NASXXX10.1177/1942602X17740142NASN School NurseNASN School Nurse 740142research-article2017

Ask the E.R. Pediatrician School Nurses on the Front Lines of Medicine Take a BREATH: The Approach to a Student With Respiratory Distress Morgann Loaec, BS Robert P. Olympia, MD

Students presenting with varying degrees athletics as well as sports-related illness dehydration, shortness of breath, severe of respiratory symptoms and distress and injuries. He has presented his allergic reaction, lacerations/abrasions, occur commonly in the school setting. research both regionally and nationally sprains/strains/contusions, head injury/ It is important to develop a differential and has lectured on a variety of topics headaches, heat-related illness, acute diagnosis for respiratory distress, to pertaining to pediatric emergency mental status changes, seizures, cardiac initiate stabilization of the student with medicine, such as fever and infectious arrest, chest pain, fainting, abdominal life-threatening symptoms, and to triage diseases, trauma, sport-related injuries, pain, and extremity fractures. these students to an appropriate level of and disaster preparedness. Special features unique to each article care (back to the classroom, home with are Extracredit Points and Report Cards. their guardian with follow up at their Who Is Dr. Olympia’s Co-Author? Extracredit Points are trivia questions or primary health care provider’s office, Morgann Loaec is a fourth-year medical clinical pearls scattered throughout the or directly to the closest emergency student at the Penn State University article related to the topic at hand. department via Emergency Medical College of Medicine. She is interested in Report Cards are concise tables Services). This article describes the initial pursuing a career in pediatrics and summarizing key points in each article assessment and management of a student completed her pediatric clinical that you can photocopy and laminate, or presenting with respiratory distress. experiences in general pediatrics and photograph and keep on your smart pediatric emergency medicine at the device, for easy access. Keywords: respiratory distress; acute Penn State Hershey Children’s Hospital. asthma; anaphylaxis Case What Is the Purpose of the Two students simultaneously present Who Is the ER Pediatrician? “School Nurses on the Front to the nurse’s office during lunch Dr. Robert Olympia, MD, is a pediatric Lines of Medicine” Series? period, both with complaints of emergency medicine physician with over The “School Nurses on the Front Lines difficulty breathing. You immediately 20 years of experience, currently of Medicine” series will present cases recognize Jenny, a 9-year-old with a working in an emergency department in reflecting emergencies commonly history of severe asthma, with frequent the Sweetest Place on Earth (Hershey, encountered in the school setting, visits to your office since the beginning PA). He is a professor in the Departments focusing on an evidence-based approach of the school year for similar symptoms. of Emergency Medicine and Pediatrics at to the initial management, stabilization, She seems out of breath and unable to the Penn State College of Medicine. His and disposition of the ill or injured child. speak. She does not have blueness of research interests include emergency and Topics to be covered in this series will her lips. Her heart rate (140 beats per disaster preparedness for children in the include children presenting with a chief minute) and respiratory rate (32 breaths setting of schools and school-based complaint of fever, vomiting/diarrhea/ per minute) are fast, she has

