethasone (DECADRON) IV
0.6 mg/kg IV/IM, ONCE, Max: 10 mg
  Pain Control (for potential future IV placement if necessary)
lidocaine (ELA-MAX, LMX) 4% cream
Topical, ONCE, Apply small amount to skin, PRN painful procedure, Note: takes 30 min to reach peak effect
lidocaine-tetracaine (SYNERA) patch 1 Patch
Transdermal, ONCE, for 30 min, PRN, painful procedure, Note: takes 20 min to reach peak effect
  Does patient have any contraindications to ondansteron?
      Allergy or hypersensitivity, long QT disorders
No
Ondansteron (Zofran) 0.15 PEDIATRIC IV infusion
0.15 mg/kg IV, EVERY 8 HOURS, PRN, nausea, vomiting
Ondansteron (Zofran ODT) ODT 4mg
4 mg PO, EVERY 8 HOURS, PRN, nausea, vomiting
  GENERAL
  Does this patient need to be NPO?
Yes
Diet NPO
Continuous
No
PO Challenge
Diet Regular
Nursing communication
Make patient NPO for respiratory distress, mental status changes or expectation of pending surgical or other procedure requiring sedation
  Does this patient require isolation?
      All patients with history of MRSA or VRE should receive Contact Isolation order.
Yes
Contact Isolation
(eg. MRSA, VRE, etc.)
Contact/Droplet Isolation
(eg. RSV, Rhinovirus, etc.)
Contact Plus
(eg. C. difficile, Norovirus)
Airborne Isolation
(eg. TB, VZV, Measles, etc.)
  Respiratory Therapy
  Supplemental Oxygen
MD to RN communication
Begin supplemental oxygen therapy for persistent oxygen saturation below 90% awake, 88% asleep or severe respiratory distress.
Pulse Oximetry/O2 Sats
STAT, CONTINUOUS, Indication: When patient is on supplemental oxygen
  IV FLUIDS
  IV Fluids
NS IV bolus
20 ml/kg, Intravenous, Once
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