UBC Department of Pediatrics Y3 Orientation Manual Appendix Clinical Resources Academic Year 2012- 2013 Appendix – Clinical Care Resources Summary The following documents are available from the UBC Pediatrics Website, Undergraduate Program Student Orientation Manual http://pediatrics.med.ubc.ca/education/undergraduate/year‐3‐student‐orientation‐manual 1. Asthma 2. Croup 3. Dehydration 4. Developmental Milestones 5. Febrile Seizure 6. Febrile UTI 7. Fever in Infants 0 – 60 days of age 8. Fluid and Electrolytes 9. Immunization Schedule 2012 10. Normal Lab Values September 2012 EMERGENCY DEPARTMENT MANAGEMENT OF ASTHMA Division of Emergency Medicine Patient > 1yr. presents to Emergency Department with 2 previous episodes of wheeze or diagnosis of asthma Mild (1) Accessory Muscle - minimal intercostal retractions Nurse categorizes Minimal wheeze - end-expiratory wheeze mild, moderate, Dyspnea - normal activity and speech, minimal dyspnea moderate severe, Peak Flow vs Personal Best - >70% severe Oxygen Sats on Room Air - >95% Moderate (2) Accessory Muscle - intercostal and substernal retractions Wheeze - pan-expiratory + inspiratory wheeze Moderate or Dyspnea - decreased activity 5-8 word sentences Moderate/Severe Peak Flow vs Personal Best - 51-70% Mild Case Severe Case Case Oxygen Sats on Room Air - 91-95% Moderate/Severe (3) Accessory Muscle - nasal flaring Notify Physician Salbutamol * Wheeze - wheeze audible without stethoscope Immediately and Exit every 20 minutes x 3 Salbutamol * every 20 Dyspnea - decreased activity <5 word sentences Pathway doses and minutes x 1-2 doses in Oxygen Sats on Room Air - 86-90% Transfer Patient to Ipratropium ** every the first hour Resuscitation Room 20 minutes x 3 doses Reassess after 1 hour Severe (4 ) EXIT PATHWAY in the first hour Accessory Muscle - nasal flaring/paradoxal movement Wheeze - silent or wheeze audible without stethoscope Give steroid as per Dyspnea - unable to speak 1-2 word sentences physician orders Oxygen Sats on Room Air - <86% after first MDI No treatment Minimal to no wheeze, no indrawing, no Physician to tachpynea, O sats >95%? reassess severity 2 Physician to assess re: Yes and categorize Severe discharge mild, moderate, Discharge Home moderate/severe, Discharge instructions: severe See asthma discharge form, Asthma education referral Follow-up With Primary Care Moderate/Severe Moderate Mild MD Within 3-7 Days Air entry Oxygen by NP/Mask Salbutamol * every 1 improved, no salbutamol * every 20 hour PRN until No indrawing, no Dose References: minutes until able to tolerate physician tachpynea every 1 hour. If vomiting reassessment O2 sats > 95%? repeat steroid or give IV * Salbutamol 5 puffs (<20 kg) or 10 puffs (>20 kg) via spacer Yes ** Ipratropium Salbutamol * every 1 Air entry improved, few 3 puffs (<20 kg) or 6 puffs (>20 kg) via spacer hour regularly and Observe for 2 hrs No wheezes, no indrawing, every 30 minutes If stable and no no tachpynea PRN further ER O sats > 95%? 2 treatment required Asthma Education Referral Criteria: Yes Diagnosis of Asthma Still 18 months of age or older Discharge Home tachypneic, Medical team and family aware of referral Observe for 2 hrs Discharge instructions: See decreased air entry, Need to have a BCCH medical record No If okay and no asthma discharge form, wheezy, indrawing, O number 2 further ER Asthma education referral sats <95% or salbutamol treatment required Follow-up With Primary Care >q4h after 8 hours? MD Within 3-7 Days BCCH Emergency Management of Admit to ERO or Asthma Clinical Pathway th Yes hospital Revised: October 28 , 2008 Name DOB: EMERGENCY DEPARTMENT ASTHMA DISCHARGE/ASTHMA EDUCATION REFERRAL This form is your child’s asthma plan and is completed by the doctor. Please follow this plan until you see your family doctor in 3-7 days. RELIEVER/RESCUE INHALER Relaxes tight muscles around the airways, starts working within 5 minutes and should last 4 hours. Used daily for a few days when recovering from an asthma attack, then only if needed. Inhale: Salbutamol/Ventolin Metered Dose Inhaler (blue) 100ug (micrograms) Other: ______ puff(s) every ______ hours for ______ days then ______ puff(s) every ______ hours as needed Next due: PREVENTER INHALER Use every day, reduces swelling and mucous in the airways. Always drink water or rinse mouth with water after each use. Inhale: Fluticasone/Flovent Metered Dose Inhaler (orange) 125ug 250ug Fluticasone/Flovent Diskus (orange) 100ug 250ug 500ug Budesonide/Pulmicort Turbuhaler (brown) 100ug 200ug 400ug Other: ______ puff(s) in the morning and at night until reassessed by your doctor Next due: ORAL STEROID Reduces airway swelling. Take by mouth: Dexamethasone ______ mg(milligrams) by mouth once a day for ______ day(s) Prednisone______ mg by mouth once a day for ______ day(s) Next due: CALL 911 IF YOUR CHILD: . has