DOI: 10.1177/1942602X17740142 For reprints and permission queries visit SAGE’s Web site, http://www.sagepub.com/journalsPermissions.nav. © 2017 The Author(s) January 2018 | NASN School Nurse 29 suprasternal and intercostal retractions, After You Take a Few retractions)? If you have a stethoscope and on lung examination, you “BREATHS,” Remember Your readily available, listen for breath sounds auscultate diminished air entry and faint ABCs in all lung fields. There should be good expiratory wheezes throughout all lung aeration in all lung fields without The management of a student fields. Her extremities are warm and crackles, rales, or wheezing. Students presenting with respiratory distress may well perfused with a capillary refill of experiencing an exacerbation of asthma be challenging, especially if the student’s 2 seconds. or lower airway obstruction will often presentation includes life-threatening The other student is John, a 7-year-old have an increased respiratory rate and signs and symptoms, such as inability to whom you do not recognize. He was may have either decreased lung sounds speak, airway edema, fast and labored eating lunch in the cafeteria when he or abnormal breath sounds, most breathing, poor perfusion of the was noted to be stumbling about with commonly wheezing, on auscultation. extremities, depressed mental status, or significant swelling to his face and lips. Wheezing is often heard most clearly at slowed respiratory rate. The initial He is pale and appears very weak and the end of expiration and is described as assessment of a student always begins unable to speak. His heart rate (146 a high pitch and whistling sound. In with the ABCs. beats per minute) and respiratory rate more severe cases (lack of air (40 breaths per minute) are fast. On lung movement), there will be an absence of examination, you auscultate no breath Airway and Breathing breath sounds in occluded airways, sounds. His extremities are cool and Is the student able to speak to you? If resulting in an absence of auscultated clammy, and his capillary refill is he or she is able to speak, then his or wheezing. In children with pneumonia, prolonged. You notice hives over his face her airway is open. If the student is you may be able to auscultate crackles/ and extremities. As you collect your unconscious or cannot speak, open his rales (high-pitched sounds on thoughts, John proceeds to vomit all over or her airway with simple positioning inspiration) and/or rhonchi (low-pitched himself. What do you do? (head tilt-chin lift) and clearing any sounds on inspiration). secretions or vomitus from the airway, if Extracredit Point: What Is present. Suspicion of an obstructing Extracredit Point: What Are Your Differential Diagnosis foreign body (a student who is gagging Normal Respiratory Rates for for a Child Presenting With or drooling, presenting with stridor [a Children? Respiratory Distress? high-pitched sound that can be heard The normal respiratory rates for Respiratory complaints, such as nasal without a stethoscope on inspiration], or children are: 30-40 breaths per minute congestion, cough, and difficulty in the “tripod” position [student leaning for older infants and toddlers, 20-30 breathing, are common reasons why forward, neck is hyperextended, mouth breaths per minute for elementary children seek medical attention. is open, and both arms extended school-aged children, and 12-20 breaths Respiratory distress may manifest as forward in front of them, as in a camera per minute for older children and either fast, labored breathing or poor tripod]) may require immediate use of adolescents. respiratory effort and decreased the Heimlich maneuver. Severe allergic Extracredit Point: What Are respiratory rate. Several studies have reactions can result in airway edema and Other Sounds You May Hear shown that respiratory distress and loss of airway, as well as involvement of Without a Stethoscope in a seizures are the most common medical the cardiovascular, pulmonary, and Student With Respiratory emergencies that prompt school nurses gastrointestinal systems; and therefore, Distress? and staff to contact Emergency Medical immediate recognition and Services (EMS) in order to transport administration of an epinephrine Grunting on expiration indicates lower students to the closest emergency autoinjector, if available, is of paramount airway disease (asthma, pneumonia). department (Knight, Vernon, Fines, & importance. Lastly, in a student with Grunting is a sound that results from Dean, 1999; Olympia, Wan, & Avner, airway compromise, it is important to closing of the glottis to maintain pressure 2005). When faced with a student keep him or her as comfortable as in the lower airways (peak end presenting with respiratory distress, it is possible. Crying, screaming, or expiratory pressure) so that the imperative for the school nurse to hyperventilation may compromise his or bronchioles do not collapse. A barky or develop a differential diagnosis, the her airway even further. seal-like cough (croup) indicates edema process of distinguishing between What is the respiratory rate? Are the in the subglottic region and tracheal symptoms to assist in guiding nursing students’ lips blue (consistent with obstruction. diagnosis and interventions. This cyanosis or lack of oxygen in their differential diagnosis can be blood)? Do the students have evidence Circulation summarized by the mnemonic of respiratory distress (fast or labored What are the students’ heart rate and “BREATHS” (Table 1: REPORT breathing, shallow breaths, absent chest blood pressure? Are their extremities well CARD). rise, suprasternal, or intercostal perfused (warm and pink skin, strong

30 NASN School Nurse | January 2018 Table 1. REPORT CARD: Differential Diagnosis of Respiratory Distress in a Child or Adolescent Student (“BREATHS”)

Category Examples Presenting Symptoms in Addition to Signs of Respiratory Distress

BRAIN Increased intracranial pressure Cushing’s Triad (hypertension, bradycardia, abnormal respiratory pattern), (tumor, bleed, hydrocephalus) depressed mental status

Meningitis, encephalitis Depressed or change in mental status, headache, stiff neck, nausea/vomiting

Intoxication or poisoning Recognition of toxidrome (Patterson, Brady, & Olympia, 2017), such as opioid/narcotics, alcohol, marijuana, cocaine/amphetamine, anticholinergics, ecstasy, inhalants, salicylates

