Download STEP BY STEP MANAGEMENT OF DKA

STEP BY STEP
MANAGEMENT OF
STATUS ASTHMATICUS
See details in the Asthma protocol
guidelines
Dr. D. Alvarez
August 2006
INITIAL PROCES
1. Call from the ED/4-B requesting bed for a patient
with Status Asthmaticus in respiratory distress.
2. Resident / Supervisor (if applicable) obtains
information on patients condition, on the phone or
going to the ED/4-B, (as activity in the unit
warrants).
3. Information needed:
•
Base line patient’s chronic condition
-
-
If previous diagnosed with asthma, state Severity: Intermittent –
Mild / Moderate / Severity Persistent (complete detail Asthma
history later)
Has patient had previous PICU admissions? Intubations?
Last Hospitalization?; last intubation?.
Has patient been seen in the Asthma / Pulmonary clinic? date last
visit
INITIAL PROCESS (continue)
•
Current event/exacerbation details:
–
–
–
-
Duration of symptoms of exacerbation
Triggering factors
Treatments / management at home.
Do they have an AAP?…. if yes
-
Did they follow their AAP, including given
steroids at home?. Time and dose given – did
patient tolerated? or patient vomited.
ED Events.
4.- Review of ED-Events
–
–
Severity of Respiratory Distress /Assessment (See chart
assessment)on presentation to ED and after therapies.
Studies / labs done (Start laboratory flow sheets record)
•
CXR in patient’s with severe respiratory distress and/or fever.
»
•
Look for: significant atelectasis, air leaks , infiltrates?
CBC with diff and Electrolytes in patient in moderate to Severe
respiratory distress, receiving frequent bronchodilator
treatments.
»
Look for signs of dehydration, HYPOKALEMIA, AND
ACIDOSIS.
5.- Communicate with PICU Attending and inform on
patient’s condition.
6.- Inform PICU Nurses that patient was accepted and
up-date them on patient’s condition.
Asthma History Focus
A. Asthma symptoms SINCE Or First wheezing episode
since/at (age)GIVE SOME DETAILS OF SEVERITY
B. Frequency of subsequent symptoms / Seasonality
and Course. .”Overall improving , same, worse
or up and down”
C. Asthma therapy received / duration / effect.
D. Symptoms control for the past year.
E. Asthma Risk Factors (Index) Positive Risk Factors if:
- Family hx of asthma / allergies.(parents),
- Eczema
- Allergies (Pt. and/or Fly),
- Eosinophillia in CBC
- Smoke exposure, etc.
- Hx of RSV + bronchiolitis.
ASSESSMENT
Physiological Problems that
need to be Address / Assess.
1. Severity of Respiratory distress: (See chart
criteria)
•
•
•
Mild
Moderate
Severe
Severity of Respiratory Distress
Mild
Moderate
Severe
Normal Alert
Mild affected
Irritable/
AffectedLethargy
Tachypnea
Norm Mild
1 ½ x standard
2 x standard
Work of
Breathing
Mild SC
retractions
SC-IT and
Supra-clav Retrac-
SC-IC-SC Retrac.&
nasal flaring ? fatigue
Air Entry
Normal
Mild decrease
Decreased
Wheezing
Mild (+)
Hypoxia /
O2 Sat in RA
> 95 %
< 95 > 90 %
< 90 %
PCO2 / PEFR
Norm/>75%
< 45 / >50% <75%
> 45 / 50 %
Mental Status
Moderate (2-3+) (3- 4 +) OR None
> imminent RF
3. Assess cardiovascular compromise. Examples:
–
Mild Tachycardia / good perfusion
–
–
Moderate Tachycardia /mild decrease perfusion.
–
–
HR < than one standard deviation of normal for age.
HR > 1 < than 2 standard deviation of normal for age
Severe Tachycardic / poor perfusion.
–
HR > 2 standard deviation of normal for age
4. Assess Fluid-Electrolyte and AB Imbalance. Examples:
(Look for sings of dehydration, hypokalemia,
Metabolic acidosis and hyperglycemia)
–
–
–
Well hydrated / No electrolyte imbalance.
Mild dehydrated / mild acidosis, lowish K
Moderate dehydrated / moderate metabolic acidosis (Bic
< 17), low K, hyperglycemia, high BUN and Creatitine.
3. Assess > If associated overlapping infection
Process.
•
By History
– Hx suggestive of Upper respiratory infection? Viral Vs
Bacterial
» Nasal symptoms: URI, Infected Rhinitis, Sinusitis
» Pharyngeal symptoms: Pharingitis? Post Nasal drip.