severe trouble breathing, talking, walking, or is feeling dizzy . has blueness of skin, lips or fingernails GO TO NEAREST EMERGENCY IF YOUR CHILD: . is using the reliever more than every 4 hours . has hard, fast breathing at rest and has pulling in of skin between the ribs While waiting for the ambulance or on the way to Emergency, you may give the reliever every 10 minutes as needed. INFORMATION HANDOUTS: FOLLOW UP APPOINTMENTS: “About Asthma” Pamphlet Family Doctor or Pediatrician: __________________________________________ Other Handouts A referral to the Asthma Education Clinic has been made. The clinic will call you. If you have any questions please call 604-875-2345 ext. 7461 MD Signature Date/Time Parent/Guardian/Patient’s Signature HEALTH RECORDS Name DOB: EMERGENCY DEPARTMENT ASTHMA DISCHARGE/ASTHMA EDUCATION REFERRAL This form is your child’s asthma plan and is completed by the doctor. Please follow this plan until you see your family doctor in 3-7 days. RELIEVER/RESCUE INHALER Relaxes tight muscles around the airways, starts working within 5 minutes and should last 4 hours. Used daily for a few days when recovering from an asthma attack, then only if needed. Inhale: Salbutamol/Ventolin Metered Dose Inhaler (blue) 100ug (micrograms) Other: ______ puff(s) every ______ hours for ______ days then ______ puff(s) every ______ hours as needed Next due: PREVENTER INHALER Use every day, reduces swelling and mucous in the airways. Always drink water or rinse mouth with water after each use. Inhale: Fluticasone/Flovent Metered Dose Inhaler (orange) 125ug 250ug Fluticasone/Flovent Diskus (orange) 100ug 250ug 500ug Budesonide/Pulmicort Turbuhaler (brown) 100ug 200ug 400ug Other: ______ puff(s) in the morning and at night until reassessed by your doctor Next due: ORAL STEROID Reduces airway swelling. Take by mouth: Dexamethasone ______ mg (milligrams) by mouth once a day for ______ day(s) Prednisone______ mg by mouth once a day for ______ day(s) Next due: CALL 911 IF YOUR CHILD: . has severe trouble breathing, talking, walking, or is feeling dizzy . has blueness of skin, lips or fingernails GO TO NEAREST EMERGENCY IF YOUR CHILD: . is using the reliever more than every 4 hours . has hard, fast breathing at rest and has pulling in of skin between the ribs While waiting for the ambulance or on the way to Emergency, you may give the reliever every 10 minutes as needed. INFORMATION HANDOUTS: FOLLOW UP APPOINTMENTS: “About Asthma” Pamphlet Family Doctor or Pediatrician: __________________________________________ Other Handouts A referral to the Asthma Education Clinic has been made. The clinic will call you. If you have any questions please call 604-875-2345 ext. 7461 MD Signature Date/Time Parent/Guardian/Patient’s Signature PATIENT CARBON COPY EMERGENCY DEPARTMENT ASTHMA DISCHARGE/ASTHMA EDUCATION REFERRAL Health Care Professionals: Please check appropriate device for patient. HOW TO USE A PUFFER/MDI (METERED DOSE INHALER) WITH A SPACER AND MASK (UP TO AGE 5 YEARS) 1. Take the cap off the puffer (MDI) 6. Hold on face for 5-10 breaths or hold breath for 2. Shake the puffer (MDI) for 30 seconds 10 seconds 3. Put the puffer into spacer 7. Slow deep breaths are best 4. Cover the mouth and nose with mask and seal 8. For second puff wait 30 seconds and repeat steps 2-7 against face 5. Push puffer (MDI) down once HOW TO USE A PUFFER (MDI) WITH A SPACER AND MOUTHPIECE (5 YEARS AND UP) 1. Take the cap off the puffer and spacer 8. Note: if you are using a blue Aerochamber, and you 2. Shake the puffer for 30 seconds hear a “whistling” sound, you are breathing in too 3. Put puffer into spacer fast! 4. Breathe out 9. Hold breath for 10 seconds (if unable to hold breath, 5. Seal lips around spacer mouthpiece take 5 slow, deep breaths) 6. Push puffer down once 10. For second puff wait 30 seconds and repeat steps 2 to 7. Breathe in slowly and deeply 9 HOW TO USE A DISKUS (ABOUT 4 YEARS AND UP) 1. Open the Diskus 5. Hold breath for 10 seconds 2. Slide the lever to click 6. Close the Diskus 3. Breathe out, then seal lips around the mouthpiece 7. For second dose repeat steps 1-6 4. Breathe in deeply and fast HOW TO USE A TURBUHALER (ABOUT 6 YEARS AND UP) 1. Remove cover 6. Place between lips 2. Hold Turbuhaler upright 7. Breathe in deeply and quickly 3. Turn the base in one direction and back 8. Hold breath for 10 seconds 4. Listen for a “click” sound 9. For second dose repeat steps 2-9 5. Breathe out away from device 10. Replace cover BACK OF PATIENT COPY PHYSICIANS’ ORDERS WRITE FIRMLY WITH A BALLPOINT PEN WEIGHT kg HEIGHT cm Pharmacy Date & Time Noted by Use Only PROVIDE PHYSICIAN NAME, COLLEGE NUMBER, PAGER NUMBER, SIGNATURE RN/UC Emergency Management of Asthma 1 hour after clinical pathway initiated by registered nurse (see flowchart overleaf) 1. Mild Exacerbation Hold further Salbutamol 2.