Seizure or postictal period Typical tonic-clonic activity, depressed mental status

Psychologic Anxiety, depression, headache, blurry vision, trouble swallowing, chest pain, palpitations, dizziness/lightheadedness, abdominal pain/nausea/ vomiting, weakness/numbness/paresthesias of the extremities

RESPIRATORY (lungs) Asthma or reactive airway disease Depressed mental status, difficulty speaking, nasal congestion, cough, wheezing on lung auscultation

Pneumonia Fever, nasal congestion, cough, chest pain, abdominal pain, vomiting

Inhalation (smoke inhalation, Lightheadedness, dizziness, weakness, confusion, headache, cough, carbon monoxide) chest pain, nausea/vomiting

Anaphylaxis, allergic reaction Depressed mental status, dizziness, lightheadedness, poor extremity perfusion, facial swelling, generalized swelling and/or hives, abdominal pain/cramping, nausea/vomiting, diarrhea

ENTRAILS Bowel obstruction Abdominal distension, abdominal pain, nausea/vomiting, decreased (gastrointestinal appetite, decreased frequency of bowel movements, pain with bowel tract) movements, hard stool

Appendicitis Right lower quadrant abdominal pain, severe pain with movement, nausea/vomiting, decreased appetite, fever, loose stool

AIRWAY Obstruction (foreign body) Gagging/drooling, cough, difficulty speaking, depressed mental status, “tripoding” position

Upper respiratory infection/sinusitis Nasal discharge, sneezing, cough, fever, headache

Pharyngitis Sore throat, fever, headache, cough, neck pain, abdominal pain, nausea/ vomiting, rash

Abscess (retropharyngeal, Fever, difficulty speaking, hoarse voice, drooling, inability to turn head, peritonsillar) cough

Croup, epiglottitis, tracheitis Fever, nasal congestion, barking cough, stridor, drooling, “tripoding” position

TRAUMA Head, face, spinal cord, chest, Symptoms depend on mechanism of injury and organ system involved abdomen

HEART Abnormal heart beats (tachycardia Chest pain, palpitations, cough, dizziness or lightheadedness, fainting or bradycardia) episode

Congestive heart failure Chest pain, cough, generalized edema, hepatosplenomegaly, tachycardia (myocardial infarction, myocarditis)

SHOCK Hypovolemic, distributive, Depressed mental status, poor perfusion of the extremities, decreased cardiogenic, septic, neurogenic urine output, tachycardia, normal or decreased blood pressure, other symptoms based on type/etiology of shock

January 2018 | NASN School Nurse 31 Table 2. REPORT CARD: Differential Diagnosis of Altered Mental Status in a Child or Adolescent Associated With Respiratory Distress: “AEIOU-TIPS”

A – Alcohol, anoxia/hypoxia (lack of oxygen provided to the brain, usually from respiratory disease or failure) E – Epilepsy or seizure (respiratory distress either during the seizure or after the seizure is over [postictal period]) I – Insufficient glucose or high glucose (hypoglycemia may lead to slow respiratory rates, hyperglycemia or diabetic ketoacidosis may lead to “Kussmaul breathing,” or abnormally deep, rapid, labored breathing) O – Overdoses (intoxications/ingestions may lead to fast or depressed breathing patterns) U – Uremia (kidney disease resulting in high blood pressure or inability of the body to remove toxins from the body) or hepatic failure (liver disease leading to the production of neurotoxins) may lead to congestive heart failure or pulmonary edema/inflammation T – Trauma (head injury or concussion leading to Cushing’s Triad) I – Infection (meningitis or encephalitis) or inflammation (vasculitis, or swelling of blood vessels in the brain, associated with connective tissue or rheumatologic diseases or disorders) affecting respiratory drive P – Psychiatric disorders (bipolar, depression, post-traumatic stress disorder, anxiety, etc.) leading to fast or slowed breathing S – Shock (inability to provide important nutrients to end organs, such as the brain, secondary to infection/sepsis, anaphylaxis, heart failure, or blood/fluid losses)

