Emergency Department Asthma Medical Directive-Paediatric Age 1 to 17 years

Medical Directive ID: 
EMG-2014-008
Lead Contact Person: 
Cathy Trocchi
Christina Scerbo
Alyson Wilson
Physician/Nurse Lead: 
Dr. Rod Lim, Site Chief Paediatric Emergency Medicine
Program: 
Emergency Medicine - Paediatric Emergency Department
Approval By: 
Medical Advisory Committee
Original Effective Date: 
Wednesday, April 10, 2013
Revised Date: 
Wednesday, June 8, 2016
To Be Reviewed Date: 
Saturday, June 8, 2019
This Medical Directive Applies to the following sites: 
LHSC-VH
This Medical Directive Applies to the following patient population: 
Out-Patients
Paediatrics
Order: 

 

The Registered Nurse (RN) / Registered Respiratory Therapists (RRT) in the Paediatric Emergency Department will initiate the following assessments and treatment for the treatment of asthma in children;

 Physical assessment and chest auscultation

  • Vital signs (temperature, pulse, respirations and blood pressure)

  • Oxygen saturation (SpO2)

  • Weight

  • Paediatric Respiratory Assessment Measure (PRAM) score (Appendix A)

  • Initiate and titrate supplemental oxygen to maintain/obtain SpO2 greater than or equal to 92%

 Mild Asthma Exacerbation:

 In the setting of PRAM score equal to 1-3 (including the presence of wheeze):

  • Administer salbutamol: metered dose inhaler (MDI) with spacer device (100 mcg/puff) 4 to 8 puffs per dose or nebulized 1.25 mg to 5 mg per dose in 3 mL sodium chloride 0.9%, as per flowchart (Appendices B &C) attached. Administer first dose as soon as possible. May administer every 60 minutes. See flowchart (Appendix B). MDI with spacer is preferred delivery system unless continuous oxygen is required. 

  • Reassess vital signs and PRAM q 60 min. If PRAM worsening at next assessment, alert physician. 

 Moderate Asthma Exacerbation:

 In the setting of PRAM score equal to 4-7:

  

  • Salbutamol: metered dose inhaler (MDI) with spacer device (100 mcg/puff) 4 to 8 puffs per dose or nebulized 1.25 mg to 5 mg per dose in 3 mL sodium chloride 0.9%, as per flowchart (Appendices B & C) attached. Administer first dose as soon as possible. May administer every 30 minutes as needed. See flowchart (Appendix B). MDI with spacer is preferred delivery system unless continuous oxygen is required.

     

  • Dexamethasone (0.6 mg /kg; max dose 16 mg) PO once, as soon as possible following salbutamol: See Ontario Lung Association flowchart (Appendix B).   Note that the maximum dose reflected in the Ontario Lung Association flowchart (Appendix B) is 12 mg.  Based on literature the physician team within the department uses the maximum dose of 16 mg (Watnick et al, 2015).

     

Reassess vital signs and PRAM q 30 min (if PRAM, Appendix A, score decreases reassess according to new score). If PRAM worsening at next assessment, alert physician.

Click the link to view the entire medical directive in detail: 

Signatures

SurnameKnown ByDate Signed
EdmondsMarciaJul 14 2016 09:21:48:993PM
HellemanKristaMar 8 2017 07:22:56:523AM
IstasyVictorSep 27 2016 09:20:02:900AM
JoubertGaryJul 7 2016 09:45:53:807AM
KilgarJenniferMar 25 2017 05:17:42:740PM
LimRodrickJul 10 2016 02:43:48:257PM
LoubaniEmanHave Not Signed
LynchTimFeb 25 2017 03:21:55:487AM
MehrotraShrutiJul 14 2016 04:16:21:317AM
MisirAmitaSep 12 2016 08:10:51:157AM
MosdossyGregoryJul 8 2016 03:02:50:300AM
PoonaiNaveenHave Not Signed
RiederMichaelOct 24 2016 08:34:16:923AM
SanghaGurinderMar 21 2017 01:22:48:880PM
WarrenDavidJul 18 2016 01:29:37:600PM