– Hx suggestive of Lower respiratory bacterial infection:
» Prolonged productive cough with thick yellow sputum
» Fever
3. Assess > If associated overlapping infection Process.
•
By Physical exam
–
–
Signs of Upper respiratory infection? Viral /Bacterial (See features
of nose exam check list)
» Examination of nose
- Nasal crease/ allergic salute
- Turbinate Normal size
- Hypertrophy
- Color- pale/red
- Secretion-amount – scanty/copious
. color- yellow/green/clear
- Patency of nose- patent /blocked.
Signs of Lower respiratory bacterial infection: Signs of
consolidation (decrease breath sounds, bronchophony, fine
crackles – POSITIVE RACKLE DOES NOT MEANS
PNEUMONIA)
3. Assess If associated /overlapping infection
Process. (Continue)
• By Studies:
– CBC with diff (manual count) if clinically
indicated
– CRP if highly suspicious
– CxR, looking for alveolar filling processes, NOT
just atelectasis, although atelectasis can be
infected.
– DON’T FORGET TO CHECK PPD STATUS.
4.-Other associated pathology
–
Snoring? Obstructive sleep apnea?
MANAGEMENT
RESPIRATORY SUPPORT
1. OXYGEN
•
•
Assess patient’s oxygen requirements and provide oxygen as
needed to keep O2Sat’s > 95% in the acute processes.
Provide Oxygen using the devices as per guidelines
- Low Flow Oxygen: Nasal Canula < than 3 L/min (~ 35 %)
- Moderate Flow Oxygen: USE AEROSOLIZE MASK, start with 40
% if switching from nasal canula OR as much as patient needs to
keep saturation > 95 %
- High Flow Oxygen: USE SAME AEROSOLIZE MASK. With this
system flow can be adjusted from 28% to 100% just dialing up and
down. Besides it delivers humidify oxygen.
•
If patient’s is requiring > 55 % FiO2 to keep Saturation > 90 %,
patient is in HYPOXIC RESPIRATORY FAILURE. NEED TO
HAVE AN ABG. (Capillary blood gasses may suffice, NOT
VENOUS)
RESPIRATORY SUPPORT (Continue)
2. Systemic Steroids
•
•
•
•
•
Use IV Solumedrol for patient who are in moderate to Severe
respiratory distress.
Initial dose is 2 mg/kg/dose to a max of 125 mg.
Follow up doses is 1 mg/kg/dose to a max of 60 mg Q6H
PO steroids (Prednisone tablets or Prelone liquid). The dose is 2 mg
/kg/day to a max of 60 mg if patient is in mild to moderate
respiratory distress.
IF SOLUMEDROL IS NOT AVAILABLE THIS CAN BE
REPLACED BY DECADRON >> THE DOSE IS:
•
•
0.05 mg/kg/dose IM or IV Q 6 -12 hrs. (Max 10 mg/24 hrs)
(0.08 -0.3 mg/kg/24 hr)
Adult dose 10 mg Q 6 hrs
RESPIRATORY SUPPORT (Continue)
3. Bronchodilators
A. Albuterol Nebulizer is the main
bronchodilator
 Q2H in patient in Mild to Moderate respiratory
distress.
 If requiring more than Q2H, add Atrovent Neb
and give it:
•
•
•
“Back to Back” alternated (Alb & Atrovent) in patients
with severe respiratory distress /Impending respiratory
failure. Order x 4 Cycles and reassess. When improving,
(usually expect it after ~ 6 hrs of the start of
Steroids)Frequency can be spaced it gradually.
Q1-2 H still alternated (Alb & Atrovent) >> if doing
well, mild respiratory distress > d/c Atrovent
Continue with Albuterol Q2-3 hours.
RESPIRATORY SUPPORT (Continue)
3. Bronchodilators (Continue)
B. Terbutaline SC and / OR IV drip. To be use in
patients who are not improving on back to
back Nebulizer bronchodilators to avoid
intubation. (See drip chart)
•
The initial dose is:
C. MgSulfate: is a weaker bronchodilator than
Albuterol or Atrovent. Recommended for its
additional effect in the initial management in
the ED. It should not be repeated at the risk to
cause Hypermagnesemia.
Fluid Therapy
NPO if patient is in moderate to Severe distress.
1. Calculate patient’s maintenance fluids (requirements);
Wt. base OR per SA(m2)
A. Basic Requiremente
•
Wt base: 100 ml/kg for the first 10 kg
50 ml/kg for the next 10 kg
20 ml/kg for the rest…. kg.