and regular pulses, capillary refill time “AVPU”: alert, responsive to verbal temperature to help in your differential less than 2 seconds)? A student with a stimulus, responsive to painful stimulus, diagnosis. Respiratory infections, such as fast heart rate and evidence of poor unresponsive. A quick assessment of the croup and pneumonia, can cause extremity perfusion may be exhibiting neurologic status of a student with respiratory distress and would present shock (inability of the body to provide altered mental status includes with a fever (temperature >100.4 F). important nutrients and oxygen to vital examination of the pupils and strength/ Also, having a temperature can increase organs). A normal blood pressure does sensation of the upper and lower your respiratory rate without a not exclude shock, especially in the early extremities: Are the pupils equal and respiratory infection. phases of shock. A child in shock may responsive to light? Are they normal in have tachypnea and respiratory distress size (2-4 millimeters)? Do the eyes move •• Skin exam: as a direct result of their poor perfusion up and down, left and right on (metabolic acidosis with compensatory command? Is there normal strength and Does the student have central cyanosis respiratory alkalosis). sensation (to touch) to the bilateral arms (blueness of the lips, tongue, and trunk)? Severe allergic reactions can result in and legs, and are the strength and Central cyanosis may indicate hypoxia, anaphylactic shock, resulting in sensation equal on both sides? or decreased oxygen in the blood. Does widespread dilation of blood vessels, The mental status of a student who is the student appear pale? Anemia (low leading to poor perfusion and overall experiencing respiratory distress is hemoglobin and hematocrit) can present compromise of the blood supply to vital usually intact, however respiratory with tachypnea and respiratory distress. organs including the brain. Cardiogenic distress may lead to severe hypoxia (very Anaphylaxis may present with skin shock, either from the heart muscle not low oxygen carried in the blood), with (hives, periorbital edema) or mucosal pumping effectively or from tamponade subsequent cardiac and/or respiratory (redness or swelling of lips, tongue, or (fluid within the pericardium from arrest. Anaphylaxis can affect the blood eye conjunctiva) findings, or both. Skin trauma or connective tissues diseases), pressure and may cause light headedness findings will occur in 90% of cases of leading to congestive heart failure, can or the student may collapse. Other anaphylaxis, and acute onset of illness present with respiratory distress. Septic causes of depressed mental status with associated skin and mucosal shock, associated with serious bacterial (mnemonic “AEIOU-TIPS”, Table 2. findings is one of the three criteria in the infections such as meningitis, REPORT CARD) may be associated with diagnosis of anaphylaxis. Petechiae pneumonia, bacteremia, or urinary tract respiratory distress from a variety of (purple, pinpoint lesions that do not infections, can result in respiratory pathophysiologic reasons. blanch with pressure), purpura (bruises), distress from various mechanisms. or erythroderma (generalized redness of Other Important Physical Exam the skin, increased in the skin folds) may Disability Findings be associated with septic shock What is the student’s neurologic exam? •• Temperature: (Silverman, 2015). Is the student alert and oriented to Lastly, examine the skin for evidence of person, place, and time? The overall In addition to paying close attention to trauma, such as tender swelling, bruising, neurologic status of a student can be the respiratory rate, heart rate, and blood or lacerations. Head trauma can present described quickly by the mnemonic pressure, take note of the body with depressed mental status and/or

32 NASN School Nurse | January 2018 Table 3. REPORT CARD: Diagnostic Criteria for Anaphylaxis

Anaphylaxis is highly likely when any 1 of the following 3 criteria is fulfilled following exposure to an allergen:

I. Acute onset of an illness (minutes to several hours) with involvement of the skin, mucosal tissue, or both (e.g., generalized hives, pruritus or flushing, swollen lips-tongue-uvula) and at least 1 of the following: a. Respiratory compromise (e.g., dyspnea, wheeze, bronchospasm, stridor, hypoxemia) b. Reduced BP or associated symptoms of end-organ dysfunction (e.g. hypotonia [collapse], syncope, incontinence)

II. 2 or more of the following that occur rapidly after exposure to a likely allergen for that patient (minutes to several hours): a. Involvement of the skin-mucosal tissue (e.g., generalized hives, itch-flush, swollen lips-tongue-uvula) b. Respiratory compromise (e.g., dyspnea, wheeze, bronchospasm, stridor, reduced PEF, hypoxemia) c. Reduced BP or associated symptoms (e.g., hypotonia [collapse], syncope, incontinence) d. Persistent GI symptoms (e.g., painful abdominal cramps, vomiting)

III. Reduced BP after exposure to a known allergen for that patient (minutes to several hours): a. Infants and children: low systolic BP (age specific) or > 30% decrease in systolic BP b. Adults: systolic BP < 90 mmHg or > 30% decrease from that person’s baseline

Source: Sampson, 2006.

Cushing’s triad (hypertension, There is no evidence of shock. You closed airways, and in constriction of the bradycardia, abnormal respiratory promptly administer four puffs of her dilated blood vessels. Administration pattern). Facial trauma can lead to upper rescue inhaler with spacer and await should be given in the mid-outer thigh airway compromise. Spinal cord trauma EMS for transport. (vastus lateralis muscle) at a dose of can result in shock, leading to respiratory You are very concerned about John’s 0.15 mg in a young child and 0.3 mg in a distress. Trauma to the chest can result in clinical presentation. His depressed child or teenager (Sicherer, Simons, & a pneumothorax, hemothorax, mental status, facial/lips swelling, lack of Section on Allergy and Immunology, pulmonary contusion, or cardiac breath sounds on auscultation, and 2017). Students who have been tamponade, leading to respiratory evidence of hypoperfusion consistent administered intramuscular epinephrine distress. Abdominal trauma may lead to with shock has you worried. In addition, should be observed in an emergency obstruction, distension, or massive he has generalized hives and department setting for at least 4 hours in bleeding, resulting in respiratory gastrointestinal symptoms. Although he the event of worsening symptoms as the compromise. has no reported past medical history or epinephrine wears off. allergies listed on his medical records, Heroic Actions Begin With you recognize that his symptoms may be Wrapping Up: Asthma and Prompt Recognition related to a severe allergic reaction Anaphylaxis You recognize very quickly that (Sampson et al., 2006), or anaphylactic Approximately 6 million children under Jenny and John both have signs of shock (Table 3. REPORT CARD), possibly the age of 18 years have a diagnosis significant respiratory distress. Both are from a food allergen he was exposed to of asthma (8.4% of the pediatric experiencing potentially life-threatening during lunch. Based on the laws of your population), resulting in 1.6 million visits symptoms and require prompt transport state and the policy of your school to an acute care setting per year for an via EMS to a higher level of care. As you district, you are able to administer acute asthma exacerbation (Centers for have a school administrator contact local intramuscular epinephrine to John while Disease Control and Prevention, 2017). EMS, you go through your differential you await EMS for transport. Unfortunately, uncontrolled asthma in a diagnosis of respiratory distress student may lead to absenteeism, poor (“BREATHS”) and perform the initial Extracredit Point: What Action school performance, frequent visits to assessment and management of ABCs. Does Epinephrine Have in the the school nurse for shortness of breath, You believe Jenny is having an asthma Treatment of Anaphylaxis? and may affect social relationships and exacerbation, as she has presented to Intramuscular epinephrine is critical to self-confidence (Isik & Isik, 2017). your office several times in the past with the treatment of a student experiencing a Students with a diagnosis of asthma are similar symptoms. Although she is severe allergic reaction because it often classified as mild, moderate, or unable to speak in full sentences, she is addresses the systemic effects of severe, based on the persistency of their able to follow commands. You realize anaphylaxis. Epinephrine administration symptoms, including nighttime that in order to auscultate expiratory results in suppression of the allergic symptoms, daytime symptoms, and wheezes, air movement is required. mediators in the body, in the opening of activity restriction (U.S. Department of

January 2018 | NASN School Nurse 33 Table 4. REPORT CARD: Life-Threatening Presentations of Respiratory Distress Requiring Immediate EMS Transport

•• Inability to speak or speak in full sentences •• Evidence of upper airway obstruction—gagging, drooling, gurgling respirations, stridor, “tripod” positioning •• Significant lips, tongue, or facial swelling •• Central cyanosis •• Evidence of lower airway disease—grunting, nasal flaring, intercostal retractions, tachypnea •• Decreased aeration on lung auscultation associated with wheezing, crackles, or rhonchi •• Depressed mental status •• Cushing’s triad (hypertension, bradycardia, abnormal respirations) •• Evidence of shock (poor perfusion of end organs) •• Evidence of anaphylaxis (TABLE 3. REPORT CARD) •• Concern for congestive heart failure (tachycardia, tachypnea, hepatosplenomegaly) •• Significant chest or abdominal pain •• Concern for chemical or thermal burn of the airway •• Ingestion or inhalational injury •• Significant trauma to head, face, cervical spine, chest, and/or abdomen