•
B.
Add Insensitive extra loses given by:
•
•
2.
Per SA (m2) 1500 mL/M2
Tachypnea
Fever
Replace deficit: take in account:
•
•
Duration of symptoms
PO intake, vomiting.
Fluid Requirement for patients in moderate to severe
respiratory distress may be estimated as 1 ½
maintenance.
Fluid Therapy (CONTINUES)
3. Follow up studies:
–
Electrolytes abnormalities
•
•
Hypo, hypernatremia / dehydration
Hypokalemia
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–
•
Hyperglycemia:
–
–
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May need to increase KCL concentration in IV solution
DO NOT HOLD KCL IN IV SOLUTION WAITING FOR
URINE OUTPUT, AS LONG AS THE SERUN K AND BUN
AND CREATININE ARE NORMAL IN INITIAL LYTES.
Check > F/U FS and UA till normalize
D/C glucose from IV if necessary
ABB (Acid – Base – Balance)
•
Check and follow up metabolic acidoses than can be a sign
of fatigue to be use as indication for respiratory support
(intubation).
Indication for intubation
(Impending / Respiratory Failure)
1. Altered Sensorium /coma
2. Fatigue
• Inhability to speak
• Diaphoresis in the recumbent position
• Lactic acidosis
3. Silent chest despite respiratory effort
4. Refractory hypoxemia (PaO2 < 60 mmHg /O2 Sat < 90 %
on Max O2)
5. Increasing PCO2 (50 mmHg and rising > 5 mmHg/hr)
6. Acute Barotrauma /Tension Pneumothorax
(Pneumomediastinum in a patient in no distress is not an indication
for intubation)
7. Respiratory or cardiac arrest
Intubation Process
1. Call anesthesia (Emergency Beeper in the board)
if PICU attending not in house.
2. Calculate / Order / Prepare Sedation Medication
RSI INTUBATION MEDICATIONS




Penthobarbital OR
Midazolan and Ketamine
Lidocaine
Vecuronium
3. Call Respiratory therapy (Emergency Beeper in the
board
4. Order initial Mechanical Ventilator setting
according to guidelines after discussion with
PICU attending
Principles of Mechanical Ventilation
in patients with Status Asthmaticus.
• There is and increase resistence and decrease
compliance therefore be aware of checking PIP if
you are ventilating with volume control (SIMV or
CMV)
– High risk for barotrauma
• If patient is started on Volume control and the reached PIP
is > 30, consider changing to Pressure control
• Because the high resistance and decrease compliance, the
time Constance is increase (need more time to fill up the
alveoli) therefore need to use lower rates to decrease
airtraping/AutoPEEP and barotrauma.
Principles of Mechanical Ventilation
in patients with Status Asthmaticus.
(CONTINUE)
• REMEMBER THE VENTILADOR WILL NOT RESOLVE THE
IMFLAMATORY PROCESS NOR THE BRONCHOSPASM; ON
THE CONTRARY IT MAY MAKE IT WORSE. BE READY TO
DEAL WITH CIRCULATORY COMPROMISE IMMEDIATELY
AFTER INTUBATION. THIS SHOULD BE TREATED WITH
FLUIDS.
• NEED GENTLE VENTILATORY SUPPORT WAITING FOR THE
MEDICATIONS (Steroids and bronchodilators) TO WORK
• The main goals of respiratory support are:
•
•
•
•
Ensure oxygenation
Decrease work load of a fatigue patient, reverse lactic acidosis.
Prevent cardio-respiratory arrest
Avoid barotrauma using “permisive hypercarbia”. DO NOT AIM TO
NORMALIZE ABG
Intubation Process (Continue)
5. Connect and read ETCO2 and O2 Sats.
6. Order Chest x Rays.
DO NOT FORGET TO REMOVE
CHEST C-R LEADS BEFORE X RAYS
TAKEN.
7. DO ABG and correlate ETCO2 with
PaCO2
TREATMENTS DURING
MECHANICAL VENTILATION
1. Bronchodilators:
a.
Continue frequent albuterol and atrovent given by MDI
alternated every 30 > 60 minutes.
•
•
4 puffs for younger child
6 puffs for older child > 5 yo
b. Continue Or start terbutaline drip (as per protocol)
2. Continue IV steroids.
3. Sedation: Deep sedation, avoid paralysing agent
after the initial use for intubation and stabilization.
a) Ketamine drip is the drug of choice plus midazonal
PRN or drip.