Health and Human Services, 2012). (Muraro et al., 2014; Sicherer & Mahr, Case Resolution Common triggers for an acute asthma 2010; Simons, 2011). Written guidelines exacerbation include seasonal allergies, may include allowing students to carry Both Jenny and John arrive to the smoke and other environmental and self-administer an epinephrine emergency department within 15 minutes allergens, infections (upper respiratory autoinjector, giving schools authority to after leaving your school. Jenny infections, sinusitis, pneumonia, and maintain a stock supply of epinephrine continues to complain of shortness of influenza), weather temperature changes, autoinjectors to use in an emergency, breath with evidence of intercostal and physical activity/exercise. For establishing policies related to allergen- retractions. Her respiratory rate is 30 students with a diagnosis of asthma, free snacks and cleaning of surfaces and breaths per minutes, and her oxygen school nurses can implement the asthma other means of reducing allergen saturation on room air is 93%. She is care checklist developed by NASN for the exposure, and creating standing orders given 3 Albuterol/Atrovent combination assessment, diagnosis, outcomes, allowing school nurses to administer nebulized treatments over 1 hour, planning, implementation, and evaluation epinephrine to those experiencing followed by 2 hours of continuous of student needs (“School Nurse Asthma anaphylaxis without a prior diagnosis of albuterol treatments and an oral dose of Care Checklist,” 2015). allergy (Wang, Sicherer, & Section on prednisone with complete resolution of Approximately 6 million children under Allergy and Immunology, 2017). her symptoms. Following an additional the age of 18 years have food allergies, Therefore, school nurses have a 1 hour of observation, she is discharged resulting in approximately 300 thousand responsibility to ensure that all students to home with a prescription for a 5 day ambulatory care visits per year for an at risk for anaphylaxis have an course of prednisone, to follow up with acute exacerbation due to exposure emergency action plan, that school staff her pediatrician in 1-2 days. (Food Allergy Research and Education, is educated to assist in the recognition On the other hand, John arrives to the n.d.). According to Branum and Lukacs and management of acute allergic emergency department with signs of (2008), the prevalence of food allergies reactions, and that efforts are made to anaphylactic shock. His heart rate is 180 in children has increased by 18% over create an allergy-safe environment on beats per minute, his respiratory rate is the past decade. The most common their school campus (Jackson, 2013). 50 breaths per minute, and his blood allergens leading to a diagnosis include pressure is low at 76/30. He is given a milk, eggs, wheat, soy, peanuts, tree second epinephrine dose intramuscularly, nuts, fish, and shellfish. Unfortunately, Life-Threatening Presentations and an IV is placed for the administration 20-25% of epinephrine administration in of Respiratory Distress of a normal saline bolus, Benadryl, schools involve students whose allergy Although most students who present to Methylprednisolone, and Famotidine. was unknown at the time of the reaction. your office with respiratory symptoms Nebulized albuterol with oxygen is National and international guidelines will not have a life-threatening condition, started for his bronchospasm. Because of support the use of a written allergy and reasons for immediate transfer via EMS his worsening mental status and concern anaphylaxis emergency plan to optimize are delineated in Table 4. REPORT for developing airway edema, he is the care of children at risk of anaphylaxis CARD. intubated and placed on a ventilator. An

34 NASN School Nurse | January 2018 epinephrine intravenous continuous drip children at school and nonschool locations. anaphylaxis. World Allergy Organization is started, and he is transferred to the Pediatrics, 103(6), E811-E815. Journal, 4(2), 13-37. pediatric intensive care unit. After 1 Muraro, A., Roberts, G., Worm, M., Biló, M.B., U.S. Department of Health and Human Services. week in the ICU, he is extubated and Brockow, K., Fernández Rivas, M., et al. National Institutes of Health. (2012). Asthma (2014). EAACI Food Allergy and Anaphylaxis care quick reference, diagnosing and subsequently discharged home with an Guidelines Group. Anaphylaxis: Guidelines managing asthma. Retrieved from https:// epinephrine autoinjector. It is determined from the European Academy of Allergy and www.nhlbi.nih.gov/files/docs/guidelines/ that John has an allergy to tree nuts, for Clinical Immunology. Allergy, 69(8), 1026-1045. asthma_qrg.pdf which he was exposed to on the day that Olympia, R. P., Wan, E., & Avner, J. R. (2005). Wang, J., Sicherer, S. H., & Section on Allergy his severe allergy symptoms started in The preparedness of schools to respond to and Immunology. (2017). Guidance on the cafeteria. An allergy emergency emergencies in children: A national survey of completing a written allergy and anaphylaxis action plan is developed by his school nurses. Pediatrics, 116(6), e738-e745. emergency plan. Pediatrics, 139(3), pii:e20164005. pediatrician and forwarded to you in the Patterson, K., Brady, J., & Olympia, R. P. (2017). event of any future allergen exposures. School nurses on the front lines of medicine: Uppers and downers: The approach to the Contact Dr. Olympia student with altered mental status. NASN Morgann Loaec, BS School Nurse, 32(6), 350-355. Medical student If you have a clinical question, send Sampson, H. A., Munoz-Furlong, A., Campbell, Penn State Hershey Children’s Hospital your question to Dr. Olympia (rolympia@ R. L., Adkinson, N. F., Jr., Bock, S. A., Branum, Hershey, PA hmc.psu.edu). Questions will be selected A., et al. (2006). Second symposium on the Morgann Loaec is a fourth-year and discussed as part of the “School definition and management of anaphylaxis: summary report-Second National Institute of medical student at the Penn State Nurses on the Front Lines of Medicine” Allergy and Infectious Disease/Food Allergy and University College of Medicine. She series. ■ Anaphylaxis Network symposium. Journal of is interested in pursuing a career in Allergy and Clinical Immunology, 117, 391-397. References pediatrics and completed her School nurse asthma care checklist. pediatric clinical experiences in Branum, A. M., & Lukacs, S. L. (2008). Food (2015). NASN. Available at https:// allergy among U.S. children: Trends in higherlogicdownload.s3.amazonaws general pediatrics and pediatric prevalence and hospitalizations (NCHS data .com/NASN/3870c72d-fff9-4ed7-833f- emergency medicine at the Penn brief no 10). Hyattsville, MD: National Center 215de278d256/UploadedImages/PDFs/ State Hershey Children’s Hospital, for Health Statistics Practice%20Topic%20Resources/2015_ Hershey, Pennsylvania. Centers for Disease Control and Prevention. asthma_c are_checklist.pdf (2017). National Center for Health Statistics: Sicherer, S. H., & Mahr, T. (2010). Section on Robert P. Olympia, MD Asthma. Retrieved from https://www.cdc.gov/ Allergy and Immunology. Management of Attending pediatric emergency medicine nchs/fastats/asthma.htm food allergy in the school setting. Pediatrics, Food Allergy Research and Education. (n.d.). 126(6), 1232-1239. physician Penn State Hershey Medical Center Food allergy facts and statistics for the U.S. Sicherer, S. H., Simons, F. E. R., & Section on Retrieved from https://www.foodallergy.org/ Allergy and Immunology. (2017). Epinephrine Hershey, PA sites/default/files/migrated-files/file/facts-stats for first-aid management of anaphylaxis. Dr. Robert P. Olympia is a physician .pdf Pediatrics, 139(3), pii: e20164006. boarded in both Pediatrics and Isik, E., & Isik, I. S. (2017). Students with asthma Silverman, A. M. (2015). Septic shock: Recognizing Pediatric Emergency Medicine with and its impacts. NASN School Nurse, 32(4), and managing this life-threatening condition over 20 years of clinical experience. 212-216. in pediatric patients. Pediatric Emergency His research interests include Medicine Practice, 12(4), 1-25. Jackson, V. (2013). School nurse’s role in emergency and disaster preparedness supporting food allergy safe schools. NASN Simons, F. E., Ardusso, L. R., Bilo, M. B., for children in the setting of schools School Nurse, 28(2), 76-77. El-Gamal, Y. M., Ledford, D. K., & Ring, J. and school-based athletics. Knight, S., Vernon, D. D., Fines, R. J., & Dean, (2011). World Allergy Organization guidelines J. M. (1999). Prehospital emergency care for for the assessment and management of

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